[Guidelines for inpatient adenoidectomy]. / Kriterien zur stationären Krankenhausbehandlung der Adenotomie.

BACKGROUND: Adenoidectomy, with or without tonsillectomy, remains as one of the most common surgical procedures. This study was undertaken to determine whether or not the criteria for adenoidectomy based on an inpatient basis in our hospital have to be revised and to evaluate the incidence of postoperative bleeding. MATERIAL AND METHODS: The data of 470 patients who underwent adenoidectomy during 1 year were analyzed in a prospective study. Age <1 year; age >16 years; underlying diseases that put the patient at increased pre-or postoperative cardiopulmonary, metabolic or general risk; >20 minutes driving time between hospital and home, lack of compliance; request of the patients/parents were criteria for adenoidectomy to be performed as an inpatient procedure. Due to the rarity of postoperative bleeding the rate of post-adenoidectomy hemorrhage was calculated in a retrospective study on the basis of the data of 8131 patients who had undergone adenoidectomy. RESULTS: A total of 249 patients underwent adenoidectomy on an outpatient basis (53%). Two patients required surgical treatment for postoperative bleeding under general anesthesia (0.43%), one of whom was initially scheduled for outpatient surgery. The parents of 17 children initially scheduled for outpatient surgery refused to take responsibility of postoperative care on the day of surgery. These children were admitted. Inpatient observation was scheduled in most cases because of the distance to the hospital (115 patients) or underlying diseases (7 patients). The rate of post-adenoidectomy hemorrhage in our retrospective study was 0.23%. There was only one adult with repeated bleeding on the day of surgery and 6 days postoperatively. 15 of 19 episodes of bleeding occurred on the day of surgery, the latest episode 6 days postoperatively. There was no case with lethal outcome. No blood transfusions or major surgical procedures at the neck were required to stop the bleeding. CONCLUSIONS: Inpatient observation should be considered in patients with underlying general diseases, postoperative bleeding, poor compliance or request of the patients/parents. Age, general risk of post-adenoidectomy hemorrhage and distance to the hospital are not criteria significant enough to indicate inpatient observation in patients who undergo adenoidectomy.

[Evaluation and surgical approaches to tumors of the parapharyngeal space]. / Diagnostik und Zugangswege bei Tumoren des Parapharyngealraums - Eine Ubersicht.

BACKGROUND: Tumors of the parapharyngeal space encompass a wide variety of benign or malignant neoplasms. The purpose of this study was to evaluate our experience with the history, diagnosis and management of parapharyngeal tumors. PATIENTS AND METHODS: In a retrospective study the data of 19 patients who underwent surgical excision between 1995 and 2001 were analyzed with regard to presenting signs and symptoms, histologic diagnosis, imaging technique and surgical approach. 12 patients were female, 7 male. The youngest patient was 17, the oldest 72 years of age (mean: 47). RESULTS: Two thirds of the resected tumors were benign. Eight tumors originated from salivary glands, neurogenic tumors were found in 6 patients, malignant lymphomas in two cases. CT was performed in 16 patients, an additional MRI was indicated in 5 patients due to the superior soft-tissue resolution. In one patient arteriography revealed a paraganglioma. Preoperative localization of the tumor was possible in all cases. The transcervical approach was performed in the majority of cases (7). An intraoral excision (4) in combination with a transcervical approach (3), transcervical-tarnsmandibular (1) or a midfacial degloving (2) was performed less frequently. CONCLUSION: Benign parapharyngeal tumors prevail. In the majority of cases they originate from the salivary glands. CT and MRI are the diagnostic procedure of choice to select the surgical approach with the least morbidity. MRI should be preferred since it provides superior soft-tissue resolution, multiplanar imaging, identification of the vascular structures and no exposition to ionizing radiation. Arteriography should be performed if indicated by MRI findings. Incisional biopsy or fine needle biopsy should be performed only in cases which appear to be unresectable. Intraoral excisions should be indicated only for small tumors. The majority of tumors can be excised using the transcervical approach. Excessive tumor growth or tumors growing close to the skull base may indicate an infratemporal approach or a mandibulotomy.

[Spontaneous defects of the lateral cranial base. 1. Clinical aspects, diagnosis and therapy]. / Spontane Defekte der seitlichen Schädelbasis. Teil 1. Klinik, Diagnostik und Therapie.

BACKGROUND: Spontaneous cerebrospinal fluid otorrhea (SCFO) or rhinorrhea originating from laterobasal defects is uncommon. An immediate closure of the defect is mandatory due to the risk of life-threatening meningitis. The purpose of this paper is to review the literature and to present two additional case reports with emphasis on diagnostic problems and surgical techniques. PATIENTS AND METHODS: Two adults have been treated for SCFO in our clinic. A 62-year-old woman was complaining of pertinent otorrhea after placement of a ventilation tube and conservative treatment of serous otitis for 1 year elsewhere. A 66-year-old male patient had been treated for acute pneumococcal meningitis. He presented with unilateral deafness and vertigo 3 months later. High-Resolution-Computer-Tomography (HRCT) revealed a unilateral defect in the female and a bilateral defect in the male patient. A transmastoidal approach was used to amputate the meningoencephalocele and modified (Mini-Craniotomy) in the second (male) patient. The defect was closed in two layers using allogenic material and fibrin glue. RESULTS: One year after surgery both patients were free of symptoms and defect closure remained stable in HRCT and under microscopic view. CONCLUSIONS: SCFO from tegment defects is an uncommon cause of otorrhea and even rhinorrhea. History and clinical presentation of our patients can be regarded as typical for adults with SCFO. Evaluation of history, HRCT and a high index of suspicion is a prerequisite for correct diagnosis. The approach (transmastoidal, transtemporal, Mini-Craniotomy) to repair leaks of the tegmen should be related to the extent of the defect.

[Spontaneous defects of the lateral skull base. 2. Etiology and review of the literature]. / Spontane Defekte der seitlichen Schädelbasis. Teil 2. Atiologie und Literaturübersicht.

BACKGROUND: Isolated cases of spontaneous cerebrospinal fluid otorrhea (SCFO) of temporal bone origin with or without meningo(encephalo)cele have been reported. Diagnosis is predicted on a high index of suspicion. Since meningitis may occur secondary to SCFO, optimal therapy with surgical closure of the defect should immediately be performed. This study was undertaken to evaluate the incidence, characteristics and type of SCFO in literature. MATERIALS AND METHODS: We reviewed the reports on SCFO in the world literature since the first description in 1897 by Escat. Clinical presentation, gender, age and surgical management were aspects of our classification. Not included were patients with cerebrospinal fluid leak following any kind of previous temporal bone surgery, head trauma or rupture of the round window membrane. RESULTS: A total of 241 CSFO in 236 patients were found to accomplish the search criteria. Gender was not found to be a risk factor. Two subtypes of SCFO exist: the majority (161 cases) developing through the tegmen tympani and a smaller number (80 cases) with a translabyrinthine SCFO. The latter group can be regarded as the childhood-type with congenital defects of the otic capsule (Mondini dysplasia) presenting with meningitis in 85% of all cases. Adulthood-type SCFO are typically located in the tegmen tympani area presenting with conductive hearing loss or otorrhea following tube placement in 86% of all cases. Recent literature recommends a combined (transmastoidal and middle fossa) approach for closure of defects in the tegmen. CONCLUSIONS: Copious otorrhea through a perforated tympanic membrane or following placement of a ventilation tube, conductive hearing loss or meningitis without impairment of cochlear or vestibular function should be regarded as warning signs for an existing SCFO in adults. Children usually present with symptoms of inner ear anomalies, meningitis and loss of cochlear-vestibular function. High-resolution computer tomography is the diagnostic procedure of choice. A follow-up of several years to disclose any recurrence of SCFO or occurrence at a different area should be considered in any patient.

[Hemorrhage after tonsillectomy. Analysis of 229 cases]. / Blutung nach Tonsillektomie. Analyse von 229 Fällen.

BACKGROUND: In Germany a hospital stay of 6 days following tonsillectomy is recommended. Our retrospective study aimed to evaluate the incidence of hemorrhage following tonsillectomy with regard to the safety of a shorter hospital stay. PATIENTS AND METHODS: 5474 patients of our clinic who underwent tonsillectomy between 1988 and 1998 were enrolled in our study. Additionally, 65 patients with hemorrhage following tonsillectomy elsewhere were included. RESULTS: Postoperative hemorrhage occurred in 145 (2.65%) of our patients, 7 patients underwent recurrent treatment, in 97% suture ligation was sufficient. Primary bleeding (< 24 h) occurred in 79.7% of our patients. A 42-month old boy died at home due to massive bleeding 6 days following surgery. In this particular case, we strictly recommended postpone dismission because the boy had recurrent episodes of bleeding the days before. Postoperative hemorrhage after tonsillectomy performed elsewhere had to be treated in most cases 7-8 days postoperatively. Suture ligation of bleeding vessels was not sufficient in 21% and ligature of the external carotid artery mandatory. In these cases were usually found signs of deep necrosis. CONCLUSION: Due to the risk of life-threatening bleeding tonsillectomy should be performed as an inpatient procedure. The time of hospital stay should be related to the results obtained by self-evaluation and definition of risk factors. Readmission of patients with hemorrhage after dismission should be recommended. The follow-up has to be extended as long as the healing process continues.

HPV DNA detection in tumours of the head and neck: a comparative light microscopy and DNA hybridization study.

A series of 22 squamous cell carcinomas (4 cases grade 1; 11 cases grade 2; 7 cases grade 3) of the oral cavity (13 cases), (naso-)pharynx (5 cases) and larynx (4 cases) were studied by conventional light microscopy and filter (dot blot) hybridization for the detection of human papillomavirus (HPV) DNA. In 4 carcinomas, tumour-free tissue from the resection margins of the surgical sample was examined in addition to the tumour specimen. The same kind of investigation was carried out on 4 oral leukoplakias without dysplasia. All cases were thoroughly examined for HPV-associated cytopathic effects (koilocytosis). In all cases, material was obtained for DNA extraction followed by dot blot hybridization. DNA hybridization was carried out under stringent conditions with mixed probes of HPV 6/11 as well as HPV 16/18. Koilocytosis was observed in 10/22 carcinomas (45%, 4/4 G1 tumours, 6/11 G2 tumours, none out of 7 G3 tumours) and 3/4 leukoplakias. Koilocytosis always occurred at the tumour surface or the surface epithelium immediately adjacent to the tumour. HPV DNA was found in 8/22 carcinomas (36%, 2/4 G1 tumours, 5/11 G2 tumours, 1/7 G3 tumours). We observed HPV 16/18 infections in 3 cases and HPV 6/11 infection in 1 case. The other 4 cases were positive under relaxed conditions and, thus, could not be grouped into one of the examined types of HPV infections. In 4 carcinoma cases, tumour tissues and resection margins were examined. 3/4 cases showed concordant findings, i.e. in 2 cases tumour tissue and tumour-free mucosa (1-2 cm distant to the tumour) were positive for HPV, 1 case was negative in both samples. In 6/8 cases positive for HPV, HPV DNA detection corresponded to the observation of intensive koilocytosis. The leukoplakias were seen to harbour HPV DNA in 3 cases (1 case: HPV 6/11; 1 case: HPV 16/18; 1 case: positive under relaxed conditions). We did not observe HPV DNA in normal mucosal tissues. Our findings provide further evidence for the presence of HPV infections in tumours of the upper respiratory and digestive tract. Prospective studies now have to clarify the biological importance of HPV infections in this group of human cancer.

[Peripheral T-lymphocytes and delayed hypersensitivity in surgically and radiologically treated patients with early stages of larynx-carcinoma]. / Periphere T-Lymphozyten mit DNCB-Test nach operativer und radiologischer Behandlung von Plattenepithel-Karzinomen des Larynx im T-Stadium.

122 patients with squamous-cell-carcinoma of the larynx (T1-stage) were examined after surgical or radiological treatment. None of these patients showed evidence of tumor recurrence. Peripheral T-lymphocytes and delayed hypersensitivity were studied in all these patients. According to their treatment, the patients were allotted into three groups and compared with a control group, consisting of 20 patients with nonneoplastic head- and neck-disease. The main finding was a significant decrease in the peripheral T-lymphocytes in surgically- or radiologically-treated patients with a squamous-cell-carcinoma of the larynx (T1-stage). This reduction of T-cells must be interpreted as a congenital or acquired defect of the immunocompetent system. In about half of the control cases the DNCB-tests showed no evidence of delayed hypersensitivity. In view of these results and those reported in the literature, the test should be used critically. In contrast to our earlier findings, where patients received radiotherapy over large areas including big vessels, radiation over a smaller, localised area does not lead to a significant depression of peripheral T-lymphocytes.

[Lymphoepithelial carcinoma of the oropharynx: incidence and differential di]. / Zum lymphoepithelialen Karzinom des Oropharynx. Häufigkeit und Differentialdiagnose.

From 1960--1980, 452 malignant tumors of the oro- and nasopharynx were observed in the Cologne university ENT-clinic. 313 tumors of the oropharynx and 119 of the nasopharynx could be reclassified using the current classifications of upper respiratory tract tumors (WHO and Cologne modification) and of malignant lymphomas (German Kiel and Rappaport classifications). The analysis showed a different distribution of histological diagnoses in the naso- and oropharynx. Whereas the squamous cell carcinoma dominates with 57% in the oropharynx it is seldom seen (only 13%) in the nasopharynx. The non-keratinizing the undifferentiated carcinomas showed an inverse distribution in both regions. Malignant lymphomas and other types of malignant tumors occur equally frequent in the naso- and in the oropharynx. Only patients with non-keratinizing and undifferentiated carcinomas of the nasopharynx showed elevated antibody titers against Epstein-Barr virus. 7 patients with tumors of the same histological type but localization in the oropharynx had no elevated antibody titers against EBV.

[Nasopharyngeal carcinoma (NPC): comparison of clinical staging-systems]. / Das nasopharyngeale Karzinom (NPC). Vergleich klinischer Klassifikationssysteme.

A group of 54 patients with nasopharyngeal carcinoma (NPC) has been classified according to the TNM-staging-systems of the UICC (International Union Against Cancer), DAG (German Work Group "Clinical Oncology"), J.H.C. Ho/Hong Kong and the 2nd International Symposium on NPC, Kyoto 1977. For several parameters the patients have been classified for AJC (American Joint Committee for Cancer Staging and End-Results-Reporting), too. Tumor extension to the base of the skull or pterygopalatine fossa can only be assessed by radiological techniques. Therefore 36 of the 54 patients have been examined for osseous lesions of these regions with both conventional and computerized tomography. New computed tomographs with high resolution power give better information about tumor involvement than conventional tomography. The value of X-ray methods for correct staging of NPC are demonstrated. A review of the results showed that the staging system of Ho is the most reliable of the staging systems. The other staging systems ie. UICC and DAG need considerable improvement before they can be recommended.

[Tatooing of tumor borders in cancer of the oral cavity and oropharynx as a guide for orientation in radical operation after radiation]. / Tätowierung der Tumorgrenzen epithelialer Malignome der Mundhöhle und des Mundrachens als Orientierungshilfe für die Radikaloperation nach Vorbestrahlung.

To improve the local rate of success or the conversion of cancers of the cavum oris and of the oropharynx which are inoperable because of their local situation, preoperative radiation is carried out in cases where this is appropriate. The radiation and the radical operation must be coordinated with each other. For this purpose the borders of the cancer are marked by tatooing them with ink. The tatooing makes it possible both to judge the effects of the radiation accurately and to locate the borders of the tumor with the naked eye after radiation treatment in apparently healthy tissues. In this way it is possible to perform the radical operation with an adequate safety margin around the pre-therapeutic borders of the tumor. With this method the rate of success in tongue-body, tongue-ground and tonsil cancers can be improved.

Sera from patients with undifferentiated nasopharyngeal carcinoma contain a factor which abrogates specific Epstein-Barr virus antigen-induced lymphocyte response.

A unique association of Epstein-Barr virus (EBV) with the undifferentiated nasopharyngeal carcinoma (NPC) is a well acknowledged phenomenon. We report here the detection of a factor present in the sera of NPC patients which inhibits the blastogenic response of lymphocytes from EBV seropositive individuals to EB virions or soluble antigens. This lymphocyte-stimulation inhibitor (LSI) was found to be associated with the IgA fraction of the serum immunoglobulins. No inhibitory activity was detected in the sera and their immunoglobulin fractions from healthy (both EBV-seropositive and seronegative) individuals and patients with other carcinomas of the head and neck region. Interestingly, the IgA-LSI was absent in the sera of NPC patients who were successfully treated and remained in remission, while it was readily detectable in the sera of NPC patients in relapse, LSI-positive IgA fractions did not inhibit mitogenic response of lymphocytes to phytohemagglutinin. Taken together, the data presented suggest that LSI is a specific inhibitor of the response of sensitized lymphocytes to EBV antigens and that it may indeed represent a marker of great clinical significance regarding undifferentiated nasopharyngeal carcinoma, particularly for its prognosis.

[Value of tattooing cancerous lesions of the mouth and oropharynx during surgical intervention after radiotherapy]. / Intérêt du tatouage des lésions cancéreuses de la bouche et de l'oropharynx lors de l'intervention chirurgicale après radiothérapie.

The survival rate of patients suffering from malignant epithelial tumours of the oral cavity and oropharynx remains at present discouragingly low. According to various publications which have appeared in the last few years, it would seem that it is possible to achieve improved results in this field by giving radiation therapy of 40-50 Gy prior to radical surgery. With the application of modern techniques in radiotherapeutics, the incidence of serious post-operative complications in areas of tissue previously irradiated is nowadays very slight. Due to the fact that during radiotherapy the neoplasma either reduces in volume or even disappears completely, its limits must be recorded without fail before treatment is begun. Explanation of the therapeutical concept and initial results.

Histological types of nasopharyngeal carcinoma as compared to EBV serology.

One hundred and thirteen cases of nasopharyngeal carcinoma (NPC) were classified histologically according to the WHO-, French and Cologne systems. The various histological tumor types were then correlated with data on Epstein-Barr virus (EBV) serology (EA, VCA, EBNA, CF, IgA-VCA). The results showed non-keratinizing carcinomas with lymphoid infiltration, and undifferentiated carcinomas to be associated with significantly elevated anti-EBV titers. These two tumor types can be easily grouped together according to the French classification scheme as "undifferentiated carcinoma of the nasopharyngeal type (UCNT)". Such a procedure, which may have therapeutic implication, simplifies the rapid diagnostic screening of NPC patients and also may enhance the reproducibility of histological tumor typing.

[Tracheal transplantation in inbred strains of rats.--III. The morphologic substratum of host-versus-graft reaction (author's transl)]. / Die Trachealtransplantation im Tierexperiment. Versuche an isohistogenen Rattenstämmen: III. Das histologische Substrat der Host-versus-graft-Reaktion.

After isogeneic, allogeneic and allogeneic second-set tracheal transplantations gradually different morphological signs of a chronic host-versus-graft reaction in the wall of the transplants are observed. In no case there was a complete necrosis by rejection evident.

[Tracheal transplantation in inbred strains of rats.--IV. Histologic and histoautoradiographic findings in the epithelium (author's transl)]. / Die Trachealtransplantation im Tierexperiment. Versuche an isohistogenen Rattenstämmen: IV. Histologische und histoautoradiographische Befunde am Epithel.

In the first ten days after transplantation isogeneic and allogeneic tracheal transplants keep their epithelium, showing metaplasia as a sign of distinct regenerative activity in this time. In various degrees dependent on the constellation of experiments there are only signs of a weak chronic rejection. After more than 280 days again a stratified epithelium can be seen. In exeptional cases mucosa of second-set-transplants only show an obvious rejection reaction.

[Tracheal transplantation in inbred strains of rats. II. Survival rates and gross findings after auto-, iso- and allogenous tracheal transplantations (author's transl)]. / Die Trachealtransplantation im Tierexperiment. Versuche an isohistogenen Rattenstämmen: II. Uberlebensdauer und makroskopische Befunde nach auto-, iso- und allogenen Trachealtransplantationen.

Report of gross findings and survival rates in 148 cases of tracheal transplants in and between isogeneic strains of rats. The results imply that the composite graft of tracheal tissue apparently possesses only minor organ specific antigenicity.

Distribution of T- and B-cells and of immunoglobulin-producing cells in tumor tissue of patients with nasopharyngeal carcinoma.

Various subtypes of 17 European nasopharyngeal carcinomas are examined by immunocytological and immunohistological methods. The T- and B-Cells in the inflammatory infiltrate are determined quantitatively and correlated with the amount and type of intracellular immunoglobulin. This data is compared with peripheral T-Cell values and the serum anti Epstein-Barr virus (EBV) titers, and finally with the tumor type and stage. Three of the 17 patients had marked local immunoglobulin producing cells, 8 only moderate, and 6 had nearly none. The intracellular immunoglobulin was primarily IgG/kappa, and no significant increase of IgA producing cells was observed as suggested by others. No clearcut correlation was found between local T- and B-Cell infiltrates and the tumor type, stage of disease, or anti EBV titers in the patients' serum. The possible implication of this data is discussed.