Cervicofacial and mediastinal emphysema after balloon eustachian tuboplasty (BET): a retrospective multicenter analysis.

PURPOSE: Balloon Eustachian tuboplasty (BET) is a new treatment modality addressing chronic obstructive dysfunction of the Eustachian tube (ET). So far, BET has been deemed a safe procedure under general anesthesia with only minor adverse effects. However, individual cases of postoperative emphysema have been reported. In the present retrospective multicenter analysis we determined the incidence rate of this potentially life threatening complication after BET. METHODS: In total we collected data from 3,670 BET procedures performed on 2,272 patients in four tertiary care ENT departments. RESULTS: Ten cases of postoperative cervicofacial emphysema were documented, whereas only in 3 of them a pneumomediastinum was developed. None of the affected patients developed at any time serious clinical signs or symptoms besides cutaneous crepitations. A complete resolution and recovery of the emphysema occurred in all patients under antibiotic prophylaxis and abstinence from Valsalva maneuver within the first 2-6 postoperative days. CONCLUSIONS: Possible causes for the development of these postinterventional emphysemas are considered to be mucosal injuries of the ET during manipulations for the correct position of the insertion instrument, through a "kinking" of the balloon catheter or even due to the relative rigid catheter itself, although its form is regarded to be atraumatic. The complication rate of postoperative emphysema was 0.27% (95% CI 0.13-0.50%). The above facts in addition to only minor and transient overall complications after BET reported in literature, can label this procedure as a safe treatment with a low risk profile.

Value of DSA in the diagnostic workup of pulsatile tinnitus.

OBJECTIVES: Pulsatile tinnitus (PT) is a rare complaint, but can be a symptom of life-threatening disease. It is often caused by vascular pathologies, e.g. dural arteriovenous fistula (dAVF), arteriovenous malformation (AVM) or vascularized tumors. The current diagnostic pathway includes clinical examination, cranial MRI and additional DSA. The aim of this study was to evaluate the diagnostic impact of DSA in the diagnostic workup of patients with PT in comparison to MRI alone. METHODS: Retrospectively, 54 consecutive patients with pulsatile tinnitus were evaluated. All patients had a diagnostic workup including cranial MRI and DSA. MRI examinations were blinded to the results of DSA and retrospectively analyzed in consensus by two experienced neuroradiologists. The MR-examinations were evaluated for each performed sequence separately: time-of-flight-angiography, ce-MRA, T2, ce-T1-sequence and ce-T1-sequence with fat saturation. RESULTS: 37 of the 54 patients revealed a pathology explaining PT on MRI, which was detected by the readers in 100% and proofed by means of DSA. 24 dAVF, four paraganglioma, two AVM and seven more pathologies were described. All patients without pathology on MRI did also not show any pathology in DSA. CONCLUSIONS: MR imaging is sufficient to exclude pathology in patients with pulsatile tinnitus.

Detection of circulating tumor cell subpopulations in patients with head and neck squamous cell carcinoma (HNSCC).

BACKGROUND: Since image based diagnostic tools fail to detect early metastasis in head and neck squamous cell carcinoma (HNSCC) it is crucial to develop minimal invasive diagnostic methods. A promising approach is to identify and characterize circulating tumor cells (CTC) in the peripheral blood of HNSCC patients. In this pilot study, we assessed which non-hematopoietic cell types are identifiable and whether their numbers differ in pre- and postoperative blood samples. METHODS: 20 ml citrated peripheral blood was taken from 10 HNSCC patients before and after curative resection. CTC were enriched using density gradient centrifugation. CTC presence was verified by multi-immunofluorescence staining against cytokeratin (CK; epithelial), N-cadherin (mesenchymal); CD133 (stem-cell), CD45 (hematopoietic) and DAPI (nucleus). Individual cell type profiles were analyzed. RESULTS: We were able to detect cells with epithelial properties like CK+/N-cadherin-/CD45- and CK+/CD133-/CD45- as well as cells with mesenchymal features such as N-cadherin+/CK-/CD45- and cells with both characteristics like N-cadherin+/CK+/CD45-. We also observed cells showing stem cell-like features like CD133+/CK-/CD45- and cells with both epithelial and stem cell-like features such as CD133+/CK+/CD45-. The number of CK positive cells (p = 0.002), N-cadherin positive cells (p = 0.002) and CD133 positive cells (p = 0.01) decreased significantly after resection. Kaplan-Meier test showed that the survival was significantly shorter when N-cadherin+ cells were present after resection (p = 0.04; 474 vs. 235 days; [HR] = 3.1). CONCLUSIONS: This is - to the best of our knowledge- the first pilot study identifying different CTC populations in peripheral blood of HNSCC patients and showing that these individual cell type profiles may have distinct clinical implications.

The role of tumour FoxP3 as prognostic marker in different subtypes of head and neck cancer.

Expression of the forkhead transcription factor (FoxP3)--an established marker of regulatory T cells--has been found in other cell types as well, including tumour cells. Recent studies indicated that high tumour FoxP3 expression might be associated with a poor outcome of patients with several types of solid cancers. Here, we investigated the role of FoxP3 expressed by the tumour cells in the prognosis of larynx and oro-hypopharynx squamous cell carcinoma (LSCC and OHSCC)--two major subtypes of head and neck cancer. To this end, we analysed by immunohistochemistry the expression of tumour FoxP3 in tissues from 83 LSCC and 89 OHSCC patients in relation to overall survival. In multivariate analysis we found that high tumour FoxP3 expression significantly associated with poor survival in OHSCC but not in LSCC patients. In further studies, we combined the prognostic value of FoxP3 with selected markers of inflammation (cyclooxygenase-2; COX2) or with markers of enhanced tumour migration/invasion (AHNAK and CORTACTIN). Interestingly, we found that the combination of FoxP3 and AHNAK (in LSCC) or FoxP3 and CORTACTIN (in OHSCC) had significantly stronger prognostic values than either marker analysed individually. Combination of FoxP3 and COX2 enhanced the prognostic accuracy only in OHSCC. Thus, our study identifies novel individual and combination markers that might have enhanced and distinct prognostic relevance in different subtypes of head and neck cancer.

Vascularised local and free flaps in anterior skull base reconstruction.

Lesions of the anterior skull base often require sufficient closure in order to prevent cerebrospinal fluid (CSF) leak, ascending infection and/or brain tissue prolapse. The transfer of devitalized autologous, allogenic or xenogeneic material is not always sufficient particularly not in larger defects or in the recurrent situation. Here the transfer of vascularised tissue seems to be more appropriate. The anterior skull base with various complex defects of 41 patients was reconstructed in an interdisciplinary setting by vascularised, autologous tissue transfer. Minor defects (<2.5 cm in max. diameter), generally occurring after extended endoscopic skull base approaches (n = 26, among those meningiomas, recurrent CSF fistulas, chordoma, chondroblastoma, metastasis, nasal fistula), were reconstructed by a local, vascularized pedicled mucosal flap of the lower turbinate (n = 3) or septum (n = 23). Patients with major defects (>2.5 cm in max. diameter, n = 15), comprising those with malignoma, meningoencephalocele, aneurysmatic bone cyst and trauma, were repaired by a "sandwich technique" with a combination of calvarian split and galea periosteum flap in 10 patients, in one case with a temporalis muscle flap, while in 4 further patients free vascularised radial forearm flaps were used for revision after multiple unsuccessful operations elsewhere. After a mean follow-up time of 30.5 months 38 of the 41 cases were successfully repaired with respect to prevention and treatment of CSF leakage or brain tissue prolapse, only 3 cases needed surgical revision. The reconstruction of the anterior skull base bearing complex lesions is feasible using vascularised, autologous local and also distal tissue transfer in a close interdisciplinary cooperation.

Virtual 3-D ¹8F-FDG PET/CT panendoscopy for assessment of the upper airways of head and neck cancer patients: a feasibility study.

PURPOSE: The aim of this study was to evaluate whether a virtual 3-D (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT panendoscopy is feasible and can be used for noninvasive imaging of the upper airways and pharyngeal/laryngeal tumours. METHODS: From (18)F-FDG PET/CT data sets of 40 patients (29 men, 11 women; age 61 ± 9 years) with pharyngeal or laryngeal malignancies virtual 3-D (18)F-FDG PET/CT panendoscopies were reconstructed and the image processing time was measured. The feasibility of assessing the oral cavity, nasopharynx, tongue base, soft palate, pharyngeal tonsils, epiglottis, aryepiglottic folds, piriform sinus, postcricoid space, glottis, subglottis, trachea, bronchi and oesophagus and of detecting primary tumours was tested. Results of fibre-optic bronchoscopy and histology served as the reference standard. RESULTS: The nasopharynx, tongue base, soft palate, pharyngeal tonsils, epiglottis, subglottis and the tracheobronchial tree were accessible in all 40, and the aryepiglottic folds, posterior hypopharyngeal wall, postcricoid space, piriform sinus, glottis, oral cavity and oesophagus in 37, 37, 37, 37, 33, 16 and 0 patients, respectively. In all 12 patients with restricted fibre-optic evaluation due to being primarily intubated, the subglottis was accessible via virtual panendoscopy. The primary tumour was depicted in 36 of 40 patients (90 %). The mean processing time for virtual (18)F-FDG PET/CT panendoscopies was 145 ± 98 s. CONCLUSION: Virtual (18)F-FDG PET/CT panendoscopy of the upper airways is technically feasible and can detect pharyngeal and laryngeal malignancies. This new tool can aid in the complete evaluation of the subglottic space in intubated patients and may be used for planning optical panendoscopies, biopsies and surgery in the future.

Cyclin B1 expression and p53 status in squamous cell carcinomas of the head and neck.

BACKGROUND: The cyclin B1/CDC2 complex governs entry into mitosis by regulating the G(2)/M checkpoint, and it can be repressed by the tumor suppressor p53. We aimed to determine cyclin B1 expression in squamous cell carcinomas of the head and neck (SCCHN) and correlate it with p53 status and clinicopathological parameters. PATIENTS AND METHODS: Cyclin B1 and p53 protein expression was analyzed by immunohistochemistry, and p53 mutation analyses were performed. RESULTS: Cytoplasmic expression of cyclin B1 was found in all 26 SCCHN studied. In contrast, nuclear staining was seen in the basal layers of normal mucosa. A total of 46% of tumors showed high cyclin B1 expression. p53 was overexpressed in 53.8% of cases, and of these 79% carried a p53 gene mutation. High cyclin B1 expression significantly correlated with the high tumor grade, but not with gender, tumor size, nodal status, local tumor recurrence or p53 expression. CONCLUSION: Cyclin B1 is frequently overexpressed in SCCHN, and its high expression is significantly associated with a high tumor grade. These data suggest that cyclin B1 may serve as a potential prognostic biomarker in SCCHN.

Toll-like receptor 4 single-nucleotide polymorphisms Asp299Gly and Thr399Ile in head and neck squamous cell carcinomas.

BACKGROUND: Chronic inflammation plays an important role in head and neck squamous cell carcinomas (HNSCC). This study addresses the impact of two single nucleotide polymorphisms (SNP) Asp299Gly and Thr399Ile of the toll-like receptor (TLR) 4 gene on the clinical outcome while accounting for the influence of adjuvant systemic therapy in a large cohort of HNSCC patients. METHODS: Genotype analysis was done using DNA from tissue samples from 188 patients with HNSCC; TLR4 protein expression was assessed immunohistochemically in tissue microarrays. Classical survival models were used for statistical analyses. RESULTS: Ten percent of patients with HNSCC presented with the TLR4 299Gly and 17% with the TLR4 399Ile allele. Patients with the heterozygous genotype TLR4 Asp299Gly had a significantly reduced disease-free and overall survival. Also, patients with the heterozygous genotype TLR4 Thr399Ile had a reduced disease-free survival. Notably, these associations seem to be attributable to relatively poor therapy response as e.g. reflected in a significantly shorter DFS among HNSCC patients carrying the Asp299Gly variant and receiving adjuvant systemic therapy. CONCLUSION: According to this study, TLR4 299Gly und 399Ile alleles may serve as markers for prognosis of head and neck cancer in patients with adjuvant systemic therapy, particularly chemotherapy, and might indicate therapy resistance.

[How to create a self-cleaning open mastoid cavity]. / Die Anlage einer selbstreinigenden offenen Mastoidhöhle.

Our experience from multiple open mastoid cavity revisions is that some of the well-proven techniques to create a self-cleaning small open cavity are not anymore practiced everywhere.The crucial steps are to considerably drill down the facial ridge, as well as the lateral bone (to the level of the sigmoid sinus) and - in cases of a well pneumatized mastoid - to ground down the mastoid tip. The bony rims should be smoothened with a diamond burr. Furthermore, the size of the cavity can be reduced by partial obliteration of the retrofacial space and the sinus-dura-angle using bone substitutes. In our hands cartilage chips have proven to be a good substitute, hydroxy apatite pellets or a musculoperiosteal flap according to Palva might be used alternatively. Finally a wide auditory canal entrance has to be created. By applying these techniques, for a selected number of cases the "open technique" still represents an essential part of cholesteatoma surgery these days.

Polymorphonuclear granulocytes in human head and neck cancer: enhanced inflammatory activity, modulation by cancer cells and expansion in advanced disease.

The progression of epithelial cancer is associated with an intense immunological interaction between the tumor cells and immune cells of the host. However, little is known about the interaction between tumor cells and polymorphonuclear granulocytes (PMNs) in patients with head and neck squamous cell carcinoma (HNSCC). In our study, we investigated systemic PMN-related alterations in HNSCC, the role of tumor-infiltrating PMNs and their modulation by the tumor microenvironment. We assessed the infiltration of HNSCC tissue by PMNs (retrospectively) and systemic PMN-related alterations in blood values (prospectively) in HNSCC patients (n = 99 and 114, respectively) and control subjects (n = 41). PMN recruitment, apoptosis and inflammatory activity were investigated in an in vitro system of peripheral blood PMNs and a human HNSCC cell line (FaDu). HNSCC tissue exhibited considerable infiltration by PMNs, and strong infiltration was associated with poorer survival in advanced disease. PMN count, neutrophil-to-lymphocyte ratio and serum concentrations of CXCL8 (interleukin-8), CCL4 (MIP-1ß) and CCL5 (RANTES) were significantly higher in the peripheral blood of HNSCC patients than in that of controls. In vitro, HNSCC-conditioned medium inhibited apoptosis of PMNs, increased chemokinesis and chemotaxis of PMNs, induced release of lactoferrin and matrix metalloproteinase 9 by PMNs and enhanced the secretion of CCL4 by PMN. Our findings demonstrate alterations in PMN biology in HNSCC patients. In vitro, tumor-derived factors modulate cellular functions of PMNs and increase their inflammatory activity. Thus, the interaction between HNSCC and PMNs may contribute to host-mediated changes in the tumor microenvironment.

Acute arterial hemorrhage following radiotherapy of oropharyngeal squamous cell carcinoma.

BACKGROUND AND PURPOSE: Vascular erosion is a rare but life-threatening complication after radiotherapy. The authors report on acute arterial bleeding and its therapy following radiotherapy of oropharyngeal tumors. PATIENTS AND METHODS: Ten patients with oropharyngeal squamous cell carcinoma of any stage developed foudroyant acute arterial hemorrhage 3-46 months (14.4 +/- 5.1 months) after primary (5/10) or adjuvant radio(chemo)therapy (R[C]T). RESULTS: All patients had a history of recurrent minor bleeding episodes and showed deep mucosal ulcerations also outside the primary tumor region. A life-threatening arterial hemorrhage appeared in the area of these mucosal defects in the pharyngeal region. Affected vessels were the common carotid artery as well as the internal and the external portion with branches like the ascending pharyngeal and superior thyroid arteries. Treatment consisted of emergency intubation or tracheotomy followed by exposure and package of the pharynx and surgical ligature and/or embolization. 6/10 patients (all hospitalized) survived the episode, however, lethal outcome in 4/10 patients (outpatients) was related to asphyxia as a result of blood aspiration or exsanguination. None of the patients revealed evidence of persistent or recurrent tumor disease as proven by biopsy/autopsy and imaging technique. CONCLUSION: Vascular erosion following primary or adjuvant R(C)T represents a rare and potentially life-threatening complication requiring immediate emergency treatment involving head and neck surgeons, anesthesiologists and neuroradiologists. For patients with oropharyngeal neoplasms treated by R(C)T and showing recurrent bleeding episodes and mucosal ulceration particularly after the acute treatment phase, hospitalization with prophylactic surgical ligature or embolization of affected arteries is recommended.

Molecular analysis of IgD-positive human germinal centres.

It is controversially discussed whether human IgM(+)IgD(+)CD27(+) B cells, which carry somatically mutated Ig variable region (IgV) genes, are derived from germinal centres (GC) B cells or originate from another developmental pathway. GC composed of IgM(+)IgD(+) B cells, which co-express the CD70 surface marker, have been described in approximately 10% of tonsils. As IgM(+)IgD(+)CD27(+) B cells might be generated in such GC, we characterized IgD(+) tonsillar GC cells. GC dominated by IgD(+) B cells were present in 10 of 67 tonsils analyzed. Three GC were additionally positive for CD70. Detailed analysis of one such GC by microdissection and single-cell DNA PCR revealed IgD(+) GC B cells undergoing somatic hypermutation during clonal expansion. However, further analysis of this GC as well as five additional microdissected GC by reverse transcription (RT)-PCR for clonally related Igmu and Igdelta transcripts indicated that the B-cell clones in five of these six IgD(+) GC belong to the IgD-only B cell subset, which has deleted the Cmu gene, and that only one GC harboured a large IgM(+)IgD(+) B-cell clone. Hence, most IgD(+) GC consist of IgD-only B cells and fully developed IgM(+)IgD(+)(CD70(+)) GC are very rare. This indicates that the rare IgM(+)IgD(+) GC B-cell clones from IgD(+) GC contribute little to the large population of IgM(+)IgD(+)CD27(+) B cells. Finally, an RT-PCR analysis with clone-specific primers for two IgD(+) GC B-cell clones showed an absence of IgG or IgA class-switched clone members, indicating strict regulation of class switching and a selective production of IgD(+) B cells from such clones.

Dynamic MRI of the vocal cords using phased-array coils: A feasibility study.

OBJECTIVE: Endoscopy for evaluation of hoarseness is an invasive procedure and the result depends, to a large extent, on the patient's cooperation. Successful laryngoscopy can also be hampered by unfavourable anatomic conditions, a severely impaired general condition, or severe coagulopathy. We evaluated the feasibility of doing ultra-fast magnetic resonance imaging (MRI), using a recent dedicated coil design and a sequence with inherently high signal-to-noise ratios (SNR), for the detection of motility disorders of the vocal cords. MATERIALS AND METHODS: Twelve consecutive patients (eight males and four females) in the age range of 24-80 years (mean age 60 years) with persistent hoarseness and presumed vocal cord palsy were included in this blinded prospective study. Two two-element phased-array carotid coils were used for signal reception. The first coronal real-time steady-state free precession (SSFP) sequence was performed during silence (i.e., with no vocal cord motion) and the second while phonating 'heee.' Qualitative MRI findings were compared with the results of the endoscopic examination. RESULTS: The examination time for setup, patient instruction and positioning, localization scans, and real-time SSFP scans was less than 10 min. Seven patients with laryngoscopically-confirmed unilateral palsy of the vocal cord were correctly identified with MRI. The five remaining patients had hoarseness due to causes other than vocal cord palsy; they showed normal motion of the vocal cords on MRI and endoscopy. CONCLUSION: Compared to preceding studies, the image quality in this study is supported by excellent SNR (carotid phased-array coils and SSFP sequence with higher SNR if compared to a spoiled gradient-echo sequence or an EPI sequence). Further studies, with larger groups of patients, are necessary to show if this protocol can serve as an alternative to endoscopy in selected cases.

EBV transformation overrides gene expression patterns of B cell differentiation stages.

EBV-associated Hodgkin lymphoma (HL) and some post-transplant lymphoproliferative disease (PTLD) cases originate from pro-apoptotic germinal center (GC) B cells that have acquired destructive somatic Ig V gene mutations and were presumably rescued from apoptosis by EBV. To find out whether B cell receptor-crippled GC B cells acquire features of HL and/or PTLD cells upon EBV-infection and to reveal the impact of EBV on expression of B cell differentiation markers, we compared lymphoblastoid cell lines (LCLs) from GC B cells (including BCR-crippled GC-LCLs) to monoclonal LCLs from naïve B cells (N-LCLs). In addition, we analyzed the controversially discussed effect of EBV-infection on the GC B-cell-specific process of somatic hypermutation in vitro. Irrespective of their cellular origin, LCLs expressed CD20, CD30, CD38, AID, Pu.1, and with one exception Syk, but lacked expression of the GC B cell marker BCL-6. Interestingly, the T cell transcription factor GATA-3 that is aberrantly expressed in HL was induced in most GC-LCLs and the memory B cell marker CD27 was activated in N-LCLs. Remarkably, only 4 of 24 GC-LCLs showed significant somatic hypermutation activity, demonstrating that EBV usually silences hypermutation upon infection of GC B cells. Notably, one of three N-LCL showed a low level of intraclonal diversification. Thus, EBV-infection deregulates multiple differentiation factors and processes in B cells, leading to a largely homogenous phenotype of EBV-infected B cells in latency III.