[Vestibular schwannoma. A new interpretation of tumor growth]. / Vestibularisschwannomer. En ny fortolkning af vaekstresultater.

INTRODUCTION: The goal of the present paper was to investigate the growth of vestibular schwannoma (VS). MATERIAL AND METHOD: A series of 123 patients with 127 tumours were allocated to the wait and scan group in the period 1973 to 1999. The material was updated three times medio 1993, medio 1996 and medio 1999. Via the Danish national register, data on whether the included patients were alive or dead were collected medio 1999. Three sets of growth results were obtained. RESULTS: The results medio 1993 revealed: tumour growth in 94 tumours (74%), no growth in 23 tumors (18%) and negative growth in 10 tumors (8%). Medio 1996 the results changed to: tumour growth in 104 tumors (82%), no growth in 15 tumours (12%) and negative growth in eight tumours (6%). The growth figures changed again in medio 1999 to: tumour growth in 108 tumours (85%), no growth in 11 tumours (9%) and negative growth in eight tumours (6%). However, the results may also be interpreted in another way: 52 patients (42%) are alive, tumour growth did not demand any intervention, 23 patients (19%) died due to non-tumour related causes and 35 patients (28%) were previously treated and alive by the termination of the third observation period. CONCLUSION: It is concluded that tumour growth is time dependent, surgery at diagnosis is the ultimate solution, however the current study provides a number of arguments in favour of the wait and scan policy.

[Vestibular neurectomy in the treatment of Meniere's disease]. / Neurectomia nervus vestibularis i behandling af morbus Ménière.

INTRODUCTION: A brief history of vestibular neurectomy is given. This treatment was introduced in Denmark by us, based upon our large experience with translabyrinthine removal of vestibular schwannomas. MATERIAL: Includes all patients (43 operations in 42 patients) who had section of the vestibular nerve performed in the period from 1980 to 1996. Mean age was 51 years and the postoperative observation period varied from 2 to 15 years, mean 6.4 years. RESULTS: The vertigo was under control in 88% of the patients. Fourteen patients developed some imbalance after surgery caused by the abolished vestibular function in the ear involved. Thirty-nine patients indicated satisfaction with the operation, 92% retained their preoperative hearing. Only few and slight complications were seen, including two re-operations for CSF leaks and a slight transient facial nerve paresis. DISCUSSION AND CONCLUSIONS: The results are in accordance with those obtained by other authors, and retrosigmoid section of the vestibular nerves is an effective treatment of vertigo refractory to other treatment modalities. In order to reduce the patients' worries about undergoing an intracranial intervention it is important to inform the patients and patients' associations about the good results obtained by this treatment and in particular to inform about the very few complications. Due to the limited number of patients needing this treatment, and the need for surgical experience in order to maintain the favorable results, centralization of the treatment is mandatory.

Cochlear implantation of Danish prelingually deaf children.

The aim of the study was to review the indications, techniques and results of cochlear implant (CI) treatment with the Nucleus CI multi-channel electrode for the first children operated on in Denmark. The study material comprised 16 children (5 girls, 11 boys). Their median age at the time of CI operation was 27 months. Anacusis was caused by pneumococcal meningitis in 31% of the children in this relatively young prelingual material. Obliteration of the cochlea was found in two children, indicating the need for surgery as soon as possible after the verification of post-meningitis, total deafness. There were no technical difficulties with operating on the youngest children in the congenital group and the age of 2 years is optimal for implantation. These preliminary results have contributed definitively to an increase in the number of cochlear implantations being carried out in young prelingually deaf Danish children.

Primary speech restoration at laryngectomy by insertion of voice prosthesis--10 years experience.

A total of 88 patients underwent laryngectomy at the ENT Department, Gentofte University Hospital, Hellerup, Denmark, from May 1989 to May 1999. Of these, 85 patients underwent salvage operations for squamous cell laryngeal carcinoma after previous full course radiotherapy. A total of 76 patients had primary tracheo-oesophageal puncture performed at the time of laryngectomy, 11 had a secondary procedure performed, 7 of these had been laryngectomized elsewhere. Eight patients were not eligible for tracheo-oesophageal puncture due to age, social reasons or extensive surgery. In all, 79 patients were able to use the prosthesis for communicative purposes weeks after the operation and developed fluent speech. During the observation time, 14 patients had their voice prosthesis removed or disconnected for various reasons. The average life duration for Provox voice prosthesis generation I vs Provox generation II was 3.1 and 2.3 months, respectively.

[Treatment of malignant parotid tumors. Results from the county of Copenhagen]. / Behandling af maligne parotistumorer. Resultater fra københavns amt.

Out of 494 parotid gland tumours treated in Copenhagen county (population 600,000 inhabitants) in the period 1986 to 1995, 50 patients (tumours) were proven to be malignant, making an incidence of 0.62/100,000 per year. Age ranged between 14 and 87, mean 64 years. According to the UICC classification system, six tumours (12%) were classified as stage I, 23 (46%) as stage II, 14 (28%) as stage III and 7 (14%) in stage IV. Four therapeutic modalities were applied: surgery only, surgery + radiation, surgery + chemotherapy and surgery + chemotherapy + radiation. Surgical radicality was achieved in 76% and radicality was unrelated to tumour histology. Normal or nearly normal facial nerve function (HB1&2) was noted at last follow up in 60%. Five year crude survival for all patients were 68%. Survival was not depends on N-classification. Patients in stage I had a better survival compared to patients in stage II, III and IV. No statistically significant difference in five year crude survival between the radically operated patients (n = 38) and patients with residual tumour (p = 0.27, log rank-test), (p = 0.48 chi2-test was found.

[Diagnosis and growth evaluation of vestibular schwannomas by SPECT combined with TL-201 thallium]. / Vestibularis-schwannomers diagnostik og vaekst bedømt ved SPECT kombineret med TL-201 Thallium.

The value of SPECT scanning in diagnosis and growth potential of vestibular schwannoma (VS) was investigated in a series of 29 patients. SPECT demonstrated all tumours > 0.8 cm3, but had limitations as a diagnostic modality of small intracanalicular tumours, when compared to gadolinium DTPA enhanced MR. SPECT was found to be valuable in determining VS growth potential as it reflects tumour vascularity, which is essential for tumour growth. A high radioactive tracer uptake in the tumour corresponded to high tumour vascularity, indicating a high growth rate and vice versa. It seems that we now have an in vivo functional radiological modality capable of providing data on VS vascularity and determination of growth potential in the individual tumour.

[Intraoral cancer in the county of Copenhagen]. / Intraoral cancer i Københavns Amt.

A retrospective study of patients treated for intra-oral squamous cell carcinoma in Copenhagen county is reported. The material included 156 patients, 66 females and 90 males. Age at diagnosis varied between 35 and 95 years with a mean of 65 years. Mean age of females/males was 70/62 years. Twelve therapeutic modalities were performed; surgery, radiotherapy, chemotherapy and different combinations of these. Five year disease specific survival related to tumours' T-classification was 84% for T1, 35% for T2, 20% for T3 and 27% for T4. A statistically significant relation between the tumours' T-classification and the disease specific survival was noted (p < 0.00001). Five year disease specific survival related to N-classification was 62% for N0, 30% for N1, 25% for N2 and 0% for N3. Crude five year survival was 37% overall, 61% for patients in stage I, 32% for patients in stage II, 16% for patients in stage III and 17% for patients in stage IV. The results are similar to those achieved in other centres. Since no significant improvement has been noted in patient survival during the last five to six decades and since the therapeutic morbidity has not always been acceptable to the patients, other therapeutic principles, such as the so called minimal invasive therapy should be considered in future treatment of intra-oral cancer.

[Is the use of surgical microscope justified in thyroid surgery? 10-year experience with thyroid surgery performed by means of microsurgical technique]. / Har operationsmikroskopet sin berettigelse ved thyreoideakirurgi? Ti års erfaring med thyreoideakirurgi udført med mikrokirurgisk teknik.

Paralysis of the recurrent laryngeal nerve is the most disastrous complication following thyroid surgery. In order to minimize this complication, different devices have been used to identify the recurrent laryngeal nerve during surgery. The presently available devices are reviewed and we present our results with the device we used, the surgical microscope. Five hundred and seventy-three patients had thyroid surgery, 451 had benign lesions and 122 malignant. Calculated as nerves at risk, primary surgery in benign/malignant disease resulted in 0.6 per cent/3.5 per cent permanent paralysis and in recurrent and completion surgery this complication rate was 4.5 per cent/2.9 per cent. These results are pleasing but also stress that primary surgery should be radical so as to avoid completion or recurrent surgery.

[Cochlear implantation in children. The first Danish results]. / Cochleaimplantation hos børn. De første danske resultater.

The aim of this study is to review indication, technique and results of cochlear implant (CI) treatment with Nucleus CI-multi-electrode of the first ten children operated in Denmark (five children with congenital deafness and five with acquired prelingual deafness due to meningitis). In the literature, the importance of early referral and operation at the age 2-3 (4) years for congenital deafness and as soon as possible on suspicion of acquired deafness (meningitis) is stressed. A short survey of our indications, technique and rehabilitation is presented. The results of treatment after 11-44 months' use of CI are that one child has language almost matching age, four use words and short sentences accompanied by support signing, three have sound reaction and say single words without sentence building, but of these two children have only used CI for a very short time and are improving. Two meningitis sequelae cases had cochlear ossification, which made the implantation difficult. Both patients had to be operated, and one of them is not using the processor.

[Microsurgical laser treatment of Zenker's diverticulum. Economic aspects]. / Mikrokirurgisk laserbehandling af Zenkers divertikel. Okonomiske aspekter.

Zenker's diverticulum (hypopharyngeal/proximal oesophageal diverticulum/pouch) is a relatively uncommon cause of dysphagia usually in elderly patients. We describe the results of the first 10 patients operated for ZD with micro-endoscopic laserdiverticulotomy (LD), where the "spur" between the diverticulum and oesophagus is coagulated by means of a CO2 laser in our department. The results are compared with the results of the last nine patients operated with conventional diverticulectomy (DE) via incision on the neck. Two patients in the DE group had complications (wound infection and pneumonia), whereas no complications were seen in the LD group. An initially good result was seen in all the patients in both groups. Symptoms recurred in 11% in the DE group (one patient), whereas this was seen in 20% of the patients in the LD group (two patients). Re-operation of these two patients in the LD group relieved the patients of symptoms, but one patient was re-operated twice before this was achieved. Surgery time was reduced by 64%. Hospitalization time was shortened from a median of 16 (9-28) days with DE to 4 (0-9) days in the LD group. These factors represent a substantial economic saving by using LD as compared to DE. To be able to evaluate the result of LD roentgenographically, it has proven necessary to produce a pure lateral view of the diverticulum both pre- and post-operatively. The size and shape of the diverticulum is mostly seen as unchanged following surgery. With a pure lateral projection, it is however possible to see how the spur between the oesophagus and the diverticulum is diminished with resulting enhanced passage of contrast and practically no retention.

[Acoustic neurinomas/vestibular schwannomas. Diagnostic evidence vs. surgery]. / Acusticusneurinomer/vestibularisschwannomer. Observation versus kirurgi.

+-f having vestibular schwannoma (VS) was conducted in a series of 123 patients (127 tumours), over a 20 year-period from 1973 to 1993. Mean follow up period was 3.4 years, mean annual growth rate was 3.2 mm/year. Tumour growth was observed in 90 patients (94 tumours, 74%), no growth was seen in 23 patients (23 tumours, 18%) and negative tumour growth in 10 patients (10 tumours, 8%). Surgery due to tumour growth was performed in 35 patients (35 tumours, 28%). Seven patients (seven tumours, 6%) were treated with gamma radiation and/or shunt insertion. Seven patients (6%) died of brainstem herniation induced by tumour compression. Nine patients (7%) died of non tumour related causes. Twenty-eight patients were classified as candidates for hearing preservation surgery and 21 patients (75%) lost their candidature during the observation period due to tumour growth and/or deterioration of hearing. The results may limit indications for allocation of patients with VS to the "wait and see" group.

[Results of hearing preservation via middle fossa approach in surgery for acoustic neurinoma]. / Resultater af hørebevarende acusticusneurinomkirurgi via fossa media-adgang.

The results of hearing preservation surgery in a series of 10 patients with 10 unilateral acoustic neuromas are reported. Mortality was 0%, complications including rhinoliquorrhoea occurred in 10%, and the tumour was removed in 100%. Hearing preservation was obtained in 80%. Normal or nearly normal postoperative facial nerve function evaluated one year after surgery was achieved in all cases. According to House-Brackmann classification, 60% had HB-1 and 40% had HB-2. The fact that no audiovestibular or electrophysiological examinations are specific for acoustic neuroma can not be overemphasized. Early diagnosis of these small tumors in patients with good hearing has made this kind of surgery possible.

[Reversible hearing loss in the contralateral ear after surgery of acoustic neurinoma]. / Reversibel hørenedsaettelse på det raske øre efter operation for acusticusneurinom.

In a prospective study of 12 patients undergoing operation for acoustic neuromas, the hearing on the contralateral ear was tested before and systematically after operation. In 11 cases a perceptive loss of at least 20 dB was found at one or more frequencies during the first two postoperative weeks. The maximal average threshold decrease was 16.5 dB in the treble and 19.6 in the low frequencies. After three months the hearing had normalized in all cases. The loss of cerebrospinal fluid during operation diminishes the CSF pressure, which is then transmitted to the perilymph via the cochlear aqueduct, producing a transitory perilymphatic hypotonia and a relative endolymphatic hypertension mimicking an endolymphatic hydrops.

[Speech rehabilitation after laryngectomy, primary insertion of a speech ventilator]. / Talerehabilitering efter laryngektomi, primaer isaetning af taleventil.

During a period of three years, 30 patients were submitted to laryngectomy in our department. In 23 of these, primary tracho-oesophageal puncture had been performed and secondary puncture was performed in one patient. Fifteen of the prostheses were of the Blom Singer type and nine were Provox prostheses. Twenty-one patients learned to use the voice prosthesis and obtained fluent or understandable speech while three patients never used the prosthesis. Three patients subsequently abandoned the speech prosthesis and preferred to continue using oesophageal speech. Side effects were restricted to leakage around the prosthesis and slight stenosis in the pharyngo-oesophageal segment.

[Acoustic neurinomas in Denmark. Incidence and therapeutic strategies]. / Acusticusneurinomer i Danmark. Incidens og behandlingsstrategier.

The annual incidence of diagnosed acoustic neurinomas in Denmark during two 7-year-periods from mid 1976 to mid 1990 is compared. Data on all patients operated via the translabyrinthine, transtemporal and suboccipital approach, as well as data on non-operated patients, was collected from the entire country. During the first period, from June 1976 to June 1983, the incidence was 7.8 tumors per million per year. During the second period, from June 1983 to June 1990, the annual incidence rose to 9.4 tumors per million per year. The number of newly-diagnosed small tumors increased, and that of large tumors decreased. A significant increase was observed in Copenhagen. An incidence of 11 to 12 tumors per million per year, or nearly 60 newly-diagnosed tumors per year is thus expected around the year 2000. This limited number supports the continuation of the present centralized model of acoustic neurinoma surgery in Denmark.

[Results of suboccipital removal of acoustic neurinomas in Denmark 1979-1990]. / Resultater af suboccipital acusticusneurinomfjernelse i Danmark 1979-1990.

In the period from 1979 to 1990, a series of 59 patients with 59 acoustic neuromas were operated upon in five departments of neurosurgery by at least five different neurosurgical teams, employing the suboccipital approach. The perioperative mortality rate was 8.5%. Complications including hematoma, ventricular hemorrhage, meningitis, hemiparalysis, abducens nerve paralysis, recurrent nerve paralysis, postoperative wound infection and CSF leak were observed in 21 patients (35.6%). Radical removal of the tumor was not possible in 17 patients (28.8%). Converting the postoperative facial nerve function to the House-Brackmann (HB) classification, 34 patients (57.6%) were regarded as HB VI. Reconstruction of the facial nerve was attempted in 19 patients (32.2%). Attempts at preservation of hearing were unsuccessful in all patients. Failure to attain better results and the importance of the centralized Danish model of acoustic neuroma surgery are emphasized.

[False-positive diagnostic findings in acoustic neurinomas]. / Falsk positiv diagnostik ved acusticusneurinomer.

In the period from 1976 to 1990 Tos and Thomsen operated on 520 patients with acoustic neuromas using the translabyrinthine approach and five other patients were operated on via middle fossa approach. The diagnostic work up in all patients included: pure tone audiometry, tympanogram with acoustic reflexes, caloric test and brainstem audiometry. Since the late seventies, CT became the radiological investigation of choice to visualize the tumor. The first generation of CT failed to reveal tumors less than 1.5 cm in the extrameatal diameter, and pantopaque cisternography was necessary in some cases. The following generation of CT did not always reveal small intrameatal tumors, and false-negative results were reported. The incidence of false-positive CT findings in our series is calculated to be 0.6%. Three patients were operated on on account of false-positive CT. Peroperatively, adhesions in and around the internal porus were found in two cases while no pathology was found in the third case. Postoperatively, anacusis was observed in two cases. This could have been avoided if magnetic resonance imaging (MRI) with gadolinium contrast had been performed. In our opinion, MRI should be considered before a definitive surgical procedure is undertaken. Until MRI becomes more widely available, intravenous contrast-enhanced tomography followed by air cisternography is recommended in the diagnosis of small acoustic neuromas.

[Parapharyngeal abscess as the cause of torticollis]. / Parafaryngeal absces som årsag til torticollis.

The combination of parapharyngeal abscess and torticollis in an adult on account of spastic contraction of the sterno-cleido-mastoid muscle is an extremely rare condition. The present authors have recently observed a case of this type where the diagnosis was difficult to establish. CT of the neck revealed the diagnosis with no difficulty. The indication for CT at an early stage in cases of unexplained neck infections is stressed.