[Topical application of tranexamic acid to prevent post-tonsillectomy haemorrhage]. / Topische Anwendung von Tranexamsäure zur Prophylaxe von Nachblutungen nach Tonsillektomie.

BACKGROUND: Haemorrhage after tonsillectomy (TE) is a frequent and possibly major complication. The aim of the present study was to examine, if the rate of haemorrhage after tonsillectomy could be reduced by the topical application of Tranexamic acid (TXA) postoperatively. MATERIAL AND METHODS: Between November 2011 and April 2013, all patients (n=246) received TXA postoperatively to prevent haemorrhage after TE. The patients were instructed to dilute 1 ampulla of TXA in 300 ml of tap water (concentration 0.2%) from postoperative day 5-10 and to gargle or spray the tonsillar fossae 5-6 times daily. The study group was compared retrospectively with a control group of patients undergoing TE with-out postoperative application of TXA from December 2010 to November 2011 (n=248). RESULTS: The overall rate of postoperative haemorrhage was 19% and 22% in the study and control group, respectively. The rate of postoperative bleeding that needed surgical intervention was at 8.9% and 11.3% in the study and control group, respectively. Topical application of TXA did not significantly reduce the rate of postoperative haemorrhage after TE. CONCLUSION: Topically applied TXA did not reduce postoperative haemorrhage after TE. However, a slight tendency to less bleeding which needed surgical intervention was found in pa-tients older than ≥ 12 years.

[Does CT-navigation improve the outcome of functional endonasal sinus surgery?]. / Verbessert die CT-Navigation bei Nasennebenhöhleneingriffen das Operationsergebnis?

INTRODUCTION: Computer-assisted surgery (CAS) has found widespread use in functional endonasal sinus surgery (FESS) over the past few years. The present study investigates if CAS leads to a better outcome in FESS. MATERIAL AND METHODS: All patients who underwent endonasal sphenoethmoidectomy were enrolled in a prospective, non-randomized study. The procedures were done without CAS (group A) in 2003 and in 2004 with CAS (group B), using a Stryker navigation unit. 62 patients (113 sphenoidectomies) were included in group A and 61 patients (109 sphenoidectomies) in group B. The underlying disease was recurrent chronic sinusitis or polyposis nasi in all patients except for inverted papilloma in one patient of group A and in two patients of group B. The follow-up period was 6 months. Preoperatively and at 6 months postoperatively, a CT-scan was obtained and symptom scores were assessed using a questionnaire. RESULTS: No significant difference was found between group A and B with respect to symptom scores, and CT-scans preoperatively and at 6 months postoperatively. The operation strategy did not change by the introduction of CAS. The frontal sinus was entered in group A and B in 59% and 64%, respectively. All parameters significantly improved postoperatively, compared to the preoperative values. As far as complications are concerned, two anterior orbital injuries and one retrobulbar haematoma occurred in group A and one postoperative lacrimal stenosis in group B. CONCLUSIONS: CAS does not lead to a better clinical outcome in FESS. Our data suggest that the rate of complications may be reduced using CAS. However, studies with a much larger number of patients would be necessary for a definite answer to this issue.

Modification of the Hörmann technique of hyoid suspension in obstructive sleep apnoea.

Hyoid suspension is a procedure to stabilise the retrolingual space in obstructive sleep apnoea. Using the Hörmann technique, a steel wire is slung around the body of the hyoid and fixed to the upper rim of the thyroid cartilage. It was observed, however, that the steel wire may lie very superficially to the pharyngeal mucosa. Evaluation of computed tomography (CT) scans showed a mean distance between the hyoid and the pharynx of only 3 mm. A modification is presented by threading a steel wire through a hole that is drilled through the hyoid bone. Thus pharyngeal exposure of the steel ligature and possible perforation of the mucosa is avoided.

[Influence of intraoperatively applied current of coagulation on the postoperative course in tonsillectomy]. / Der Einfluss des bipolaren Koagulationsstromes bei der Tonsillektomie auf den postoperativen Heilungsverlauf.

BACKGROUND AND METHODS: Postoperative pain after tonsillectomy is greater using diathermy compared to the use of ligatures for hemostasis. In the present paper, the influence of coagulation current on the postoperative course is assessed quantitatively. The applied coagulation current was registered in Watt per second (Ws) in 63 patients. Intraoperative blood loss, operation time, experience of the surgeon, postoperative pain and the consumption of analgesics were registered. RESULTS: The mean intraoperative blood loss was correlated to the amount of applied coagulation current. Operation time was reduced with increased coagulation current. The energy of the applied coagulation current correlated significantly with pain in the late postoperative period. There was no influence in the amount of coagulation current on the consumption of analgesics or postoperative hemorrhage. Blood loss was less and operation time was shorter with more experienced surgeons. Six secondary postoperative hemorrhages were observed. Hemorrhage occurred more often with inexperienced surgeons. The applied coagulation current was, however, not dependent on the surgeon's experience but on his individual technique for intraoperative control of hemostasis. CONCLUSIONS: Pain following tonsillectomy is related to the amount of intraoperatively applied coagulation current, especially in the late postoperative course (days 10 - 14). This may be explained by tissue damage and increased eschar due to coagulation. Careful and reserved use of intraoperative coagulation will reduce postoperative pain.

[Sinonasal hemangiopericytoma]. / Das sinunasale Hämangioperizytom.

Hemangiopericytomas are rare perivascular tumors. The nasal cavity and paranasal sinuses are most often involved in the head and neck region. A case of hemangiopericytoma in a 63 year old patient is presented. The initial symptom was recurrent bleeding from the nose. The patient had a history of radiotherapy for a pituitary adenoma 30 years previously. Computed tomography and magnetic resonance imaging showed a polypoid opacification of the ethmoid, sphenoid and basal aspects of the frontal sinus on the right side. Histological diagnosis was obtained from nasal biopsy. Preoperatively, arteriography and tumor embolisation were performed. The tumor was completely excised using a combined endonasal and external approach as an osteoplastic revision of the frontal sinus via bicoronal incision. There was no recurrence at follow-up 1 year later.

Evaluation of persistent torticollis following adenoidectomy.

Post-operative neck complaints are not an uncommon finding following adenotonsillectomy. However, non-traumatic subluxation of the atlantoaxial joint (Grisel's syndrome) should be considered in cases of persistent neck pain and stiffness. An early diagnosis and adequate treatment of this rare condition is mandatory to prevent potentially serious complications. We describe three cases with persistent torticollis in the post-operative period, discuss the pathogenesis and evaluate the clinical management of these patients.

[Experiences with the treatment of vascular malformations using the Nd-YAG laser]. / Erfahrungen in der Behandlung von vaskulären Malformationen mit dem Nd-YAG-Laser.

Lasers have been used for about 15 years in the treatment of vascular malformations and haemangiomas in the head and neck area. The physical properties of the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser system make it particularly suitable for this purpose. We review our first experience with the treatment of vascular malformations using the Nd-YAG-laser. 9 Patients with 10 vascular malformations were treated. A complete remission was achieved with 9 of the 10 vascular malformations and a partial remission with the remaining case. No complications were observed. The neodymium:yttrium-aluminum-garnet (Nd:YAG) laser therapy has proven itself as simple to use, being highly effective and having a low complication rate.

Choanal atresia in premature dizygotic twins--a transnasal approach with Holmium:YAG-laser.

Twins born prematurely presented with choanal atresia and were successfully treated using a transnasal, endoscopically and microscopically controlled Ho:YAG-Laser assisted technique. One twin, who had bilateral choanal atresia was operated immediately, the other one, with unilateral choanal atresia, received surgery 8 months after birth. The rare feature of twins both suffering from choanal atresia and a technique for definitive treatment of this disease in premature neonates are presented and discussed. This report of dizygotic twins with nonsyndromal choanal atresia suggests the possibility of an autosomal recessive inheritance with various penetration or an undefined teratogenic etiologic factor.

[Detection of central auditory compensation in unilateral deafness with functional magnetic resonance tomography]. / Nachweis zentral-auditiver Kompensationsvorgänge bei einseitiger Ertaubung mit funktioneller Magnetresonanztomographie.

BACKGROUND: Functional magnetic resonance imaging (fMRI) is a noninvasive method to detect focal brain activity at high spatial resolution. Acoustic stimulation induces an increase of regional cerebral blood flow in the primary auditory cortex. This entails an increased concentration of diamagnetic oxyhemoglobin in the capillaries and the venous system. The resulting decrease of the local magnetic susceptibility was detected as a signal increase in T2*-weighted images. The central auditory pathways predominantly cross to the contralateral hemisphere in normally hearing subjects. The aim of the present study was to investigate the primary auditory cortex after acoustic stimulation in unilateral deaf patients using fMRI. METHODS: Magnetic resonance images were acquired on a 1.5 T Siemens Vision scanner. For fMRI, a single shot gradient recalled, echo planar imaging (EPI) sequence with decreasing excitation order was used, allowing the aquisition of 9 slices within 1.8 s. The 9 slices covered a slab of 3.6 cm in cranio-caudal extension in the region of the temporal lobes. For statistical processing of the raw image data the SPM96 software package was used. A p-value of p < 0.01 was applied to differentiate between activated and non-activated. The resulting functional activation maps were superimposed onto the EPI scan. The number of activated pixels was used to quantitate the cortical response upon acoustic stimulation. Stimulation consisted of a 1000-Hz sine tone (100 dB SPL at the distal end of the head phone, pulsed at 6 Hz) to which the patients were asked to listen passively. A piezoelectric loudspeaker was mounted on the subject table and connected to a plastic tube system leading to a combination of bilateral ear- and headphones. Auditory paradigms require disentangling experimental excitation from the scanner noise that approximates 90 dB. Headphones suppress noise by approximately 30 dB. To decrease the acoustic background-to-stimulation ratio and to keep background noise constant during stimulation and resting, we employed short scanning (1.8 s) and long resting periods (10.2 s; TR = 12 s). This acquisition mode allows sufficient recovery during off-periods and sufficient excitation during on-periods. 14 unilateral deaf patients were examined. The mean duration of deafness was 22.5 years. RESULTS: Acoustic stimulation of the deaf ear revealed only weak cortical activation which could be explained by sound transmission via bone conduction to the other ear. A significant increase of BOLD (blood oxygen level dependent)-activation in the primary auditory cortex could be demonstrated in all patients after stimulation of the hearing ear. However, remarkable individual differences were noticed concerning the absolute number of activated pixels. The lateralization ratio was calculated by the number of activated pixels on the hearing side divided by the number of activated pixels on the deaf side. A mean lateralization ratio of 0.9 (Stdv +/- 0.6) was found. The mean lateralization ratio for patients with a right deaf ear (n = 8) and those with a left deaf ear (n = 5) was 1.1 (Stdv +/- 0.7) and 0.6 (Stdv +/- 0.3) respectively. However, the difference was not significant (Wilcoxon test: p = 0.08). CONCLUSIONS: Central-auditory compensation by bilateral cortical activation was demonstrated in unilateral deaf patients. Moreover, a tendency towards a dominance of the left primary auditory cortex was found, although the difference between both hemispheres was not significant. The lateralization ratio in unilateral deaf patients is similar to findings after binaural stimulation in normally hearing subjects.

[Visualization of central auditory processes with functional magnetic resonance tomography]. / Visualisierung zentral-auditiver Prozesse mit funktioneller Magnetresonanztomographie.

BACKGROUND: Central auditory processes can be visualized using functional MRI in a non-invasive manner and at high spatial resolution. Acoustic stimulation leads to an increase of blood flow of activated areas in the plane of the superior temporal gyrus. Radiologically, this may be visualized based on the long T2-relaxation time of oxyhemoglobin. PATIENTS: Ten normal-hearing subjects with ages between 28 and 38 years took part in the investigations. They received binaural, monaural right, and monaural left stimulation with pulsed sine tones of 1000 Hz at a pulse rate of 6 Hz and a sound pressure level of 100 dB SPL. Tonotopic organization of the auditory cortex was visualized using stimulation by pulsed sine tones of 500 Hz and 4000 Hz. RESULTS: Following monaural acoustic stimulation, increased activity of the contralateral auditory cortex could be demonstrated in 9 subjects. In one subject, bilateral activity was noted. Concerning the tonotopic organization of the auditory cortex, we could show that the higher frequencies were localized more medially and anteriorly; the lower frequencies were localized more laterally and posteriorly in the superior temporal gyrus. However, considerable overlap was noted. CONCLUSIONS: The overlap of the different frequencies could explain the controversial discussion of the tonotopic organization of the auditory cortex. The results of the monaural acoustic stimulation show clearly the predominant signal increase of contralateral areas in the primary auditory cortex. These results confirm the opinion of the current textbooks that the fiber of the auditory pathways mostly cross. Further investigations using functional MRI are necessary for better understanding of physiological and pathophysiological central-auditory processes.

Auditory cortical responses in hearing subjects and unilateral deaf patients as detected by functional magnetic resonance imaging.

Functional magnetic resonance imaging is a non-invasive method for the detection of focal brain activity at high spatial resolution. Acoustic stimulation leads to a blood oxygenation level dependent signal change in the plane of the superior temporal gyrus. The dependence of this response in the auditory cortex on binaural, monaural left and monaural right acoustic stimulation for 10 healthy subjects and five monaural deaf patients is described. Acoustic stimulation consists of 1000 Hz pulsed sine tones at a pulse rate of 6 Hz and a sound pressure level of 95 dB. For monaural stimulation, normal-hearing subjects revealed a strong lateralization of cortical response towards the contralateral hemisphere. The lateralization ratios between left and right hemispheric response areas were 3.4-5.2 for monaural stimulation and nearly balanced for binaural stimulation. Additionally, the sum of cortical activation volumes induced by monaural left and right stimulation was approximately 30% smaller than for binaural stimulation, indicating either inhibitory mechanisms or neuronal facilitation within the auditory pathways. For monaural deaf subjects the lateralization ratio between left to right response was just 1.3 towards the contralateral hemisphere of the healthy ear, which is comparable to binaural responses of normal-hearing subjects. This observation seems to indicate a plasticity or a reorganization of auditory pathways of monaural deaf patients.

Tonotopic organization of the human auditory cortex as detected by BOLD-FMRI.

Functional magnetic resonance imaging is a noninvasive and nonradioactive method for the detection of focal brain activity. In the present study the auditory cortex was investigated in nine normal subjects who were binaurally stimulated using pulsed sine tones of 500 Hz and 4000 Hz. The BOLD (blood oxygenation level dependent) signal change coincided with the stimulation paradigm and was detected in the plane of the superior temporal gyrus. The comparison of the spatial distribution of activated areas revealed a different behavior for the two frequencies. The present findings underline the existence of a frequency specific organization in the medio-lateral, fronto-occipital and cranio-caudal extension in both hemispheres of the auditory cortex in human. The activated areas for the high tone were found more frontally and medially orientated than the low tone stimulated areas. Furthermore, a slight cranio-caudal shift was observed for the higher frequency, more pronounced in the right than in the left temporal lobe. Finally, for most of the subjects investigated the BOLD activation area of the 500 Hz sine tone was larger than that of the 4000 Hz stimulation. Both frequencies showed a lateralization of signal response to the left temporal lobe.

[Local infiltration of epinephrine and bupivacaine before tonsillectomy]. / Zur lokalen Infiltration von Epinephrin und Bupivacain vor Tonsillektomie.

The effects of peritonsillar injections of epinephrine and local anesthetics before tonsillectomy on blood loss and postoperative pain were evaluated in a prospective, randomized double-blind trial on 103 children. Patients were randomly assigned into one of three groups: controls given injections of 0.9% NaCl (n = 34), patients injected with 0.4 ml/kg (1:200,000) epinephrine combined with 0.25% bupivacaine (n = 33) and patients given only 1:200,000 epinephrine (n = 36). All injections and operations were performed by the same surgeon (KS). Blood loss was calculated by weighing all blood aspirated perioperatively and swabs used during surgery. Postoperative pain was assessed at regular intervals by using three methods: (1) use of a visual analogue scale by parents and nurses to estimate pain; (2) postoperative need for nalbuphine as analgesic; (3) the Hannallah-Broadman semi-objective pain score (including crying, anxiety, restlessness, and changes in blood pressure). The mean blood loss in the control group (given NaCl) was 132 g, which was significantly increased when compared with the epinephrine/bupivacaine group (85 g) and the group treated with only epinephrine (90 g). However, analysis of the postoperative pain scores did not reveal any significant differences among groups. These findings indicate that the peritonsillar injection of bupivacaine does not decrease postoperative pain, but peritonsillar injections of epinephrine will significantly reduce blood loss during tonsillectomy.

Local injection therapy in 107 patients with myofascial pain syndrome of the head and neck.

Myofascial pain syndrome of the head and neck is a frequent cause of facial pain and is characterized by tender trigger points. In a double-blind study of 107 patients, local injection therapy using one of three solutions was applied at the trigger points by intracutaneous injection of 0.3 ml solution followed by deep infiltration of the site. Results using bupivacaine 0.25%, lignocaine 1% and saline 0.9% were compared. There was no significant difference among groups with respect to reduction of pain and overall rating by patients of the therapeutic benefits. Fifty-three patients (49%) were free of symptoms after treatment, 40 patients (38%) reported substantial relief and in 14 patients (13%) symptoms remained unchanged. The findings suggest that relief of pain is mainly due to reflex mechanisms rather than to the pharmacological effects of the injected solutions. Physiological saline solution is recommended for use in local injection therapy.

[The context effect in speech recognition of sentences]. / Der Kontexteffekt bei der Spracherkennung von Sätzen.

Context plays an important role in speech recognition. The goal of the present study was to quantify context effects in speech recognition using the Basel Sentence Understanding Test. This test consists of two types of sentences according to the amount of contextual information: sentences with high predictable (HP) final words and sentences with low predictable (LP) final words. The effect of different contextual situations on speech recognition was investigated in this study using the Basel Sentence Understanding Test. The speech recognition threshold of HP sentences was found to be 6 dB lower than that of LP sentences. However, contextual effects can only be demonstrated if the context is clearly understandable. In the Basel Sentence Understanding Test, this is achieved by special masking techniques. The significance of the contextual part of the sentence with respect to the recognition of the whole sentence is different in HP and LP sentences.

[Context effects in speech recognition of sentences]. / Der Kontexteffekt bei der Spracherkennung von Sätzen.

Context plays an important role in speech recognition. The goal of the present study was to quantify context effects in speech recognition using the Basle Sentence Understanding Test. This test consists of two types of sentences according to the amount of contextual information: they contain sentences with highly predictable (HP) final words and sentences with low predictable (LP) final words. The effect of different contextual situations on speech recognition was investigated in this study using the Basle Sentence Understanding Test. The speech recognition threshold of HP sentences was found to be 6 dB lower than that of LP sentences. However, contextual effects can only be demonstrated if the context is clearly understandable. In the Basle Sentence Understanding Test, this is achieved by special masking techniques. The significance of the recognition of the contextual part of the sentence with respect to the recognition of the whole sentence is different in HP and LP sentences.

[Effect of linguistic competence on speech audiometry results using the Basel Sentence Test]. / Einfluss der linguistischen Kompetenz auf die sprachaudiometrischen Ergebnisse mit dem Basler Satztest.

Linguistic competence, such as a mental lexicon knowledge of syntactic rules of the language and the use of semantic constraints, may impact central speech processing and play an important role in speech recognition. The influence of linguistic ability on speech understanding was investigated using the Basel Sentence Understanding Test. The subject's linguistic ability was determined based upon educational background (elementary school, high school and or university) and intelligence quotients (IQ) based on the reduced version of the Hamburg-Wechsler Intelligence Test. Forty normally-hearing subjects listened to five test forms of the Basel Sentence Understanding Test. Each test form comprised a fraction of 15 low-predictable (LP) test items and 15 high-predictable (HP) test items based on the amount of contextual information in the phrases. No effect of educational background and IQ-value could be demonstrated on the scores of LP sentences. However, there was a small but significant influence of educational background and IQ-value on the scores of HP sentences. The implications of these findings on clinical speech audiometry are discussed.

Allergic contact dermatitis from tixocortol pivalate in a nasal spray masquerading as infectious complication of sinusitis.

Allergic contact dermatitis to corticosteroids is not uncommon and is increasingly reported. Contact allergy to nasal corticosteroids is rare and may present with atypical symptoms, which may be confused with infectious complications. We report on a patient in whom the misinterpretation of her allergic nasal symptoms to the corticosteroid tixocortol pivalate resulted in hospitalization and considerable medical expenses.

[New aspects in surgery of the thyroid gland with intraoperative monitoring of the recurrent laryngeal nerve]. / Neue Aspekte in der Schilddrüsenchirurgie mit dem intraoperativen monitoring des N. laryngeus recurrens.

A method for electrophysiological monitoring of the recurrent laryngeal nerve during thyroid surgery is described. An electromyographic record from the muscles of the vocal folds is obtained using two fine needle electrodes. The electrodes are placed endoscopically. The nerve is identified by electrical stimulation, and the electromyographic activity is registered using a Nerve Integrity Monitor NIM-2 (Xomed-Treace). Our experience with this method in 43 patients is described. The safety of the integrity of the recurrent laryngeal nerve is increased using intraoperative monitoring. This has led to a modification of the operative concept in thyroid surgery. Electrophysiological monitoring is mandatory in surgery of large goitres, retrotracheal and substernal extension, for re-operations and malignant diseases of the thyroid gland.