Vascular Malformations of the Head and Neck in Children.

BACKGROUND/AIM: Vascular malformations are congenital abnormalities that result from disturbances in the embryologic development of the vascular system. A retrospective study at a single institution was performed to determine the localization and treatment patterns for vascular malformations in children. PATIENTS AND METHODS: A total of 198 pediatric patients were identified. Age at diagnosis and presentation, sex, localization, diagnostics, and therapy were described. RESULTS: The most common diagnosis was lymphatic malformation (LM, 58.6%), followed by venous (VM, 31.8%) and arteriovenous malformation (AVM, 4.5%). The mean age at diagnosis was 2.2 years, while the mean age at presentation at our hospital was 7.2 years. The sex ratio showed a female predominance (1.44:1), which was most evident in children with AVM. The neck, cheek/parotid gland and oral cavity were the most predominant locations. Half of the patients required at least one intervention at our hospital. Especially, CM and LM were managed by watch-and wait, whereas lymphovenous malformation (LVM) and AVM were most often treated. Treatment differed between the various malformation types, the most common used treatment was conventional surgery followed by laser therapy. In case of treatment, the average number of procedures in our hospital was 1.58 for VM, 1.53 for LM, 1.33 for AVM, and 1.0 for LVM. CONCLUSION: In children with vascular malformations interventional treatment is often necessary, in many cases more than one treatment step is needed. Correct identification of the malformation type is important for optimal treatment and appropriate care of patients with vascular malformations.

[Analysis of the emergency patients of a university ENT hospital]. / Analyse der Notfallpatienten einer Universitäts-HNO-Notfallambulanz.

OBJECTIVE: The number of patients visiting emergency departments has substantially increased in recent years. The time of visiting an emergency room does not say anything about the true urgency of the treatment. The aim was to analyse the patient population of the emergency outpatient department of a university ENT hospital. METHODS: All patients presenting as an emergency in an ENT university hospital in 2014 were evaluated with regard to demographic data, time of presentation, type of admission, diagnosis and therapy. RESULTS: 4234 patients were treated as emergencies. 56 % presented without referral on their own initiative, 24 % were referred by the general practitioner or ENT specialist, 8 % came by ambulance. 66 % presented outside regular working hours. The highest number of emergencies occurred on Saturdays, followed by Fridays and Sundays. The ten most frequent diagnoses were epistaxis, peripheral-vestibular vertigo, cerumen, tinnitus, otitis externa and media, tonsillitis, nasal bone fracture, acute hearing loss and sinusitis. 715 patients (17 %) were admitted to hospital. In 123 patients surgery was performed under general and in 204 patients under local anesthesia. The most frequent diagnosis of patients presented on their own initiative was cerumen obturans. 8 % presented on their own initiative did not show any pathological findings. CONCLUSION: As there is no ENT emergency service available in the region outside normal office hours, this gap is closed by the emergency outpatient department of the ENT University Hospital. A triage of the patients is necessary in order to distinguish the real emergencies from the easy cases.

The laryngeal disease of the German Emperor Friedrich III: treatment failure or fateful course.

BACKGROUND: Since the death of the Emperor Friedrich III in June 1888, there are still controversial discussions whether the Crown Prince could have been healed from his laryngeal cancer by a thyrotomy planned by his German physicians for May 21, 1887. METHODS: In order to find an answer to this historical question, the Emperor's biographies, the literature on laryngology published in the late nineteenth and early twentieth century, German manuals on laryngology and ENT, the BMJ and Lancet were thoroughly studied where in particular not only Mackenzie but also Virchow had published several articles on the disease of Friedrich III. RESULTS: Prof. Gerhardt had decided not to perform biopsies of the tumor. Furthermore, he did not perform iodine potassium treatment ex juvantibus as it was common practice at that time in order to confirm the diagnosis of carcinoma by excluding syphilitic gumma. So Mackenzie was perfectly right when insisting on performing excisional biopsy before surgery. It is tragedy that Virchow by making the diagnosis of pachydermia laryngis provided the justification for canceling the surgical intervention that had already been decided. It was also mistake that Prof. Gerhardt did not accompany the Crown Prince during his stay in England in summer 1887. The authority of the delegated medical officer Dr. Landgraf did not suffice to persuade Mackenzie to discuss again the matter of performing surgery together with Gerhardt and von Bergmann. The drawings made by Dr. Landgraf show an impressive tumor growth. The refusal of new consultations with Gerhardt and von Bergmann by Mackenzie can only be explained by the fact that Mackenzie was generally against such a surgical intervention. Regarding the question of the chances of such a surgery it can be said that thyrotomy and laryngectomy had been refused by the majority of laryngologists since the Congress of London in 1881 and the publication of P. v. Bruns in 1878. In Berlin, however, the improvement of surgical and anesthetic techniques by E. Hahn led to a positive opinion. F. Semon, who had strictly refused thyrotomy until 1886, supported the indication of thyrotomy of the Crown Prince since Hahn had successfully operated one of his patients in London. So the chance of healing a limited carcinoma of the vocal folds by thyrotomy was given. However, it may be questioned if partial resection had the desired outcome. The limited mobility of the left vocal fold that had been diagnosed already in May 1887 indicates that probably laryngectomy would have been necessary. The prognosis of this procedure, however, was extremely poor at that time. It is irony of history that T. Gluck who performed the separation of the airways from the digestive pathways in an animal model already in 1880 under von Langenbeck could not further develop his technique under von Bergmann. CONCLUSIONS: The Crown Prince acquired his disease at a time when the acceptance of surgical treatment of laryngeal carcinomas had reached its lowest point. Ten years later, the technique of thyrotomy was successfully established by Hahn, Butlin, and Semon so that Morell Mackenzie would probably have agreed to the intervention. Ten years later, due to Gluck and Sörensen, even the technique of laryngectomy had reached the performance that is still valid today so that the Emperor could have been treated successfully even with an advanced laryngeal carcinoma.

Effect of training frequency on the learning curve on the da Vinci Skills Simulator.

BACKGROUND: The purpose of this study was to evaluate the effect of training on the performance outcome with the da Vinci Skills Simulator. METHODS: Forty novices were enrolled in a prospective training curriculum. Participants were separated into 2 groups. Group 1 performed 4 training sessions and group 2 had 2 training sessions over a 4-week period. Five exercises were performed 3 times consecutively. On the last training day, a new exercise was added. RESULTS: A significant skills gain from the first to the final practice day in overall performance, time to complete, and economy of motion was seen for both groups. Group 1 had a significantly better outcome in overall performance, time to complete, and economy of motion in all exercises. There was no significant difference found regarding the new exercise in group 1 versus group 2 in nearly all parameters. CONCLUSION: Longer time distances between training sessions are assumed to play a secondary role, whereas total repetition frequency is crucial for improvement of technical performance. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1762-E1769, 2016.

Cervical lymph node metastases from remote primary tumor sites.

Although most malignant lymphadenopathy in the neck represent lymphomas or metastases from head and neck primary tumors, occasionally, metastatic disease from remote, usually infraclavicular, sites presents as cervical lymphadenopathy with or without an obvious primary tumor. In general, these tumors metastasize to supraclavicular lymph nodes, but occasionally may present at an isolated higher neck level. A search for the primary tumor includes information gained by histology, immunohistochemistry, and evaluation of molecular markers that may be unique to the primary tumor site. In addition, 18F-fluoro-2-deoxyglocose positron emission tomography combined with CT (FDG-PET/CT) has greatly improved the ability to detect the location of an unknown primary tumor, particularly when in a remote location. Although cervical metastatic disease from a remote primary site is often incurable, there are situations in which meaningful survival can be achieved with appropriate local treatment. Management is quite complex and requires a truly multidisciplinary approach. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2374-E2385, 2016.

Survival After Distant Metastasis in Head and Neck Cancer.

BACKGROUND/AIM: In addition to locoregional recurrence distant metastases can limit the survival of patients with head and neck cancer. The aim of the study was to analyze survival after distant metastasis of head and neck cancer. PATIENTS AND METHODS: Patients with head and neck cancer and M0 status at initial diagnosis, who were treated with curative intent but developed distant metastases without synchronous locoregional recurrence were analyzed. Predictors for the duration of survival were evaluated using Cox regression analysis. RESULTS: A total of 46 patients developed distant metastases which were detected after a mean time of 16 months, most were lung (59%) and bone metastases (24%). The most common therapy for distant metastasis was palliative chemotherapy; due to poor general condition, 21% of patients were treated with best supportive care. The mean survival was 7.5 months, the overall survival at 1 and 2 years after diagnosis of distant metastasis were 40.4% and 26.2%, respectively. Regression analysis showed no significant predictors for prolonged survival, however, the three patients surviving at the time of data collection were treated by surgical resection of solitary metastases. CONCLUSION: In cases of distant metastases, due to poor prognosis of the patients, palliation is important and the treatment approach should be chosen taking into account the general condition of the patient. In individual cases, resection of solitary metastases may be useful.

Indications of cone beam CT in head and neck imaging.

CONCLUSION: Cone Beam Computed Tomography (CBCT) can be widely used in imaging of bony structures of the anterior and lateral skull base. Significant differences of applied dosages result from the different protocols of the various indications. OBJECTIVES: CBCT is increasingly being used in head and neck imaging. Until now, no precise knowledge about its dedicated usage existed. METHODS: All CBCT of 2012 and 2013 were analysed with regard to the technical parameters, the performance, and the indication for imaging. RESULTS: In total, 1862 patients were examined in 2012 and 2013. The top eight indications of the anterior skull were (1) chronic rhinosinusitis with disturbed nasal breathing (30.3%); (2) chronic rhinosinusitis (17.6%); (3) midfacial traumatology (13.7%); (4) disturbed nasal breathing (12.8%); (5) acute rhinosinusitis (7.9%); (6) polyposis nasi (6.3%); (7) search for focus (3.9%); and (8) persistent rhinorrhea (1.2%). For the lateral skull base, the top eight were (1) control after cochlear implantation (28.4%); (2) cholesteatoma (19.7%); (3) visualization of ear anatomy (8.7%); (4) chronic otitis media mesotympanalis (6.3%); (5) conductive hearing loss (5.1%); (6) suspected mastoiditis (4.8%); (7) pathology of external auditory canal (4.8%); and (8) otosclerosis (3.3%). Applied dosage for the anterior skull base was significantly lower than for the lateral skull base (2.90 mGy vs 5.92 mGy, p < 0.05); 2.4% and 3.6% of patients' images, respectively, had to be repeated.

Transoral surgery for oropharyngeal tumors using the Medrobotics(®) Flex(®) System - a case report.

INTRODUCTION: Transoral resection of pharyngeal tumors with acceptable oncological and functional results can be challenging due to their location in a narrow anatomic space. CASE PRESENTATION: In this case report, we demonstrate successful visualization and resection of a squamous cell carcinoma of the oropharynx using the novel Medrobotics(®) Flex(®) System. The Medrobotics(®) Flex(®) System (Medrobotics Corp., Raynham, MA, USA) is an operator controlled flexible endoscope system that includes a rigid endoscope and computer-assisted controllers, with two external channels for the use of compatible, 3.5mm flexible instruments. DISCUSSION: In a 74-year old female patient a T1 squamous cell carcinoma of the oropharynx was visualized and completely resected using this system. The Medrobotics(®) Flex(®) System is a promising device for transoral approaches in resection of tumors within the pharynx. CONCLUSION: Good visualization, access, and flexibility of the endoscope and instruments are hereby clear advantages of the system compared to commonly used systems.

Post-tonsillectomy hemorrhage--some facts will never change.

Bleeding remains the most significant complication following tonsillectomy (TE), sometimes requiring revision surgery under general anesthesia. This study was undertaken to verify whether or not bleeding rates changed after bipolar coagulation was replaced by suture ligation to achieve hemostasis at a single institution. The charts of all patients who had undergone tonsillectomy between April 1, 2007, and April 30, 2013, at our institution were reviewed. The tonsils were bluntly dissected with scissors and a rasp. While hemostasis was achieved with bipolar coagulation during the first 36 months (group A), this method was replaced after a transition period of 1 month by intraoperative suture ligation (group B) during the last 36 months. Group A encompassed 2,137 patients including 963 children scheduled for adenotonsillectomy (ATE), and group B consisted of 1,521 patients and included 435 ATE cases. Bleeding from the tonsillar wounds occurred in 111/2,137 group A (5.2 %) and 68/1,521 group B patients (4.5 %). The difference was not found to be significant (p = 0.317). The incidence of primary bleeding (PB) and secondary bleeding (SB) was significantly (p = 0,000) associated with the method to achieve hemostasis: PB prevailed in group B and SB prevailed in group A. The overall incidence of post-tonsillectomy hemorrhage (PTH) varied at different ages, but the difference was not significant in group A (p = 0.401) and group B (p = 0.661). Repeated episodes of PTH occurred in 11/111 group A (9.9 %) and 8/68 group B (11.7 %) patients. The statistical difference was not found to be significant (p = 0.725). However, there were significantly more male patients with bleeding complications in both groups. Despite the strongest efforts to avoid it, the potential risk of PTH remains a fact to be accepted by surgeons and patients. An increased surgical precision achieved by introduction of a surgical microscope as well as replacing bipolar cautery by suture ligation to achieve hemostasis could only reduce the overall rate of PTH. Another fact remains unchanged: PB occurs predominantly when electrosurgical means are avoided and SB prevails, whenever surgeons use them. We will continue our research on refined methods of cold steel microsurgical TE including suture techniques.

A cisplatin-resistant head and neck cancer cell line with cytoplasmic p53(mut) exhibits ATP-binding cassette transporter upregulation and high glutathione levels.

PURPOSE: Head and neck squamous cell carcinoma (HNSCC) cell lines with cytoplasmically sequestered mutant p53 (p53(mut_c)) are frequently more resistant to cisplatin (CDDP) than cells with mutant but nuclear p53 (p53(mut_n)). The aim of the study was to identify underlying mechanisms implicated in CDDP resistance of HNSCC cells carrying cytoplasmic p53(mut). METHODS: Microarray analysis, quantitative reverse transcription polymerase chain reaction, Western blot analysis and immunocytochemistry were used to identify and evaluate candidate genes involved in CDDP resistance of p53(mut_c) cells. RNAi knockdown or treatment with inhibitors together with flow cytometry-based methods was used for functional assessment of the identified candidate genes. Cellular metabolic activity was assessed with the XTT assay, and the redox capacity of cells was evaluated by measuring cellular glutathione (GSH) levels. RESULTS: Upregulation of ABCC2 and ABCG2 transporters was observed in CDDP-resistant p53(mut_c) HNSCC cells. Furthermore, p53(mut_c) cells exhibited a pronounced side population that could be suppressed by RNAi knockdown of ABCG2 as well as treatment with the ATP-binding-cassette transporter inhibitors imatinib, MK571 and tariquidar. Metabolic activity and cellular GSH levels were higher in CDDP-resistant p53(mut_c) cells, consistent with a higher capacity to fend off cytotoxic oxidative effects such as those caused by CDDP treatment. Finally, ABCC2/G2 inhibition of HNSCC cells with MK571 markedly enhanced CDDP sensitivity of HNSCC cells. CONCLUSIONS: The observations in this study point to a major role of p53(mut_c) in conferring a stem cell like phenotype to HNSCC cells that is associated with ABCC2/G2 overexpression, high GSH and metabolic activity levels as well as CDDP resistance.

Smell and taste in patients with vascular malformation of the extracranial head and neck region.

BACKGROUND: Olfactory and gustatory functions have not been investigated in patients with vascular malformation of the extracranial head and neck region with validated smell and taste tests. Although olfactory and gustatory deficiencies are often not outwardly apparent, they substantially affect daily life. METHODS: Smell and taste tests using sniffin sticks and taste strips were administered in 40 patients. RESULTS: For all age groups and both sexes, odor threshold (THR) values were, on average, lower in patients than in healthy individuals; whereas, values of odor identification and discrimination were not significantly lower. Regarding odor THR, 33 (82.5%) patients were hyposmic. Taste values (sweet, sour, salty, bitter, and total taste) were, on average, lower in patients than in healthy individuals; 21 (52.5%) patients were hypogeusic. Disease duration did not correlate with smell and taste test values. Patients with and without tongue involvement had decreased odor threshold and taste values. No significant differences were identified when taste values on the left and right sides of the tongue were compared in patients without tongue involvement and with unilateral and bilateral tongue involvement. Patients with venous malformations had lower smell test values, and patients with lymphatic malformations had lower taste test values than patients with other malformations. CONCLUSION: Patients exhibit significantly reduced olfactory and gustatory function even when the nose and/or tongue are not malformed. Patients should be tested with validated smell and taste tests to adequately inform and advise them about overcoming smell and taste deficits.

The value of elective parotidectomy in advanced squamous cell carcinoma of the skin of the head.

BACKGROUND: Parotid metastases from cutaneous squamous cell carcinoma (CSCC) are associated with poor prognosis. However, the incidence of occult parotid lymph node metastases in high-risk CSCC is unclear. Therefore, the role of elective parotidectomy is still controversial. The purpose of the present study was to analyze the value of elective parotidectomy in patients with high-risk CSCC. PATIENTS AND METHODS: The clinical data including histological and radiological results, as well as surgery-related complications, of 13 patients with high-risk CSCC who underwent elective parotidectomy were retrospectively analyzed. RESULTS: Occult parotid lymph node metastases were detected by histological examination in only 1 out of 13 patients after elective parotidectomy. Surgery-related complications and morbidity were not observed. CONCLUSION: In the absence of clinical disease in the parotid gland, the risk of occult metastases is not high enough to warrant for elective parotidectomy in patients with CSCC.

Establishing a transoral robotic surgery program in an academic hospital in Germany.

The application of robot technology in the field of surgery has grown rapidly in recent years. Also in Europe, robot-assisted surgery has become increasingly popular, predominantly in the fields of urology and gynecology. Transoral robotic surgery (TORS) is widely practiced in North America after receiving FDA approval in 2009. This technique was also adopted and is being practiced at specialized institutions in various European countries, including Germany. Due to significant differences in the health-care system and divergent developments of the use of transoral surgery in the treatment of laryngeal and pharyngeal malignancies in the last decade between North America and Europe, there are unique barriers and challenges to introducing TORS in these two parts of the world. This article describes experiences in developing a TORS program at an academic hospital in Germany. Specifically, steps that were required to obtain institutional approval and financial support, as well as to train surgeons and allied health-care personnel, and to establish a sufficient and adequate technique for reprocessing the used instruments are presented. Introducing a TORS program in Europe is still a challenge in regard to financial issues, acceptance, and practicability and therefore it is only practiced in specialized centers, although systems are widely available and often used in the same hospital by urology departments.