Prof. Dr. med. O. Michel

Abstract: Warum sollte es ein neues Buch über Rhinosinusitis geben? Ist es wirklich notwendig? Die Rhinosinusitis ist eine der häufigsten Erkrankungen, die der Menschheit zusetzt. Zahlreiche Studien, Meta-Analysen, Konsensuskonferenzen, Leitlinien und unzählige Einzelpublikationen erscheinen jedes Jahr über Rhinosinusitis. Und diese stammen von den verschiedenen Fachdisziplinen: Pädiatern, Mikrobiologen, Allergologen, Pulmonologen, Otorhinolaryngologen aber auch Allgemein- und Hausärzte veröffentlichen ihr Wissen und ihre Ratschläge zu Diagnostik und Therapie. Viele Wege führen also nach Rom. Wer kann da den �berblick bewahren und die optimale Therapiestrategie für seinen Patienten wählen, wenn die Spontanheilung nicht greifen will? Diese Buch möchte hier eine Hilfestellung geben und ein Leitfaden sein. Einerseits soll es das aktuelle Wissen ordnen und sichten helfen, um das aktuelle Kenntnisniveau schnell überblicken zu können, andererseits soll das Buch auch schwierige Fragen der Praxis beantworten helfen. Im Grunde genommen soll es ein Ratgeber sein, der mit Tipps aus der Praxis für die Praxis auch ein wenig verkrustete Ansichten lockern möchte, aber auch den vom Arzt gewählten �eigenen Weg� zur Heilung des Patienten unterstützen soll. Auf jeden Fall ist es ein Anliegen dieses Buches über Rhinosinusitis Behandlungspfade aufzuzeigen, die nicht zu dem oft ausgesprochenen �damit müssen Sie leben� führen, sondern auch moderne Aspekte von vielleicht noch nicht so etablierten Behandlungsmethoden zum Ausdruck bringen. Dabei sollen alle � seien es Rhinochirurgen, Pädiater, Allergologen, Hausärzte oder Physiotherapeuten - zu Wort kommen und ihre verschiedenen Sichtweisen und den sich daraus ergebenden Behandlungsmethoden zu einem Medikamentenkoffer zusammenfügen, der nur wartet, vom Leser geöffnet zu werden.

Abstract: Menierova choroba p�edstavuje stále jeden ze sou�asných svízelných problémů, neboť postižené osoby nemoc i poruchy rovnováhy mohou vy�adit ze spole�enského i ekonomického života, nehled� na jejich závažnost zdravotní. Monografie p�edního n�meckého odborníka je velkým p�ínosem a je p�ehledem i dokonalým souhrnem dosavadních znalostí. Zna�n� obohatí práci specialistů i léka�ů první linie, kte�í se s t�mito nemocnými prakticky denn� setkávají. Titul "Morbus Meniere und Verwandte Gleichgewichtsstörungen" vydalo nakladatelství.

Abstract: Descrizione Raramente una malattia, sia nell'ambito specifico dell'otorinolaringoiatria che in altre discipline, ha impegnato costantemente, da più di 130 anni, i ricercatori ed è stata oggetto di un numero così elevato di pubblicazioni come il complesso sintomatico descritto da Prosper Menière. Ancora più sorprendente è che, oggi, con i mezzi a disposizione, la medicina non sia ancora in grado di spiegare il quadro clinico rispetto alla patogenesi e di effettuare un trattamento causale. Nonostante il volume di letteratura, negli ultimi dieci anni non si trova una descrizione estesa della malattia di Menière. La monografia facilita la navigazione in questo oceano di nozioni e cerca di fornire a ogni domanda una risposta pertinente. Obiettivo: ordinare i frammenti di conoscenza ed evidenziare i punti fondamentali della malattia che possano migliorare la padronanza del quadro clinico.

Abstract: Kaum eine Erkrankung - weder auf dem Hals-Nasen-Ohren-Fachgebiet noch auf anderen Fachgebieten - hat konstant seit über 130 Jahren den Forschungsgeist so beflügelt und eine so unglaubliche Zahl von Publikationen hervorgebracht, wie der nach Prosper Menière benannte Symptomenkomplex. Dies mag zum einem an dem den Patienten und den Arzt gleicherma�en beeindruckenden und als mysteriös empfundenen Anfallsleiden liegen. Zum anderen spiegeln sich in der Menière�schen Erkrankung die Grenzen unseres Wissen über das Hör- und Gleichgewichtsorgan wieder. So stellt die Menière�sche Krankheit eine ständige wissenschaftliche Herausforderung dar, die Generationen von Otologen, Neuro-Otologen und Otochirurgen - darunter fast ausnahmslos alle hervorragenden Fachvertreter - in ihren Bann gezogen hat. Trotz der Fülle von Publikationen, die für einen nicht in der Materie behafteten Arzt kaum noch überschaubar ist, findet sich in der jüngsten Literatur der letzten 10 Jahre keine umfassende wissenschaftliche Darstellung des Morbus Menière. Die hier vorliegende Monographie unternimmt den Versuch, diese Literatur zu sichten und übersichtlich zusammenzutragen; Widersprüche, Ungereimtheiten und Unerforschtes aufzuzeigen, aber auch gleichzeitig durch die Zusammenstellung zahlreicher Einzelbeobachtungen zu einer kritischen Sichtung der bisherigen Ergebnisse beizutragen. Sie ist dazu bestimmt, die Navigation in diesem unübersichtlichen Meer der Einzelerkenntnisse zu ermöglichen und auf jede Fragestellung eine Antwort oder wenigstens einen Hinweis auf die entsprechende Textstelle zu liefern. Der Leser wird feststellen, da� bei diesem Unterfangen eine Reihe von gesichert geltenden Erkenntnissen in ihrer Bedeutung relativiert werden und auch vehement und dogmatisch verfochtene Behandlungen im Laufe der Zeit zurücktreten. In der Ordnung der Erkenntnissplitter werden Grundzüge des Morbus Menière sichtbar, die auf neue Ansätze zur Erforschung und vielleicht auch der zukünftigen Beherrschung des Krankheitsbildes deuten.

Abstract: Der Hörsturz, eine akute Funktionsstörung des Innenohres, stellt eine elementare Gebrauchseinschränkung eines der wichtigsten Sinnesorgane des Men¬schen dar. Da das Ohr auf alle Schädigungen immer gleichförmig mit einer Hörminderung reagiert, ist eine lückenlose Ausschlu�diagnostik der verschiedenen Ursachen erforderlich. Vor dem Hintergrund der Erkenntnisse der modernen Innenohrforschung werden Krankheitsursachen, Erkennung und Unterscheidung zu anderen Innenohr¬störungen und die zum Teil verwirrende Literaturvielfalt über Ursachen und Behandlung geordnet und zusammengefa�t. Die neuesten Erkenntnisse zur Hörtheorie - wie der aktiven Haarzelle, der Schallaussendung des Ohres, der Regulation der Durchblutung - werden als funktionelle Grundlagen verständlich dargestellt und in ihrer Bedeutung für die Entstehung des Hörsturz beleuchtet. Die Therapiemodalitäten des Hörsturzes sind kaum zu überschauen und stellenweise divergierend. Anhand von Analysen und �bersichten werden die im Innenohrbereich als wirksam eingestuften Medikamente geordnet und hinsichtlich ihrer klinischen Effektivität und Zweckmä�igkeit kritisch betrachtet. Dabei werden auch aktuelle und strittige Behandlungskonzepte, aber auch rechtliche Fragen von der Sorgfaltspflichtverletzung bis zur Nichthandlung umfassend berücksichtigt. Damit wird dem Interessierten die zur Zeit bedeutendste und umfassendste Abhandlung über das Krankheitsbild Hörsturz in die Hand gegeben.

Abstract: Das Schädeltrauma ohne ohrnahe Fraktur ähnelt dem Knalltrauma und kann eine Hochtonsenke zur Folge haben. Die durch Schädeltraumen entstandenen Innenohrschäden verschlechtern sich in der Regel nicht, sind aber unmittelbar in ihrer Ausprägung vorhanden. Bagatelltraumen reichen nicht aus, um eine Innenohrschädigung hervorzurufen. Leider wird die �Contusio labyrinthi� viel zu häufig nach leichten Kopfanstö�en als Verlegenheitsdiagnose gebraucht und führt dann in der Regel zu vielfältigen diagnostischen Ma�nahmen, ausufernder Behandlung, Hoffnung auf Entschädigung und langwierigen Gerichtsprozessen.

Abstract: Die neue revidierte Leitlinie �Hörsturz� (gültig bis 2012) definiert die einseitige, plötzliche Innenhörstörung nicht als Notfall hinsichtlich Diagnostik und Therapie. Die erforderliche Minimaldiagnostik sollte eine Hals-Nasen-Ohren-ärztliche Untersuchung mit Ohrmikroskopie, Tonaudiogramm und Stimmgabelprüfungen, sowie Tympanogramm und Vestibularisprüfung umfassen. Die Klassifikation nach dem vorherrschenden Frequenzverlust wird zur klinischen Differenzierung möglicher pathogenetischer Mechanismen, die im übrigen noch weitgehend unklar sind, nützlich gehalten. Aus Erfahrung heraus haben sich Glukokortikoide und rheologische Therapien als meistversprechend auch vor dem Hintergrund jüngster Studien herausgestellt. Die intratympanale Gabe von Glukokortikoiden kann angesichts der Datenlage als Reservetherapie in Erwägung gezogen werden.

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Abstract: Die Wahrscheinlichkeit, an einer Insektengiftallergie zu leiden, liegt bei 2�5%. Relative Gewissheit kann ein Hauttest bringen. Im Falle einer allergischen Reaktionsbereitschaft ist eine Hyposensibilisierung zu empfehlen, die sich bis zur vollen Immunität über Jahre erstrecken kann und dann regelmä�ig aufgefrischt werden muss. Erfolg hat eine SIT in 80�90% der Fälle; dieser Erfolg ist aber nicht vorhersagbar.

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Abstract: �rztliche Ma�nahmen möglichst schmerzfrei zu gestalten, ist die Grundlage einer �menschlichen� Medizin. Besonders die HNO-Heilkunde ist ohne Anästhetika nicht mehr vorstellbar. Durch Oberflächen betäubung lassen sich Untersuchungen und Behandlungen lassen wenig belastend durchführen und Entzündungsschmerzen aufheben. Kleinere und mittlere Eingriffe können in Lokalanästhesie mit geringem Personalaufwand und ohne Narkoserisiko durchgeführt werden. Das Zusammenspiel von bewährten Rezepten und Neuentwicklungen erlaubt eine den jeweiligen Erfordernissen angepasste Betäubung.

Abstract: Abstract Hypertonic (3 % ) vs. Isotonic Brine Nosespray � A Controlled Study � Purpose: In several in-vitro research studies was shown that hypertonic salt water solution has an enhancing eff ect on mucociliary beat frequency. Nevertheless nose sprays with isotonic salt water solution are more popular on the market. They are sold as wellness products but also for care and cure of various nose diseases. Methods: In a randomized double-blind trial with n = 20 healthy volunteers the eff ect of a 7-day application of hypertonic sodium chloride solution (3 % NaCl) measured by saccharineclearance- test (SCT), rhinomanometry and questionnaires was evaluated in comparison to a isotonic salt solution (0,9 % NaCl). Results: The SCT showed in both groups no signifi cant change. In rhinomanometry a signifi cant higher rate of airfl ow could be measured after a 7 day period of applicating hypertonic spray. The volunteers evaluated the hypertonic solution as �more effective� in regard their nasal airfl ow. Conclusion: Although in this RCT an eff ect on mucociliary clearance could not be detected after a 7 day application of salt water nose spray, a hypertonic spray showed objectively and subjectively a signifi cant infl uence on nasal airfl ow. This eff ect could be of interest eg. in reducing the use of decongestive nose sprays.

Abstract: Tab. 1 Kombinierte Bewertungstabelle (sog. Kombitabelle) nach Michel und Brusis (2007) zur Abschätzung des Invaliditätsgrads für Hörverlust mit Tinnitus für die PUV

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Abstract: Tinnitus kann zur Invalidität führen. Ob eine Private Unfallversicherung leistungspflichtig ist, hängt davon ab, ob ein Organschaden als Ursache des Tinnitus nachweisbar ist.

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Abstract: Das Ohr ist zwar so gro� wie eine Kaffeebohne � aber sein Stoffwechsel ist relativ zu seiner Grö�e enorm. Das Ohr verbraucht viel Sauerstoff. Wir wiesen aus Versuchen, dass der Stoffwechsel sich noch erhöht, wenn das Ohr beansprucht wird � z.B. bei Lärm. Hoher Sauerstoffumsatz bedeutet viele Möglichkleiten, dass Radikale entstehen. Eigentlich möchte man annehmen, dass das Ohr in Stille mehr arbeiten müsste, da es doch dann verstärken muss, um leise Geräusche zu hören. Das Gegenteil ist der Fall � das Ohr ist für die Ruhe gebaut und muss sich anstrengen, wenn es laut ist. Denn dann werden etliche Schutzmechanismen in Kraft gesetzt, die Energie benötigen und Sauerstoff verbrauchen. Allerdings: absolute Stille verträgt das Ohr auch nicht, da dann das Grundrauschen zu deutlich wird. Auch kleine Störungen in der Blutzirkulation gleicht das Ohr aus � es hält dann quasi die Luft an und produziert Energie ohne Sauerstoff. Dieser �Notstrom� hält jedoch nur für begrenzte Zeit, dann muss wieder Sauerstoff her. In der Folge entstehen dann mehr Radikale, die das Gewebe � also hier die Haarzellen � schädigen können. Ganz besonders chaotisch geht es bei Entzündungen zu. Hier wehrt sich der Körper mit allen Mitteln uns setzt dabei selber � als chemische Keule - Radikale gegen Bakterien und Viren ein. Kein Wunder, dass es da im Kampfgetümmel auch zu Schäden am eigenen Zellen kommen kann � �Kollateralschäden�. Angeschlagene Haarzellen können zur Quelle von Tinnitus werden, da sie sich nicht ehr isolieren können und elektrische Impulse aussenden, ohne dass damit ein Reiz von au�en verbunden wäre. Wenn solche Erkenntnisse bekannt werden, dann sagt natürlich jeder, dass dagegen Sauerstoffradikalfänger quasi als Schutzschild helfen müssten, Eigenschäden zu vermeiden. Bis zu einem gewissen Ma�e ist das auch richtig. Diese Ansicht wird auch dadurch verstärkt, dass man wei�, dass Vitamin C und Vitamin E � die Klassiker der Radikalfänger - kaum im Körper gespeichert werden können und daher regelmä�ig zugeführt werden müssen. Andererseits kann jeder auf den Nahrungsmittelinformationen nachlesen, dass der normale Mitteleuropäer alle diese Stoffe reichlich jeden Tag mit der Nahrung zu führt.

Abstract: he provisions and the aims of private accident insurance are not comparable to those of the statutory accident insurance. The ear nose throat- (ENT-)specialist is often consulted on the question of a possible causality between an accident and sequelae. Loss of smell, taste disorder and loss of hearing are specified in a table with a fixed percentage for compensation. The individual invalidity for ear ringing, vertigo and other disorders have to be determined separately from this table. In private accident insurance a probability bordering on absolute certainty must be given when establishing a possible causal connection whereby mental reactions are excluded from compensation and all sequelae have to have continued for at least 3 years. The occupation or specific skills of the injured person are not essential for the judgement. The current jurisdiction and conditions of private accident insurance for tinnitus and vertigo have to be taken into consideration Das Regelwerk und die Zielsetzung der privaten Unfallversicherung sind mit der gesetzlichen Unfallversicherung nicht vergleichbar. Der HNO-Arzt wird häufig in der Frage einer Unfallzusammenhangsbeurteilung gutachterlich in Anspruch genommen. Riechverlust, Schmeckstörung und Hörverlust sind in einer Invaliditätstabelle mit abstrakten Prozentwerten festgelegt, während Ohrgeräusch, Schwindel und andere Störungen au�erhalb der Gliedertaxe festzulegen sind. Hinsichtlich der Kausalität muss eine an Sicherheit grenzende Wahrscheinlichkeit gegeben sein, psychische Reaktionen sind von der Leistung ausgeschlossen und die Unfallfolgen müssen auf Dauer über 3 Jahre nach dem Unfall hinaus bestehen. Der Beruf oder besondere Fähigkeiten der versicherten Person spielen keine Rolle bei der Beurteilung. Die neueste Rechtsprechung hinsichtlich der Versicherungsleistung für Tinnitus und Schwindel ist zu beachten.

Abstract: Heterotopic salivary gland tissue (HSGT) is a rare finding in the lower neck. Bilateral lesions are even more exceptional. It is generally accepted HSGT originates from defective embryogenesis within the branchial apparatus and are closely related to branchial cysts and sinuses. The true aetiology however is not fully understood. Here we report a rare case with bilateral lesions in the neck that drained a clear substance after drinking. Surgical resection of a 2 cm upwards fistula tracks was performed under general anaesthesia. Microscopic examination of resection peaces showed arguments for HSGT on both sides. Several aetiological theories are also discussed.

Abstract: For centuries endonasal irrigations using salt solutions have been prescribed for the treatment of paranasal sinus diseases without the efficacy having been determined by scientific data. In 1895, the civilised nose was described in an Editorial in The British Medical Journal as: �... one of the dirtiest organs in the body� and for washing it, one was �to plunge the face into a basin of cleanwater, cold or tepid, and take slight sniffs, in and out, while under water�. Since than � beginning in the late �50s of the last century a plethora of investigations have been published. Messerklinger in Graz/Austria was first to describe in detail the ciliary movement of the mucosal layer in the paranasal sinuses in the early �60s. He found that the mucosal layer existant in the nose, the sinusses, the larynx and the trachea aswell in the middle ear is the �binding link� in the speciality of ear-nose-and-throat (otorhinolaryngology). Nevertheless, its physiological function is of utmost importance to maintain a healthy condition in the upper airways.

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Abstract: Ein hoher Prozentsatz der Kieferhöhlenentzündungen geht auf das Konto von Zähnen bzw. des Zahnhalteapparates. Gro�e Füllungen, alte Kronen und kariöse Zähne weisen oft schon darauf hin, wo die Wurzel des �bels zu finden ist. Doch auch hinter einem äu�erlich schönen Gebiss kann sich ein Unruheherd verstecken. Mit roter schmerzhafter Schwellung der Wange sitzt der Patient im Untersuchungsstuhl: Sinusitis, Wurzelspitzenabszess oder beides? Ein solch spektakuläres Auftreten eines kranken Zahns ist aber eher die Ausnahme. Viel häufiger gefallen sich die Zähne in der Rolle der heimlichen Störenfriede und tarnen sich hinter Veneers, Bleaching, Vollkronen und Implantaten. Bis zu 30% der chronischen Kieferhöhlenentzündungen sind odontogen, ohne dass es gleich offensichtlich wird. Aber auch andere Kieferhöhlenerkrankungen können von den Zähnen ausgehen. Die Zähne und ihr Zahnfach bilden eine natürliche Schwachstelle in der sonst dichten anatomischen Abschottung zwischen der stark keimbesiedelten Mundhöhle und dem sterilen Nasennebenhöhlenbereich. Im Oberkiefer sind die Zahnwurzeln so tief in der Maxilla verankert, dass ein Teil der Wurzelspitzen bis an den Kieferhöhlenboden (Recessus maxillaris) heranreichen kann. Die Situation reicht von knöcherner Bedeckung der Wurzelspitze über die reine Schleimhautbedeckung bis hin zu am Boden der Kieferhöhle freiliegenden Zahnwurzeln. Anzeige Der Zahn besteht vor allem aus Dentin, das nach innen hinein einen röhrenförmigen Hohlraum besitzt, die Pulpa. In dieser verlaufen Blutgefä�e und Nerven, die wiederum durch den Knochen der Maxilla an der Zahnwurzelspitze in die Pulpa treten. An der Au�enseite der Zahnwurzel findet sich das Zement, das durch Fasern mit dem Knochen elastisch verbunden ist. Der sichtbare äu�ere Bereich � die Zahnkrone � ist vom Zahnschmelz umgeben. Die Zähne und ihr Halteapparat können von Entzündungen befallen werden. Ist es der Zahn, so wird meist von Karies gesprochen, ist es der Halteapparat, dann von einer Parodontitis. Die Entzündung des Nervenkanals wird als Pulpitis bezeichnet. Stirbt der Nerv ab, hört zwar der Schmerz schlagartig auf, nicht aber die Aktivität der Bakterien. Die Bakterienzahl muss dabei gar nicht dramatisch hoch sein � aber stetige Entzündung höhlt den Knochen. Der ständige Granulationsreiz durch über die Pulpa oder den Zahnhalteapparat einwandernde Bakterien lässt ein Granulom entstehen, dass sich im Knochen um die Wurzelspitze ausbreitet. Der Körper, der vergeblich gegen das Entzündungsgewebe angeht, gibt schlie�lich irgendwann auf und kapselt es mit Bindegewebe ein. Von au�en sind solche Granulome kaum bemerkbar. In der Röntgenaufnahme sind sie als Verschattung an der Wurzelspitze zu erkennen. Auch radikuläre Zysten, die sich durch den Boden in die Kieferhöhle vorwölben, sind möglich. Diese Unruheherde können Ursprung für eine weitergehende Entzündung werden. Solche Entzündungen werden dann als dentogen (vom lateinischen Wort �dens� für Zahn) oder odontogen (vom griechischen �odont� für Zahn) bezeichnet. Der Hals-Nasen-Ohren-Arzt kann durch eine Inspektion der Mundhöhle erste Hinweise erhalten: kariöse, ruinöse Zähne, Klopfschmerzhaftigkeit, Verfärbungen des Schmelzes, gro�e Füllungen und alte Kronen (Abb. 1) legen eine dentogene Entzündung nahe. Andererseits sagt ein äu�erlich schönes Gebiss noch nichts über die inneren Werte: Blendkeramiken, Veneers, Goldkronen oder gebleichte Zähne können darunter gelegene Herde kaschieren. alle Fotos © : O. Michel Abb. 1 Kranke Zähne können die Ursache einer chronischen Sinusitis sein. alle Fotos © : O. Michel Die odontogene Sinusitis maxillaris Die Kieferhöhle ist physiologischerweise steril. Eine pathologische Keimbesiedelung findet in der Regel aus der Nase über das Ostium naturale statt. Zahnwurzeln ragen mit ihrem apikalen Ende in die Kieferhöhle oder kommen ihr zumindest sehr nahe, so dass die eigentlich dichte Barriere zwischen Kiefer- und Mundhöhle hier eine Schwachstelle bekommt. Infektionen, die über den Zahnkanal oder den Zahnhalteapparat in die Kieferhöhle gelangen, können eine Sinusitis auslösen und unterhalten (Abb. 2). Dies ist auch der Fall, wenn im Laufe der Zeit ein sich ausbreitendes Wurzelspitzengranulom über Um- und Abbauvorgänge des Knochens Anschluss an die Kieferhöhle bekommt. Abb. 2 Koronares CT der Nasennebenhöhlen: einseitige Verschattung, blo�liegende Zahnwurzel bei blander Gegenseite � typische Zeichen einer odontogenen Sinusitis Abb. 3 Fistelbildung zwischen Mundhöhle und Kieferhöhle Als typische Infektionsquelle finden sich zumeist avitale, abgestorbene Molaren, Prämolare oder Schneidezähne (Incisivi). Gerade die Backenzähne haben häufig Füllungen und �berkronungen, die ihrer Natur gemä� alle Fäule überdecken. Auch die Infektion retinierter oder verlagerter Zähne ist möglich. Eine weitere Ursache dentogener Kieferhöhlenentzündungen sind Zahnextraktionen oder Wurzelspitzenbehandlungen. �ber das apikale Ende des Zahnfachs kann bei tiefsitzenden Wurzeln eine Verbindung entstehen. Das geschieht weit häufiger als angenommen. Die �ffnungen schlie�en sich jedoch durch Bildung eines Blutkoagels und eines anschlie�enden Knochenumbaus oder einer Fibrosierung, so dass eine Verbindung normalerweise nicht erhalten bleibt. Geschieht dieser Verschluss nicht, entsteht eine Mund-Antrum-Fistel. Sind diese Fisteln sehr klein ist, fallen sie dem Untersucher nicht sofort ins Auge. Sie können sich zudem hinter einer Schleimhautfalte verstecken, so dass sie schwierig zu entdecken sind. Das gelingt meist nur über das Endoskop und die gebogene Sonde (Rosenblatt- oder eine feine RitterSonde) oder den Valsalva-Versuch. Die Therapie einer Fistel erfolgt chirurgisch (z.B. Rehrmann-Plastik und Variationen). Seltener ist eine Fistel im Bereich des harten Gaumens (Abb. 3). Das typische klinische Kennzeichen einer odontogenen Kieferhöhlenentzündung ist in der Regel die Einseitigkeit der Erkrankung; die Kieferhöhle der Gegenseite zeigt sich völlig normal (Abb. 2). Ein schlechter Zahnstatus und der Nachweis einer Infektion mit Anaerobiern oder Pilzen ist ebenfalls richtungsweisend. Ist die Kieferhöhle völlig verschattet und voll, kann ein Abstrich aus dem mittleren Nasengang genommen werden. Die Kieferhöhle läuft dann über die natürliche �ffnung gewisserma�en über. Auf fötiden Geruch achten! Das wichtigste Diagnoseverfahren ist jedoch die Computertomographie in koronarer Schichtung, sie kann auch Hinweise auf den Ursprungszahn liefern. Die Therapie ist zumeist zweizeitig operativ: Der Zahnarzt wird sich um den befallenen Zahn kümmern, der HalsNasen-Ohren-Arzt um die Kieferhöhle. Die Reihenfolge ist im Prinzip nicht festgelegt. Seit Einführung der schonenden endoskopischen Techniken hat sich die HNO-Heilkunde die Kieferhöhle zurückerobert, so dass die anstehende Kieferhöhlenfensterung überwiegend in der Hand des Hals-Nasen-Ohren-Arztes liegt und nicht zwangsläufig in der Hand des Kieferchirurgen. Allerdings darf ein Zahnarzt nur zum Kieferchirurgen überweisen nicht jedoch direkt zum HalsNasen-Ohren-Arzt! Pilzinfektion der Kieferhöhle Ebenfalls einseitig, aber mit geringeren entzündlichen Parametern behaftet, ist die Pilzinfektion der Kieferhöhle. Sie tritt häufig im Gefolge von Zahnwurzelbehandlungen auf. Bei der Zahnwurzelbehandlung befreit der Zahnarzt mit kleinen Handbohrern den Wurzelkanal des Zahnes bis hin zur Spitze vom darin verlaufenden Nerv und Blutgefä� und versieht den Kanal mit einer Füllung. Dabei können geringe Mengen schwermetallreiches Füllungsmaterial (z.B. Zinkoxid) in die Kieferhöhle gelangen. Pilzarten wie Aspergillus haben die Eigenschaft, Schwermetalle anzureichern und zu speichern. Dadurch erklärt sich auch eine im Röntgenbild ins Auge fallende hohe Dichtigkeit bei einer Pilzinfektion (Abb. 4). Die Röntgendichte kann bis an Knochen- oder Metalldichte heranreichen, so dass häufig der Eindruck entsteht als sei ein Fremdkörper in der Kieferhöhle. Erst bei der Operation wird deutlich, dass man vergebens nach einem Fremdkörper sucht, sondern es �nur� mit grau-bräunlichem bröckeligen Material zu tun hat � einem �Pilzball� (�fungus ball�). Zusätzlich zeigen befallene Kieferhöhlen durch die entzündlich veränderte Mukosa in der Computertomografie einen hypodensen Randsaum. Abb. 4 Pilzbefall der Kieferhöhle mit fast metalldichtem Fungusball In der Kernspintomografie stellen sich Aspergillome oft fast gar nicht dar. Man hat den Eindruck, es sei bei einer signalintensiveren Zone als schmalem Randsaum eine Luftfüllung vorhanden. Dadurch kann ein Aspergillom in der Kernspintomografie fehlinterpretiert werden. Die Behandlung des �fungus balls� ist immer chirurgisch. Die betroffene Nasennebenhöhle muss eröffnet und ein weiter Zugang zur Nasenhaupthöhle geschaffen werden. Spülungen mit antimykotischen Lösungen oder gar eine systemische antimykotische Behandlung wird nicht empfohlen, wenn es sich um eine �normale� Pilzerkrankung handelt. Anders ist die Lage bei aggressiven Pilzen bei der Mucormykose, die insbesondere bei Diabetikern auftritt. Hier kann die Pilzerkrankung den Knochen befallen und fulminant, u. U. sogar tödlich verlaufen, wenn nicht zügig chirurgisch und medikamentös reagiert wird. Odontogene Zysten Die Zahnanlagen finden sich schon vor der Geburt in der Kieferhöhle und wandern im Rahmen der Dentition nach kaudal. Es finden sich nicht immer nur acht Zahnanlagen im Oberkiefer. Im Bereich der Molaren (Weisheitszähne) können sich Doppelanlagen finden. Dann wächst plötzlich im Erwachsenenalter nach Weisheitszahnextraktion ein Zahn nach. Teilweise können diese in der Kieferhöhle gelegenen Zahnanlagen sehr spät ausreifen und zystenförmige Strukturen um sich herum aufbauen (Abb. 5). Ab einer entsprechenden Grö�e können diese Zysten Beschwerden bereiten: Sie bedrängen die Schleimhaut, so dass der mukoziliäre Selbstreinigungsprozess zum Erliegen kommt und eine Kieferhöhlenentzündung und die Ausbildung einer Pyozele die Folge ist. In der Regel verursachen diese Zysten jedoch keine Beschwerden und sind daher oft Zufallsbefunde. Ihre Therapie ist operativ; mit etwas Geschick lassen sie sich transnasal entfernen (Abb. 6). Abb. 5 3-D-CT mit rudimentärem Zahn Abb. 6 Operationspräparat mit deutlich zu erkennendem, fast vollständigem Zahn Ameloblastom Der häufigste odontogene Tumor ist mit bis zu 18% das Ameloblastom. Die frühere Bezeichnung �Adamantinom� ist nicht mehr gebräuchlich, da im Tumor keine Schmelzbildung stattfindet und der Name daher falsch ist. Der Tumor entsteht aus den Ameloblasten des Zahnfollikels. Das Ameloblastom tritt häufig in der dritten und vierten Lebensdekade auf und betrifft in 55% den Oberkiefer. Der Tumor ist in der Regel semimaligne, da er in Hohlräume einwächst (Markrauminfiltration). Er bildet in der Regel keine Metastasen, verursacht keine Schmerzen und wächst langsam. Er fällt daher meist spät und häufig erst auf, wenn seine Grö�e entstellend wird oder eine Begleit-Sinusitis auftritt. Kann er weit im Gesunden (mit Sicherheitsabstand bis ca. 1 cm) entfernt werden, treten keine Rezidive auf. Maligne Ameloblastome sind selten. Pindberg-Tumor Der kalzifizierende epitheliale odontogene Tumor (auch Pindberg-Tumor) ist im CT als Raumforderung zu erkennen, die einen äu�ert inhomogenen Inhalt zeigt. Inmitten der amorphen Masse finden sich kleine knochendichte Einsprengsel, die Zahnteilen entsprechen (Dentikel). Der Tumor wird als nicht maligne betrachtet, da er nie Metastasen bildet und auch in der histologischen Untersuchung nur wenige Mitosen gesehen werden. Auch er kann durch eine Sinusitis auffallen. Der Sinuslift In den letzten beiden Jahrzehnten ist die implantierbare Prothetik zu einer der besten und teuersten Zahnersatzlösungen geworden. Die Implantation der knochenverankerten Titanhülsen setzt jedoch zwingend voraus, dass ausreichend Knochensubstanz vorhanden ist. Ist dies nicht gegeben, kommt es nicht zur Knochenverankerung (Osseointegration) und damit zu einer geringen Belastbarkeit bis hin zum Verlust des Implantates. Ohne Zähne und die damit verbundene Beanspruchung auf Zug atrophiert der Knochen. Dies ist besonders im Bereich des Alveolarkamms der Fall. Der Knochenkamm kann bei Gebissträgern fast vollständig verschwinden. Eine Möglichkeit, den Kamm wieder aufzubauen und Knochensubstanz herzustellen, ist der sogenannte Sinuslift oder die Sinusbodenelevation. Bei der Operation wird im Prinzip die Periost-Schleimhautschicht des Kieferhöhlenbodens (Zahnchirurgen sprechen von der Schneiderschen Membran) gelöst und in das entstandene Fach Knochen(ersatz)material eingebracht. In der gleichen Narkose erfolgt dann sofort auch das Einsetzen der Implantate, die ca. 10 mm lang sind. Um den Boden zu erreichen, wird von vorne ein Fenster in die Kieferhöhle gefräst. Das Ergebnis ist nach etwa 9 Monaten belastbar. Ein Misserfolg des Sinusliftes kann auf einer mangelhaften präoperativen Diagnostik beruhen, etwa wenn eine akute Sinusitis oder ein Kieferhöhlenempyem übersehen wird. Eine Infektion des Augmentationsmaterials führt unweigerlich zum Herauseitern und erfordert eine Revision unter Entfernung des eingebrachten Materials. Allerdings sind einige Kieferchirurgen der Meinung, dass eine chronische Sinusitis einen Sinuslift nicht kompliziert, da eine hyperplastische antrale Schleimhaut bei der Präparation mechanisch beständiger sei. Wurde bereist eine Caldwell-Luc-Operation durchgeführt, was bei den zum Teil älteren Patienten doch noch häufiger der Fall ist, kann der Sinuslift wegen der Narben- und Knochenneubildung sehr erschwert oder sogar unmöglich sein. Fazit für die Praxis Kieferhöhlenentzündungen sind nicht selten durch eine Infektion im Zahn- oder Zahnhaltebereich verursacht, so dass dies bei der Ursachensuche stets zu bedenken ist. Im Zweifelsfall ist eine zahnärztliche Stellungnahme einzufordern. Auch Tumoren in den Nasennebenhöhlen stehen in einem Zusammenhang mit den Zähnen und dem Zahnhalteapparat. Bei bestimmten richtungsweisenden Befunden wie Einseitigkeit, reichhaltigem Keimspektrum und Anaerobiern oder Pilzen sollte in jedem Fall ein Zahnarzt oder ein Zahn-Mund-Kieferchirurg konsultiert werden. Nur so kann eine ursächliche Behandlung erfolgen. Zeitschrift: HNO-Nachrichten, 2010/6 13.12.2010 16:00 Autor: Prof. Dr. med. Olaf Michel Quelle: HNO Nachrichten 2010;12 (6):22-25

Abstract:

Abstract: Von schaumig bis schäumend, sanft bis fluffig, gelförmig oder schwammartig, die neuen Mittel zur Blutstillung in der Nase oder nach Nasennebenhöhleneingriffen wollen weich wie Marshmallows sein, sind aber meist nicht so preiswert. Was man über die neue Generation wissen sollte, ihre Vor- und Nachteile und wie sie angewendet werden, ist im folgenden Artikel zu erfahren. Für den HNO-Arzt stellt sich zudem die Frage, ob sie einen Fortschritt bedeuten und einem Vergleich mit den martialisch daherkommenden klassischen Nasentamponaden standhalten. Oder gilt am Ende nur für den Hersteller �mit Speck fängt man Mäuse�?

Abstract: Abstract. Nasal dorsal hump reduction is a frequently performed and basic step in non-functional rhinoplasty. The literature has described multiple techniques for nasal hump removal. However, most of the descriptions consider new or modified techniques. No papers have been published comparing any of these different surgical interventions. The aim of this paper is to review several techniques in common use, looking at their inherent advantages and disadvantages in the light of the authors' personal experiences. Particular attention is devoted to a comparison of component and composite hump reduction. The latest trends in hump removal techniques aim for predictable and realistic results with pleasing aesthetic outcomes based on precise resection techniques and the optimal preservation of nasal anatomy and function.

Abstract: Tinnitus is defined as hearing sensation without external noise source. The aetiology contains also occupational causes such as noise industrial pollution and inner ear trauma, nevertheless the origin of tinnitus is vastly unexplained. For the expert assessment in the public insurance a step-by-step procedure is recommended: Is there a tinnitus? Was the accused cause able to provoke tinnitus? How profound is the insured person hindered in his individual work ability by the tinnitus and potential psycho vegetative reactions? In this publication hints for tinnitus-matching and for expert opinion related questions are given: is there a noise-caused tinnitus in the low frequencies? Is it possible that a noise-induced tinnitus worsens after retirement? Can stress be a potential candidate to evoke tinnitus? Under which circumstances a psychiatric assessment can be necessary? In the assessment of tinnitus crucial differences between public accident insurance, civil right, public health and handicap right are explained.

Abstract: Schleimhäute sind für Pilzinfektionen prädisponiert, da hier die idealen Lebensbedingungen für Pilze herrschen: Feuchtigkeit, Wärme, Schatten. Ein ausgeklügeltes System schützt den Menschen vor diesen Pilzinfektionen, aber auch vor allergischen Reaktionen gegen Pilze. Doch im Fall einer generellen oder lokalen Abwehrschwäche können diese die Oberhand gewinnen und sich ausbreiten. Gefürchtet sind hier vor allem der generalisierte Pilzbefall und sich im Knochen ausbreitende Pilze, die beide nur schwer zu behandeln sind.

Abstract: Als Firewall des Ohrs wehrt der Gehörgang schädliche Einflüsse ab: von Staub bis zum Schwimmbadwasser, vom �stchen bis zum Insekt, vom Pilz bis zum Bakterium. Ist der Angriff aber erfolgreich, ist in der Regel der Hals-Nasen-Ohren-Arzt gefordert. Im Beitrag werden die wichtigsten Fragen zur Otitis externa beantwortet.

Abstract: In einem Witz wird der alte Kapitän gefragt, was sein Rat gegen Seekrankheit sei. �Sich unter einen Baum setzen� lautet die kurze Antwort. Sicherlich richtig, aber zu Beginn der Reisesaison fragen sich viele von See- und Reisekrankheit Betroffene, gibt es da nicht vielleicht besseres als Resignieren, an Land bleiben oder sich zu regurgitieren?

Abstract: Früher wurden plötzliche Schwellungen auf der Zunge, im Gesicht, Rachen oder Kehlkopf unter der Diagnose �Quincke-�dem� zusammengefasst. Jetzt ist klar, dass sich hinter dem Symptom viele Erkrankungen verbergen, die nur eines gemeinsam haben: ein Versagen der Komplemente. Einst als schicksalhaft angenommen, gibt es nun neue Therapieoptionen für die verschiedenen Angioödeme. Um gezielt zu behandeln, dürfen diese jedoch nicht verwechselt werden.

Abstract:

Abstract: BACKGROUND: According to special arrangements in private accident insurance, it is now possible that tinnitus as exclusive sequel (psychogenic tinnitus) can be compensated. This new situation leads to the unanswered question of how such a psychogenic (somatoform) tinnitus should be compensated in regard to the valid compensation tables. METHODOLOGY AND RESULTS: The differentiation between an otogenic and somatoform tinnitus allows a judgement as defined by the general terms and conditions of the private accident insurance. An individual compensation of 5 % or of a complex, decompensated tinnitogenic psycho-syndrome 10 % of the sum insured is proposed. CONCLUSIONS: All impairment of the psychic function as exhaustion, nervous excitability, sleeplessness, depression and concentration disturbances are included in this invalidity of 10 %. In case of a tinnitogenic psycho-syndrome, the medical assessment should be done by a neurologist/psychiatrist.

Abstract:

Abstract:

Abstract: Der Hörsturz selber ist aber nach wie vor als ei von der Ursache her unklares Ereignis verschiedener möglicher auslösender Faktoren anzusehen. Unter diesen Ursachen können auch Faktoren sein, die mit der Schwangerschaft als soicher direkt oder indirekt in Verbindung stehen. Em für die Behandlung des Hörsturzes zugelassenes Medikament ist Pentoxifyllin (Handeisname Trental®). Trental® 400 als Tablette stelit das einzige zugelassene Produkt dar, das auch bei Kindern und stillenden Müttern mit der Indikation >>Hörsturz<< verwendet werden kann. Es liegen mehrere Veröffentlichungen vor, in denen Pentoxi1rl- un auch während der Schwangerschaft gegeben wurde. Es liegen keine Benchte vor, die eine mogliche Gefahrdung beschreiben. Auch von frauenärztlicher Seite wurden bisher keine Einwände laut, wenn sie danach gefragt wurden. Daher wird Pentoxifyllin auch hàufig als Infusion in physiologischer Kochsalz-Lösung in die Vene verabreicht. Der Hersteller allerdings gibt an, dass ausreichende Erfahrungen über die Anwendung beim Menschen nicht vonliegen würden. Der Tierversuch habe keine Hinweise auf Fehibildung erzeugende Wirkungen erbracht. Em weiteres Medikament, für das einige Hersteller lediglich eine strenge mdikationsstellung vorgeben, aber keine Kontraindikation in der Schwangerschaft sehen, ist das pflanzliche Praparat Ginkgo-biloba-Extrakt. Dies ist besonders zu empfehlen, wenn em Ohrgeräusch im Vordergrund der Erkrankung steht oder das Ohrgerausch als belästigender als der Hörvenlust empfunden wird oder em aus der Naturheilkunde stammendes Prâparat gewünscht wird.

Abstract: Die in der Literatur bisher veröffentlichten zahlreichen Originalarbeiten, Reviews (1), Metanalysen (2,3), Guidelines (4) und nicht zuletzt ein Cochrane-Review (5) sprechen überwiegend für eine Gabe von Gluccorticoiden bei der Tonsillektomie, indem sie eine Signifikanz hinsichtlich des geringeren Auftretens von postoperativem Erbrechen nachwiesen. Allein die Dosis, die für einen solchen Effekt ausreicht, ist noch nicht standardisiert und wurde bisher empirisch gewählt. Daher wollten Kim und Mitarbeiter eine noch vertretbare untere Dosierung finden und konzipierten die vorliegende Dosis-Wirkungsfindungs-Studie. Sie hatten eine Abstufung der Wirkung in Abhängigkeit von der jeweiligen Dosis erwartet, mit einer Grenzdosis, die gerade noch genügend Wirksamkeit erbracht hätte. Randomisierte, verblindete Studien können aber auch unerwartete Resultate erbringen: in dieser Studie hatten selbst die Ausführenden das Ergebnis nicht vorhergesehen, nämlich dass eine in ihren Augen an der Placebo-Grenze liegende, geringe Dexamethasondosis unerwarteter Weise die gleichen Erfolge zeigte wie die Gabe einer 15-fach höheren Dosis von 1 mg/kg KG. Für 1 mg/kg KG Dexamethason waren in einer anderen Studie von Pappas und Mitarbeiter (6), auf die sich auch Kim und Mitarbeiter bezogen, gegenüber Plazebo eindeutige Ergebnisse erzielt worden. In der Plazebo-Gruppe erbrachen 88 % aller Kinder, während in der Dexamethason-Gruppe das Erbrechen nur bei 44 % der Kinder postoperativ auftrat (6).

Abstract:

Abstract: Auslöser bei der CRS sind u. a. von Bakterien produzierte Superantigene (SAG), die an den �major histocompatibility complex II� (MHC-II) und an T-Zell Rezeptoren binden. Sie lösen in geringsten Mengen eine massive Ausschüttung von Interleukin-2 (IL-2) und anderen Zytokinen aus und bewirken eine Dysregulation des Immunsystems (2). Im Verband mit der Bildung von Biofilmen stellen diese Bakterien einen konstanten Trigger für eine (chronische) Entzündung dar. Biofilme sind strukturierte, spezialisierte Bakterienkolonien, die sich in einer extrazellulären Polymersubstanz (EPS) einschlie�en und so untereinander schnell Informationen z. B. über die Ausbildung von Antibiotikaresistenz austauschen können und dadurch weniger stark dem schädigenden Einfluss von Antibiotika ausgesetzt sind. Zur Biofilm-Bildung neigen Staphylokokken, z. B. auch der Methicillin-resistente Staphylococcus aureus (MRSA). Trotz aller medikamentösen Neuentwicklungen wird in allen Leitlinien nach wie vor die Gabe von Cortison als Standardbehandlung empfohlen. Dabei stellen die oberflächenwirksamen Cortisonsprays unangefochten die erste Wahl in der Behandlung dar. Dies gilt durch viele kontrollierte Studien als gesichert, so dass diese Erkenntnis den Level Ib nach der Cochrane-Gruppe und einen Empfehlungsgrad �A� erreicht (so wie kürzlich wieder im EP3OS �European Position Paper on Rhinosinusitis and Nasal Polyps 2007� der European Academy of Allergology and Clinical Immunology (EAACI) niedergelegt). Topisch angewandte Glucocorticoide wie Budesonid, Beclomethason, Fluticason, aber auch Triamconolon wirken auf vielen molekularen Ebenen hauptsächlich an den Oberflächenzellen der Nasenschleimhaut. Sie binden an einen spezifischen zytoplasmatischen Glucocorticoid-Rezeptor. Dies führt zu einer Verminderung der Zahl Antigen-präsentierenden Zellen, aktivierter T-Zellen, eosinophiler Granulozyten sowie von Mastzellen. Nach dem EP3OS sollen systemische Glucocorticoide eingesetzt werden, wenn eine CRS mit derart massiven Nasenpolypen vorliegt, dass Atmung und Geruchvermögen eingeschränkt sind oder zusätzlich ein Asthma bronchiale vorliegt. Die systemische Anwendung wird durch die durchgängige klinische Erfahrung gestützt, dass Nasenpolypen auf Cortison so gut reagieren, dass sie � im Klinikerjargon � �dahinschmelzen wie Butter in der Sonne�. Leider � und das zeigt die klinische Erfahrung auch � ist es aber kein Effekt auf Dauer. Nach Absetzen kommen die Polypen in gleichem Umfang wieder. Vor diesem Hintergrund kommt der operativen Therapie der CRS mit Nasenpolypen nach wie vor ein hoher Stellenwert zu (1).

Abstract:

Abstract: BACKGROUND: Laryngeal cancer as an occupational disease in the rubber industry is under subject of continuous epidemiological research because of the lack of stable statistical data. METHOD: Epidemiological studies published in the period between 1982 and 2006 were analysed in regard of the risks employment and laryngeal carcinoma. 23 own cases of medical expert opinion and the documentation of the German Occupational Cooperatives were analysed. RESULTS: A significant statistical correlation between a specific exposition to cancerogenics in the rubber industry and a development of laryngeal carcinoma could not be found in the literature, still there is evidence for an increased mortality. It points to asbestos, talcum, dust as one risk factor. CONCLUSION: Recognition and compensation for laryngeal carcinoma according to [section sign] 9 Abs. 2 SGB VII is possible after intense individual investigation, although up to now no clear statistical evidence for the coincidence between employment in the rubber industry and general could be proven.

Abstract: Head and neck cancer can be caused by the occupational contact with cancerogenic substances, which contribute to the formation of cancer. The knowledge about those cancer entities which are frequently found under similar circumstances and working conditions, helps for getting compensation and alternatively for a realistic view when other influences--particularly lifestyle factors like smoking, alcohol and nutrition--have mainly contributed for the origin of the cancer disease. Our knowledge increases and therefore it is helpful from time to time to keep up to the state-of-art of cancer genesis. This article has two parts: part I deals with occupational cancer diseases, which are listed in a decree of the German government and part II deals with the cancer diseases, which could likely be caused by occupational factors according to latest scientific findings and are not yet listed.

Abstract: Until 2004, tinnitus was vieved as a psychic reaction according to the provisions of private accident insurance and therefore excluded from compensation. In two recent judgements of the Federal Supreme Court in Germany the assessment of tinnitus in private accident insurance has been newly defined. According to this jurisdiction, the compensation of tinnitus is possible, when a proven physical defect in the inner ear or the auditory pathway (hearing loss) can be established and has a causal connection to the accident. This leads to the question of how a quantitative assessment of tinnitus can be carried out. The compensation should be in accordance to the general terms and conditions of private accident insurance. A compensation table is proposed, which recognises the physical defect of tinnitus and is based on medical and scientific findings of the relation between hearing loss and tinnitus.

Abstract: Substances such as cement dust, polycyclic aromatic carbonhydrates (PAC), diesel exhaust and lubricatant cooling may contribute to the formation of cancer, but are not yet recognized as to be causing occupational cancer. By decree, these diseases can be recognized for compensation when there is enough new evidence for causality. The knowledge about these conditions is crucial for judgement. The technical supervisory board of the Employer's Liability Insurance Association should be asked to report information about the working place concentration of the accused substances before a decision can be made, because life-style factors (alcohol, smoking, nutrition) may contribute also.

Abstract: According to the provisions of private accident insurance, mental or psychic reactions are excluded from compensation. Until now, tinnitus was taken as fully psychic and therefore excluded. In two recently published judgments of the Federal Supreme Court in Germany the assessment of tinnitus in private accident insurance and particularly the exclusion clause section sign 2 Abs. 4 AUB 88 has been newly defined. According to this actual jurisdiction the compensation of tinnitus could be possible, when as physical underlying reason a proved harm in the inner ear or the auditory pathway (hearing loss), which can be traced back to the accident according to the rules of causality. This leads to the question how Tinnitus could be compensated without modification of the general terms and conditions of the private accident insurance. A compensating table is proposed, which recognizes the somatic (physical) part of tinnitus and is based on medical and scientific findings of the relation between hearing loss and tinnitus.

Abstract: OBJECTIVE: A clinical staging system for children with lymphatic malformations that would allow for a standardized comparison of disease and treatment outcomes. METHODS: We developed an examination sheet for the determination of a disease score ranging from 0 (worst) points to 10 (best) points, Cologne Disease Score (CDS). Disfigurement, dysphagia, dysphonia, dyspnea and an observer statement towards progression were contributing to CDS. Each parameter yielded two, one or zero points. Two points were given when no limitation was seen in the patient concerning the respective item. One point was given at mild limitation and zero points were given when considerable limitation in the respective item could be observed. We evaluated 26 patients with lymphatic malformations of the head and neck retrospectively by completing one examination sheet for each patient-visit. RESULTS: Four patients had an initial CDS value of three or less points (severe disease-group). After therapy the mean value of their score increased only slightly to 3.9+/-2.6 points. Six patients had an initial CDS value of four, five or six points (advanced disease-group). After treatment their mean score value increased dramatically to 9.0+/-1.5 points (P<0.001). Sixteen patients initially had seven points or higher (moderate disease-group), they had 9.8+/-0.4 points after treatment. CONCLUSIONS: The evaluation of the CDS was easy and expeditious. The score itself was a good predictor in view of the outcome. This new disease score for paediatric patients might be appropriate to evaluate therapeutic trials in paediatric patients.

Abstract: Nasal irrigation has proven in several recently published articles its clinical effectiveness and its neglectable rate of side effects even in children and during pregnancy. In most guidelines for the treatment of various nasal pathological conditions nasal irrigation is recommended as stand alone or as additional therapy. Although no common treatment protocol exists, a isotonic (0.9 %) or slightly hypertonic solution (3 - 5 %) is suggested because of its positive influence upon mucociliary clearance. Buffered solutions bring a more pleasant feeling during rinsing, which explains also the beneficial effect of natural brine solutions. In children, nasal irrigation can save antibiotics and reduce decongestant to nil. Important is the hygienic application in order not to introduce additional pathogenic germs into the nasal system.

Abstract: In two recently published judgments of the Federal Supreme Court in Germany dating June 23rd, 2004 (IV ZR 130/03) and September 29, 2004 (IV ZR 233/03) the assessment of tinnitus in private accident insurance and particularly the exclusion clause section sign 2 Abs. 4 AUB 88 has been newly defined. This exclusion clause is still valid according to the actual jurisdiction in the case a tinnitus is asserted following an accident without any organic (physical) damage. In this case tinnitus has to be regarded as mental (psychic) reaction in the meaning of paragraph 2 AUB. According to the actual jurisdiction the compensation of tinnitus could be possible, when as physical underlying reason a proved harm in the field of the inner ear or the auditory pathway is found, which can be traced back to the accident according to the rules of causality.

Abstract: In Germany, the in-patient treatment of sudden deafness is possible according to the indications given in the guide-lines of the Association of the Scientific Medical Societies. But public and private health insurances often reject bearing the costs later. Their arguments are that there is no rational justification for an in-patient treatment for lack of evidence and that any treatment could be done also on an out-patient basis. Hospitals sued these insurances and now judgments - particular of the Federal Supreme Court (FSC) - are published which strengthen the legitimacy of an in-patient treatment under certain circumstances. According to the law suits, the hospital doctor is mainly responsible for the indication of hospitalization. Also the FSC stressed that the chosen treatment in the hospital can not be questioned retrospectively by the insurance company as long as it is within good medical practise (see guide lines). The grade of evidence is not the decisive factor. The only institution, which can exclude treatments from being practiced in a hospital, according to the German Social Security Code, is the Federal Joint Committee Hospital. The treatment protocol itself must reveal the necessity of hospitalization (need for surveillance, side effects etc.).

Abstract: The protein kinase Akt (protein kinase B) can be activated by numerous growth factors via PI-3 kinase-generated phosphoinositides and is thought to have anti-apoptotic properties. Activated Akt/PKB boosts the activity of endothelial NO synthase (NOS III), which has been found in the key areas of the inner ear (e.g., hair cells and stria vascularis). In order to localize activated Akt/PKB (phospho-Akt) in the cochlea of guinea pigs, sections of ten temporal bones were observed immunohistochemically. The strongest immunoreactivity was found in and underneath inner hair cells (IHC). Within the organ of Corti, reactivity was found in supporting cells, while outer hair cells remained unstained. Spiral ganglion cells, the endothelium of the lateral wall and the vascular area of the modiolus showed moderate staining. The results give evidence that activated Akt/PKB influences the activity of the NO/cGMP pathway in the cochlea. Because of the antiapoptotic properties, activated Akt should now be examined under non-physiological conditions.

Abstract: The aim of this study was to investigate the involvement of oxidative stress and apoptosis in an animal model of Meniere's disease. Endolymphatic hydrops (ELH) is generally accepted as the decisive histological characteristic of Meniere's disease. Closure of the endolymphatic duct (Kimura's method) was used to induce endolymphatic hydrops in guinea pigs. Sham-operated animals served as controls. After 4 weeks the animals operated showed a significant elevation of the hearing thresholds as measured by audiometric brainstem responses (ABR) pre- and postoperatively. Immediately after the second ABR measurement, the animals were sacrificed for further immunohistological examinations of the inner ear with specific antibodies to active caspase-3 (cas-3) as a marker for apoptosis and antibodies to 8-isoprostane (8-iso) and nitrotyrosine (NT) as indicators of oxidative stress. Compared with the sham-operated controls, hydropic cochleae showed strong immunostaining for both oxidative stress markers in spiral ganglion cells, in the blood-vessels and fibrocytes of the lateral wall, as well as in supporting cells of the organ of Corti. Activation of cas-3 in spiral ganglion cells and the lateral wall was found exclusively in hydropic cochleae. Our findings suggest that oxidative stress is involved in the development of endolymphatic hydrops and may lead to cellular damage which induces apoptosis by activation of cas-3. Apoptotic cell death might contribute to the sensorineural hearing loss found in later stages of Meniere's disease.

Abstract: Ger Med Sci. 2005; 3: Doc04. Published online 2005 June 23. PMCID: PMC2703248 Copyright © 2005 Michel et al. β-trace protein (prostaglandin D synthase) - a stable and reliable protein in perilymph Olaf Michel,*1 Stephan Bamborschke,2 Marko Nekic,2 and Gregor Bachmann3 1University of Cologne, Department of Otorhinolaryngology, Head and Neck Surgery, Cologne, Germany 2University of Cologne, Department of Neurology, Cologne, Germany 3University of Tromsoe, Department of Otorhinolaryngology, Tromsoe, Norway *To whom correspondence should be addressed: Olaf Michel, Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Universität zu Köln, 50924 Köln, Tel.: +49-221-478-86635, Fax: +49-221-478-86636, E-mail: michel@uni-koeln.de This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free to copy, distribute and transmit the work, provided the original author and source are credited. * Other Sections� o Abstract o Introduction o Subjects and methods o Results o Discussion o References Abstract Objective: Beta-trace protein (β-TP) has been analysed in human cerebrospinal fluid (CSF) and other body fluids. Beta-trace protein is a very sensitive and specific clinical marker and can confirm reliably the presence of CSF in patients with a suspected CSF leakage. Design: Perilymph specimens from the scala vestibuli (n=10) and from the lateral semicircular canal (n=4) were taken from patients undergoing stapedotomy or surgery for acoustic neuroma. During post-mortem examinations perilymph specimens from the scala vestibuli (n=70), the scala tympani (n=11), endolymph specimens (n=21) and CSF specimens (n=17) were obtained. All specimens were analyzed by a one-dimensional immunoelectrophoresis using a polyclonal, monospecific antibody. Results: Specimens from live surgery showed a mean concentration of 51.5 ± 48.9 mg/l β-TP in scala vestibuli perilymph. Specimens from post-mortem examinations revealed a mean concentration of 49.1 ± 17.7 mg/l in CSF, 71.9 ± 29.3 mg/l in perilymph and 68.0 ± 21.7 mg/l in endolymph. There was no evidence of a circadian alteration of β-TP in CSF or inner ear fluids. Conclusions: Our results demonstrated clearly that β-TP is contained in human perilymph and endolymph. This is the first published data that point out the aptitude of the β-TP-test in verifying traces of p

Abstract: We set out to determine predisposing psychosocial and personality factors of experienced distress in chronic, decompensating tinnitus by a prospective investigation of 48 patients at two points: within 4 weeks of first tinnitus symptoms, and 6 months later, by sociodemographic, otological and psychological findings in a test battery [Symptom Checklist-90-Revised, Freiburger Persönlichkeitsinventar, Tinnitus Questionnaire]. Data were processed by multiple regression analysis. Forty-four patients (92%) returned complete data sets. Thirty-four patients displayed chronic tinnitus. The factors sleeping disturbance attributed to tinnitus, anxiousness and satisfaction with own life, each at the time of the first investigation, could explain 56% of variance of tinnitus distress at the time of the second investigation. Our results suggest that patients with psychological disturbances and sleeping difficulties at first presentation shortly after the onset of tinnitus have a higher risk of developing tinnitus-related distress. We suggest that our results support the fact that early psychosocial intervention in patients at risk may prevent development of chronic tinnitus with high psychological distress.

Abstract: In this study, the temporal shape of voice-induced nitric oxide (NO) signals in exhaled air has been investigated in eight healthy individuals by means of laser magnetic resonance spectroscopy. The results of the experimental part have been compared with calculated signals obtained by using a simple one-compartment model of the paranasal sinuses. In the experimental part, a rapidly increasing NO concentration has been found when the subjects started humming. After reaching a maximum, the emission starts to decrease with the shape of an exponential decay and finally reaches a constant level. The time constant of this decay (NO washout) is 3.0 +/- 1.2 s. The peak height of the NO emission during humming increases when the time between two humming processes increases. When no voice-induced NO emission takes place, the NO concentration in the paranasal sinuses rebuilds again to a maximum concentration. The typical time constant for the NO recovery is 4.5 +/- 3.2 min. A three-compartment model defining exactly the geometry and anatomy of the paranasal sinuses has been developed that is based on three main assumptions of the NO dynamics: 1) constant NO production of the epithelium in the sinuses; 2) the rate of the chemical reaction of NO with the epithelium of the paranasal sinuses is proportional to the NO concentration; and 3) the emission of NO from the sinuses (volume/s) is proportional to the NO concentration. It is shown that the three-compartment model under the experimental conditions can be reduced to a one-compartment model, which describes the complete temporal behavior of the NO exchange.

Abstract: OBJECTIVE: To study the significance by analyzing the expression of angiopoietin-1 (Ang-1) and Angiopoietin-2 (Ang-2) in the tissues of squmaous cell carcinoma (SCC) of the head and neck areas and in normal mucosa tissues. METHODS: The expression of Ang-1 and Ang-2 in 45 tumor samples and 7 normal mucosa tissues were determined by the immunohistochemical method with avidin-biotin-peroxidase complex technique. The results were scored by two independent observers and analyzed statistically. RESULTS: The positive expression of Ang-1 and Ang-2 existed in the endothelial cells, epithelial cells and also in SCC cells. The positive expression rates of Ang-1 in tumor samples was 78% in the endothelial cells, and 87% in SCC cells. The positive expression rates of Ang-2 in tumor samples was 69% in the endothelial cells, and 76% in SCC cells. The scores of positive expression of Ang-1 and Ang-2 were higher in endothelial cells and in SCC cells of tumor tissues than that of normal mucosa tissues (rank sum test, P < 0. 05). There was positive correlation between the expression of Ang-1 and Ang-2 in the endothelial cells and also in SCC cells (Chi-square test with contingency table, P < 0.05). Ang-1 expression in endothelial cells of tumor tissues was higher in clinical stage III-IV than that in clinical stage I-II (rank sum test, P < 0.05). Ang-2 expression in both endothelial cells and SCC cells, were higher in clinical stage II-IV than that in clinical stage I-II (rank sum test, P < 0.05). There was no statistical significance for degrees of Ang-1 and Ang-2 expression in different histological grades (P > 0.05). CONCLUSIONS: The expressions of Ang-1 and Ang-2 in advanced SCC were remarkable. Ang-1 and Ang-2 may play a critical role during the progress of SCC of head and neck areas.

Abstract: The treatment of rhinosinusitis seen in the light of uncertain pathogenesis and variable symptoms is under discussion and ranges from the administration of antibiotics, decongestants and anti-allergic agents to no treatment. In this randomized, prospective, double-blind and controlled study the effect of a 14-day treatment (1-2 sprays into each nostril t.d.) with either isotonic Ems Mineral Salts (EMS) solution (Siemens & Co., Bad Ems, Germany) or xylometazoline solution (0.05%) was tested in children (n=66) aged 2-6 years. Main outcomes: the degree of mucosal inflammation, nasal patency, general state of health, condition of the middle ear, auditory function as well as an assessment of complaints by the parents. With the exception of the hearing defects, all parameters showed a clear improvement in both treatment groups at the end of the observation period (p>0.001). The hearing defects showed only a trend towards improvement. At the end of the study no differences between the treatment groups could be determined. However, at the intermediate examination after the first 7 days of treatment more favourable results were seen in the group treated with EMS. No undesired medicinal effects were observed, although in 7 out of 34 cases the nasal spray was improperly used in the group treated with xylometazoline. The results of the study show that there is no difference in efficacy between an exclusive treatment by EMS solution in children aged 2-6 years and a treatment with xylometazoline, but with the distinction that with EMS the length of use was not restricted, there were not the potential side effects of nasal decongestants, and there was no contraindication in the newborn and infants.

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Abstract: A diagnosis of perilymphatic fistula is still controversial. Recently, a case report indicated that beta-trace protein (prostaglandin D synthase) might be a potential marker for perilymphatic fluid. In this multicentre clinical case series study beta-trace protein was used as a marker for perilymphatic fluid fistula. Fifteen fluid samples were collected during diagnostic tympanoscopy. In addition, five samples were collected from patients with tympanic membrane perforation for use as as negative controls. Samples were obtained using precision glass capillaries and were analysed for beta-trace protein using laser nephelometry. The diagnosis of perilymphatic fistula was defined by the patient's history, the audiological and vestibular investigation and the findings at tympanoscopy. The cut-off level of beta-trace protein for perilymph-positive samples was chosen at 1.11 mg/l. The sensitivity and specificity were calculated using a 2 x 2 contingency table. There was no false positive result, but in two cases a false negative result was found. The specificity was 1 and the sensitivity was 0.81. The material of this first clinical study is small owing to the rarity of patients undergoing diagnostic tympanoscopy for perilymphatic fluid fistula. However, according to these preliminary results beta-trace protein might be a promising marker in the diagnosis of perilymphatic fluid fistulas.

Abstract: BACKGROUND: The available cross-sectional and retrospective evidence does not provide a clear answer to the question whether the multiple psychological problems and disturbances found in patients with chronic decompensated tinnitus are cause or consequence of the tinnitus. The present research took a longitudinal approach to examine this question. METHOD: Psychopathological symptoms, personality, socio-demographical variables and otological features were assessed in 48 patients which had suffered from tinnitus for a period of no longer than 4 weeks. Six months after first assessment 92 % of the original sample (n = 44) were re-examined. 34 of these patients displayed chronic tinnitus. Univariate and multiple regression analyses were conducted in order to identify variables at first assessment which predicted tinnitus distress at second assessment for the 34 patients with chronic tinnitus. RESULTS: Tinnitus attributed sleep disturbance, anxiousness, and life satisfaction, each assessed at first investigation, independently predicted tinnitus distress at second assessment six months later. These three variables together predicted 56 % of the variance of tinnitus distress at second assessment. CONCLUSIONS: Our results support the model that the symptom tinnitus may develop on the basis of an enhanced psychophysiological tension and become a condensational core of preexisting psychological distress as a facilitatory process. Our results suggest that early psychotherapeutic interventions in patients at risk may prevent decompensation.

Abstract: Loud acoustic stimulation is known to cause inner ear disturbance. We examined immunohistochemically the vestibule of 12 guinea pigs after acoustic stimulation. The animals were divided into two equal groups: a control group and an acoustic stimulation group. The temporal bones were fixed by means of a cardiac infusion of fixative and immunohistochemically stained for inducible nitric oxide synthase (iNOS). The temporal bones in the control group did not show any iNOS. In the acoustic stimulation group, immunoreactivity for iNOS was detected in the supporting cells and sensory cells of the sensory epithelium, in the dark cell areas and in the vestibular ganglion cells. These findings suggest that free radicals are involved in the pathogenesis of noise-induced inner ear damage. Furthermore, free radicals may cause vestibular damage, as is seen in noise-induced inner ear damage.

Abstract: A prerequisite for a qualified analysis of nystagmus is the recognition of uncommon forms of this condition. In internuclear ophthalmoplegia (INO), a dissociated nystagmus in side gaze is typical. This is accompanied by limited medial excursion of the adducted eye together with a dissociated nystagmus, which is stronger in the abducting fellow eye. This motility disturbance stems from a lesion in the medial longitudinal fasciculus running in the brain stem between the sixth and the third nerve nuclei. The lesion is often due to multiple sclerosis, but can also be ischemic, traumatic, neoplastic or inflammatory (e.g. HIV infection).

Abstract: OBJECTIVE: The auriculotemporal syndrome is known worldwide as Frey's syndrome. However, the Jewish physician Lucja Frey, after whom it was named, has fallen into obscurity. The little information about her is fragmentary, contradictory, and often incorrect. STUDY DESIGN: To reconstruct the life of Lucja Frey, who was murdered by the Nazis in her native town of Lwów, it was imperative to look for original documents as irrevocable proof of her life. METHODS: During this research, more than 100 archives and institutions in 8 countries have been contacted. RESULTS: With the archive materials, it was possible for the first time to create a complete picture of the life of this fascinating physician. Furthermore, her day of death, unknown until now, could be determined with great plausibility. The lasting impression is not only of a tragic death under the Nazis but also of a tragic life as a whole. CONCLUSION: Lucja Frey would have been forgotten if not for the eponym Frey's syndrome. In this way, she is remembered not only as an unusual woman, physician, and scientist but also as one of millions of Jews murdered by the Nazis. This may be the only key remaining to prevent the repetition of one of the most haunting and devastating times in history.

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Abstract: Patienten mit einer Schwellung in der Parotisregion suchen in aller Regel den niedergelassenen HNO-Arzt auf. Hier werden die Weichen gestellt, ob das Geschehen beherrschbar bleibt oder zu einer Katastrophe mutiert. Vor blindem diagnostischen oder gar therapeutischen Aktionismus ist jedoch zu warnen.

Abstract: OBJECTIVE: The present study was to analysis the pharmacokinetics of prednisolone-21-hydrogensuccinate in the perilymph after local and systemic application. METHOD: On the local application, 5% prednisolone-21-hydrogensuccinate was directly applied into the round window niche under the microscopy. On the systemic application, the drug (60 mg/kg) was used intraperitoneal. Perilymphatic samples were obtained after variable periods of application. Levels of prednisolone-21-hydrogensuccinate in perilymph were measured by using HPLC. RESULT: The highest level of the drug was on (952.3 +/- 382.7) mg/L after 180 min. And remained on (18.72 +/- 16.97) mg/L after 960 min in the local application groups. In the systemic application group, the highest level of the drug was on(14.71 +/- 7.05) mg/L after 150 min. CONCLUSION: The results demonstrate that high levels and long time remain of prednisolone-21-hydrogensuccinate in perilymph are achievable by a single dose local application into the round window niche.

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Abstract: BACKGROUND: The response to lipopolysaccharide exposure is highly variable and might be a result of genetic diversity between individuals. The toll-like receptor 4 (TLR-4) is the principal receptor for lipopolysacharide. OBJECTIVES: We investigated the association between single-nucleotide polymorphisms in the TLR4 locus and levels of systemic inflammatory markers in response to lipopolysaccharide. METHODS: Healthy subjects (n = 116) were genotyped for the most frequent polymorphisms found in the promoter and coding region of the TLR4 gene (-2026A/T, -1607T/C, +896A/G, and +1196C/T relative to the translation start site). Subjects were challenged with 20 microg lipopolysaccharide by inhalation. RESULTS: Polymorphisms at +896 and +1196 were in complete linkage disequilibrium, and no homozygotes for the less common allele, G and T respectively, were found. After lipopolysaccharide inhalation, subjects heterozygous for either TLR-4/+896 or TLR4/+1196 had significantly lower numbers of white blood cell counts and lower levels of C-reactive protein and lipopolysaccharide-binding protein compared with homozygotes with the common allele. None of the heterozygous subjects (n = 18) except 1 were high responders to lipopolysaccharide (defined as a rise in C-reactive protein > 10 mg/L), whereas 36 of 98 homozygous subjects were high responders (P <.02). No association was observed between the TLR-4/-2026 and TLR-4/-1607 polymorphisms and lipopolysaccharide responsiveness. CONCLUSION: The single-nucleotide polymorphisms at position +896 or +1196 in the TLR-4 gene is associated with systemic inflammatory hyporesponsiveness to inhaled lipopolysaccharide.

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Abstract: Growth factors such as vascular endothelial growth factor (VEGF) exert their proliferative properties partly through activation of mitogen-activated protein kinase/extracellular signal-regulated kinase (MAPK/ERK1/2). Although both VEGF and inactive ERK could be detected in the inner ear of guinea pigs, under normal conditions activated ERK (phospho-ERK) was found only sparely. Cochleae of adult guinea pigs were removed, incubated with VEGF in a carbogen-gased organ-bath for 5, 15, 30 and 60 min (n=6 in each group), fixed with PFA 4%, embedded in paraffin and sectioned, followed by immunohistochemical staining to inactive and active ERK. Whereas inactive ERK was found in all cochleae, in sensory and supporting cells of the apex activated ERK was strongly detected after 5-min VEGF-incubation. After 15 min all Corti-organs showed clear staining corresponding to activated ERK, which decreased again after 30 min. Faint staining in endothelial cells of the spring-coil-vessels and in the spiral ganglion cells was found after 30 min and was increased after 60 min, while the staining in the Corti-organs vanished. Addition of the MEK-inhibitor PD 98059 to the organ-bath led to diminished phospho-ERK1/2 immunostaining. These findings provide evidence for a VEGF-dependent phosphorylation of ERK1/2 in the cochlea. Activated ERK1/2 is thought to support axonal outgrowth, enhancement of cell survival and to regulate the turnover of the NO/cGMP-pathway.

Abstract: BACKGROUND: Cisplatin (CDDP) is known to cause inner ear damage while carboplatin (CBDCA) induces less ototoxicity than CDDP. We examined apoptotic changes in the cochlea of guinea pigs after injection of CDDP or CBDCA using immunohistochemical and electrophysiological techniques. METHODS: Three days after the injection of each solution, the cochleas were immunohistochemically examined for the presence of fragments of single-stranded DNA (ssDNA). The auditory brain stem response was recorded before and three days after the injection. RESULTS: We detected fragments of ssDNA in the stria vascularis and the spiral ligament of the CDDP-treated cochlea. In this group, the threshold of the auditory brainstem response was significantly elevated, however, in the CBDCA group, no apparent change of the threshold was detected. In the CBDCA group, fragments of ssDNA were detected in the stria vascularis and the spiral ligament. The number of cells that stained positive for ssDNA, was less than that in the CDDP group. CONCLUSIONS: Our findings indicate that CBDCA induces less apoptosis than CDDP and that this phenomenon contributes to the ototoxicity of CDDP.

Abstract: Most patients with neurofibromatosis type 2 (NF2) lose hearing either spontaneously or after removal of their neurofibromas. The patient may benefit from conventional hearing aids if, due to modern microsurgery and intraoperative monitoring the integrity of the cochlea and the 8th nerve is preserved. With lost auditory function but preserved electrical stimulibility of the 8th nerve a cochlear implant may be appropriate. But if the patients have no remaining 8th nerve to stimulate, there is no benefit from cochlear implants. Until some years ago, vibrotactile aids, lip-reading, and sign language have been the only communication modes available to these patients. With auditory brain stem implants it is now possible to bypass both the cochlea and the 8th nerve and to stimulate the cochlear nucleus directly. Stimulation of the devices produces useful auditory sensations in almost all patients. Testing of perceptual performance indicated significant benefit from the device for communication purposes, including sound-only sentence recognition scores and the ability to converse on the telephone. Also lip-reading is significantly improved with brain stem implants. The successful work of an auditory brainstem program center depends very much on the close interdisciplinary collaboration between the Departments of Neurosurgery and ENT-surgery. In the future new developments like speech processing strategies and new designed electrodes accessing the complex tonotopic organization of the cochlear nucleus may further improve rehabilitation in these patients who would have been deaf some years ago.

Abstract: OBJECTIVE: beta-Trace protein (beta-TP) is an immunological marker for the detection of cerebrospinal fluid traces. The aim of the study was to evaluate the predictive values of a new research assay for beta-TP. METHODS: A total of 154 specimens from patients with otorrhea or rhinorrhea were investigated for cerebrospinal fluid (CSF) by use of a laser-nephelometric assay for beta-TP. Samples were obtained between January 1994 and November 2000. A sample was reported to be positive for CSF when the beta-TP concentration was more than 6 mg/L. Case evaluations were performed retrospectively and tabulated for indication, clinical course, additional investigations, surgical procedure, and follow-up. RESULTS: beta-TP was detected in 16 specimens; 138 samples were negative for beta-TP with a value less than 3 mg/L. One sample was suggestive of CSF traces at 4.6 mg/L. In correlation with the clinical course, the intraoperative findings, intraoperative visualization with sodium fluorescein, high-resolution computed tomography of the paranasal sinuses or the petrous bone, computed tomographic cisternography, magnetic resonance imaging, and radionuclide cisternography, there was no false-positive result. On four occasions, false-negative results occurred, with an overall accuracy of 0.974. The beta-TP test had a negative predictive value of 0.971 and a positive predictive value of 1. CONCLUSION: Analysis of betas-TP via the nephelometric assay is a valuable and reliable test in cranial base surgery for the identification of CSF.

Abstract: BACKGROUND: beta-trace protein is an immunological marker for cerebrospinal fluid or inner ear fluids. We present two initial cases in which a beta-trace protein nephelometric assay provided immunological proof of perilymph in samples taken from the nasopharynx. PATIENTS AND METHODS: Two cases are presented of an acute vestibulocochlear disorder following stapedotomy. Fluid samples, taken from the nasopharynx, were investigated using beta-trace protein laser nephelometry. The samples were collected using Merocel tamponades, which were left in place over night. RESULTS: In both cases, the samples were positive for beta-trace protein. Tympanoscopy was performed and the oval window was closed. After tympanoscopy a partial recovery of the hearing impairment was observed. CONCLUSION: Using beta-trace protein, it seems to be possible to diagnose a perilymphatic fistula by noninvasive means.

Abstract: The factors involved in the development of chronic inflammation and edema in nasal polyps remain to be clarified. The expression of vascular endothelial growth factor (VEGF) has been described in plasma cells, suggesting that plasma cells may play a major role in the development of edema in nasal polyps through the production of VEGF. We performed immunohistochemical analysis using specific antibodies to VEGF and to the known VEGF receptors, VEGFR-1 and VEGFR-2, on paraffin sections of human nasal polyps ( n=11) and controls of human mucosa of the normal middle turbinates ( n=6). In normal turbinate mucosa, sporadic immunostaining for VEGF was observed throughout the endothelial cells of the small veins and arteries. VEGFR-1 and VEGFR-2 expression was faint in the healthy turbinates. In nasal polyp tissues, strong immunostaining for VEGF was found in the endothelium of blood vessels and in the infiltrating perivascular inflammatory cells. Fibroblasts also stained for VEGF. Strong immunolabeling to VEGFR-1 was evident in the vascular endothelium, whereas weak to moderate VEGFR-1-staining was generally confined to scattered mononuclear round cells. Mononuclear round cells and the endothelium of capillaries revealed immunoreactivity to VEGFR-2. These findings support a role for VEGF and its receptors, VEGFR-1 and VEGFR-2, in the development and perpetuation of edema and angiogenesis in nasal polyps.

Abstract: Paragangliomas or glomus tumours of the head and neck region are rare somatostatin receptor-expressing neuroendocrine tumours. Precise preoperative diagnosis is of special importance in order to adequately weigh the potential benefit of the operation against the inherent risks of the procedure. In this study, the clinical value of somatostatin receptor imaging was assessed in 19 patients who underwent somatostatin receptor scintigraphy because of known or suspected paraganglioma of the head and neck region. The results were compared with the results of computed tomography and/or magnetic resonance imaging, histology and clinical follow-up. [(111)In-DTPA- D-Phe(1)]-octreotide scintigraphy was performed 4-6 and 24 h after i.v. injection of 140-220 MBq (111)In-octreotide. Whole-body and planar images as well as single-photon emission tomography images were acquired and lesions were graded according to qualitative tracer uptake. Somatostatin receptor imaging was positive in nine patients, identifying paragangliomas for the first time in three patients and recurrent disease in six patients. In one patient, a second, previously unknown paraganglioma site was identified. Negative results were obtained in ten patients. These patients included one suffering from chronic hyperplastic otitis externa, one with granuloma tissue and an organised haematoma, one with an acoustic neuroma, one with an asymmetric internal carotid artery, two with ectasia of the bulbus venae jugularis and one with a jugular vein thrombosis. In two patients with a strong family history of paraganglioma, individual involvement could be excluded. In only one patient did somatostatin receptor imaging and magnetic resonance imaging yield false negative results in respect of recurrent paraganglioma tissue. It is concluded that somatostatin receptor scintigraphy provides important information in patients with suspected paragangliomas of the head and neck region and has a strong impact on further therapeutic management.

Abstract: OBJECTIVE: To determine the incidence of occult cerebrospinal fluid fistulas after endoscopic paranasal sinus surgery. DESIGN: Prospective diagnostic test study with a 6-month follow-up in case of cerebrospinal fluid detection. SETTING: Tertiary care hospital. SUBJECTS: The study population comprised 69 patients undergoing routine endoscopic paranasal sinus surgery. Patients with an obvious intraoperative or postoperative cerebrospinal fluid fistula were not included. INTERVENTION: Analysis of 112 samples from intraoperative applied tamponades and of 69 serum samples using a nephelometric research assay for beta-trace protein (prostaglandin D synthase). MAIN OUTCOME MEASURES: Incidence of occult cerebrospinal fluid fistula during endoscopic paranasal sinus surgery as indicated with the help of a test for beta-trace protein; at least a 6-month follow-up of patients with an occult cerebrospinal fluid fistula; and relation of occult cerebrospinal fluid fistula with surgical experience of the surgeon. RESULTS: Beta-trace protein was found in ethmoid roof samples from 2 patients, giving an incidence of 2.9% for occult cerebrospinal fluid fistula. Both patients were operated on by very experienced surgeons. Signs of a cerebrospinal fluid fistula were not found at follow-up at least 6 months after surgery. CONCLUSIONS: Nephelometric beta-trace protein assay is a highly sensitive method to detect otherwise unobserved cerebrospinal fluid fistulas. The clinical course of the 2 patients with an occult cerebrospinal fluid fistula indicated the possibility of an uneventful follow-up of patients with small fistulas.

Abstract: BACKGROUND: Cisplatin is reported to damage the stria vascularis of the cochlea. Free radicals, especially large amounts of nitric oxide catalyzed by inducible nitric oxide synthase, are considered to have an important role in this toxicity. The induction of inducible nitric oxide synthase is regulated by nuclear-factor kappa B (NF-kappa B). We examined the damage of the stria vascularis by immunohistochemical techniques. MATERIALS AND METHODS: Cisplatin (15 mg/kg b.w.) was injected intraperitoneally into the mice. Three days after the injection, the cochleas were immunohistochemically-stained using specific antibodies for nuclear-factor kappa B (NF-kappa B), inducible nitric oxide synthase (iNOS) or single-stranded DNA. RESULTS: NF-kappa B was expressed in the cisplatin-treated cochlea, especially in the stria vascularis and the spiral ligament. iNOS was also expressed in the stria vascularis and the spiral ligament. Fragments of DNA were observed only in the stria vascularis. CONCLUSION: The large amounts of NO catalyzed by iNOS led to inner ear dysfunction. Our results indicate that apoptosis is triggered by iNOS and that it mediates the ototoxicity induced by cisplatin.

Abstract: Between 1995 and 1998, 11 patients with disabling Menière's disease were treated at our institution with a continuous gentamicin infusion into the middle ear via a microcatheter. The patients had frequent attacks of vertigo and vomiting (functional levels 3-5). Hearing threshold on the affected side was significantly worse than on the healthy side (stage 4+5). Gentamicin was applied by a high-precision insulin pump with a flow rate of 40 mg per day directly in front of the round window. Application was stopped as soon as signs of vestibular affection appeared. A good overall control of vertiginous spells was achieved in 8 patients. Eight patients experienced complete hearing loss on the affected side, 1 experienced a slight worsening, and 1 had no hearing change. There was no correlation between the cumulative gentamicin dosage and the hearing loss. Our findings show that in terms of hearing loss and hospitalization time the continuous gentamicin application is inferior to other applications presented in the literature.

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Abstract: Influence of an Internal Nasal Dilator (Nasanita) on Nasal Flow in Healthy Adults.In a prospective, randomized study the influence of dilatation of the vestibulum nasi by an internal dilatator type Nasanita on the nasal flow of healthy adult persons was tested. Primary target was the inspiratory nasal flow as measured by rhinomanometry. Secondary targets were subjective evaluation of the nasal breathing and the judgement of the subjects on the comfort of carrying the stent. The insertion of the stent type Nasanita increased the nasal flow from 614 +/- 151 ccm/sec about 54 % to 920 +/- 198 ccm/sec (p = 0,00000016). The expiratory nasal flow increased from 622 +/- 169 ccm/sec about 55 % 928 +/- 230 ccm/sec (p = 0,0000008). Subjectively the insertion of the stent improved the nasal breathing slightly to significantly. The comfort of wearing was classified mostly indifferent to slightly unpleasantly. The internal nasal stent Nasanita has proven to be an agent to increase nasal flow significantly.

Abstract: This study was undertaken to examine the expression of inducible nitric oxide synthase (iNOS / NOS II) in the hydropic vestibule of guinea pigs. Animals were systemically sensitized with 500 microg of keyhole limpet hemocyanin. Two weeks after the first injection, keyhole limpet hemocyanin (100 microg/5 microl) was injected into the endolymphatic sac following the intradural approach, and the next day temporal bones were removed for the immunohistochemical examination. Endolymphatic hydrops was evidenced by the expansion of the Reissner's membrane in the cochlea after direct injection of keyhole limpet hemocyanin into the endolymphatic sac. Inducible nitric oxide synthase expression was increased in the sensory cells, supporting cells and vestibular ganglion cells, while temporal bones, where only phosphate buffered saline was injected, did not show any inducible nitric oxide synthase immunoreactivity. High levels of inducible nitric oxide synthase-catalyzed nitric oxide were detected prior to the development of the inner ear dysfunction. Our results suggest that the occurrence of inducible nitric oxide synthase immunoreactivity parallels the inner ear disturbance as seen in endolymphatic hydrops.

Abstract: This study was undertaken to examine, electrophysiologically and immunohistochemically, the effect of endotoxin on the guinea pig cochlea. A bacterial endotoxin (lipopolysaccharide, LPS, 5 mg/ml, 0.2 ml) was injected into the middle ear trans-tympanically. The electrocochleograms were continuously recorded from before to 48 h after the injection with an electrode inserted into the facial canal. Then, the animals were sacrificed by intracardiac perfusion of a fixative, temporal bones were removed and immunohistochemically stained for single-stranded DNA (ssDNA) and caspase 3 (CPP32). ssDNA was detected at 48 h in the stria vascularis and spiral ligament. CPP32 was observed in the stria vascularis, the spiral ligament and the organ of Corti. The threshold of the compound action potential increased significantly at 48 h in the LPS group. These results suggest that the activation of CPP32 and fragmentation of DNA are involved in the dysfunction of the cochlea observed under inflammatory conditions.

Abstract: BACKGROUND AND OBJECTIVE: Prednisolone is the drug of first choice for the treatment of cochleovestibular disorders, such as sudden hearing loss. Because of the known side effects, the efficient drug levels to be achieved within inner ear fluids are limited by intravenous administration. The aim of the study was to determine the concentration in the perilymph of prednisolone-21-hydrogen succinate applied into the round window niche in comparison to the concentration after intraperitoneal application. METHODS: Application of prednisolone-21-hydrogen succinate (5 mg in 0.1 ml) on the round window membrane was performed after sedation under microscopic view directly into the round window niche of the guinea pig. In order to compare the results, perilymph samples after systemic application of 60 mg/kg body weight prednisolone were used. The time between application and taking specimens of perilymph from the cochlea varied. Specimens of perilymph were obtained after 15, 20, 80, 180, 330, and 960 min (10 specimens in each group, n = 60) by dissecting the cochlea and opening the apex cochleae. Levels of prednisolone-21-hydrogen succinate in perilymph were measured by isocratic high-pressure liquid chromatography (HPLC). RESULTS: The highest levels of prednisolone-21-hydrogen succinate were found after 180 min: 952.3 mg/l (95% confidence interval: 382.7). After 960 min the level was 18.72 mg/l (95% confidence interval: 16.9). In the group with systemic application, the levels measured were below 14.71 mg/l (95% confidence interval: 7.05). CONCLUSION: The results demonstrate that high levels of prednisolone-21-hydrogen succinate in perilymph are achievable by local application of a single dose into the round window niche. After application of 5 mg, the levels of prednisolone are measurable up to 16 h.

Abstract: OBJECTIVE: The question whether progressive sensorineural hearing loss during childhood is the fateful course of a main illness has been discussed controversially over 60 years. No medicamentous therapy with satisfactory results has been described in the literature. The goal of this study was to determine whether an infusion therapy, developed for the treatment of sudden hearing loss in the elderly, can induce recovery after progression in sensorineural hearing loss during childhood. METHODS: Out of 20 children suffering from acute progression in sensorineural hearing loss, seven children were treated with an infusion therapy containing prednisolone, pentoxifylline and a plasma expander (group I), and 13 children were not treated (group II). All children were advised not to use hearing aids for 6 weeks. RESULTS: In group I, we observed partial to complete restoration of hearing threshold towards the original hearing threshold given by previous routine controls in 6/7 children. In group II, only three children recovered, with the state of ten children's' hearing loss remaining unchanged. The long-term follow-up, however, showed no distinct difference in either group. CONCLUSION: Infusion therapy can be helpful when treating acutely progressing sensorineural hearing loss during childhood. The benefit for communicative competence has to be discussed. Further studies should be conducted.

Abstract: The incidence of perilymphatic fistula as cause of sudden hearing loss is not known. We present a case with sudden unilateral hearing loss associated with a positive beta-trace protein test of an epipharyngeal fluid sample. The patient presented with sudden sensorineural hearing loss on the right side. A stapedotomy had been performed nine months previously due to otosclerosis. Intravenous therapy for the treatment of sudden hearing loss was unsuccessful. At the time of sudden hearing loss, epipharyngeal fluid was collected using a Raucocel sinus pack. Investigation using rocket immunoelectrophoresis showed the presence of beta-trace protein. Upon repeating tympanoscopy there was no obvious labyrinthine fluid egress, but the oval window was sealed with fibrin sponge and fibrin glue. The patient's hearing improved over a period of five months.

Abstract: Vascular endothelial growth factor (VEGF) is known as an endothelial cell-specific mitogen. There are no reports concerning the presence of VEGF in the inner ear. To gain information, immunohistochemical analysis using specific antibodies to VEGF and to both known VEGF receptors Flt-1 and KDR/Flk-1 was performed on paraffin-sectioned temporal bones from five guinea pigs. Immunoreactivity of VEGF, Flt-1 and KDR/Flk-1 was detectable in spiral ganglion cells. VEGF could also be found in the endothelium of blood vessels, in the spiral ligament and in the organ of Corti. Flt-1 was found in the limbus epithelium, in all supporting cells of the organ of Corti, in Claudius cells, cells of the sulcus and in the spiral ligament. Flk-1 could be detected in some supporting cells of the organ of Corti (inner pillar cells and Deiters' cells). Immunoreactivity to Flk-1 was also found in endothelium of blood vessels and in the spiral ligament. Hair cells showed VEGF immunostaining, but did not contain staining to Flt-1 nor Flk-1. In the stria vascularis any immunoreactivity to all used VEGF and VEGF receptor antibodies could not be detected. The findings were supported by Western blot analysis on inner ear tissues and ovaries from guinea pigs. We may conclude that the growth factor VEGF and both receptors participate in cochlear physiology.

Abstract: OBJECTIVE: To evaluate the safety and efficacy of transnasal orbital decompression for severe Graves' ophthalmopathy. DESIGN: Retrospective noncomparative case series with extended clinical follow-up. PARTICIPANTS: Seventy-eight consecutive subjects who were operated on for compressive optic neuropathy with loss of visual acuity or visual field defects after failure of medical and radiation therapy. INTERVENTION: Strictly transnasal, endoscopic-controlled bilateral decompression of the medial and inferomedial wall of the orbit. MAIN OUTCOME MEASUREMENTS: Preoperative and postoperative examination, including vision, Hertel exophthalmometry, ocular motility, visual fields, Goldmann perimetry, and notification of complications, intranasal signs of inflammation, and subjects' assessment of the procedure. RESULTS: One hundred forty-five endonasal decompressions were performed on 78 subjects (63 women, 15 men, 52.2 +/- 10.3 years) during a 10-year period. Sixty five patients were bilaterally operated on; 15 required only unilateral decompression. Four of 78 needed repeat surgery. Visual acuity increased from a preoperative average of 0.50 +/- 0.27 (range, 0.01-1.25) to 0.75 +/- 0.21 (range, 0.01-1.25) postoperatively. An average reduction of proptosis of 3.94 +/- 2.73 mm (range, -1.0-11.0 mm) was achieved with a mean preoperative Hertel measurement of 22.19 +/- 3.13 mm (range, 15-34 mm). Ocular motility was corrected by recession of the medial rectus muscle in 58 of 78 cases. Twenty-six of these 58 cases were simultaneously operated on in the same surgical session immediately after the transnasal decompression, and the others after a period of 2 to 3 months. CONCLUSIONS: The transnasal orbital decompression procedure improved vision, decreased proptosis in a range comparable to more invasive techniques, and had favorable cosmetic results without additional disfiguration by scars. Morbidity was far less than with other approaches. Postdecompression strabismus was successfully managed by recession of both medial orbital muscles in the same surgical session.

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Abstract: Paroxysmal vertigo, permanent vertigo, positional and postural vertigo, and transient vertigo are special forms, which are differentiated by their temporal course. Paroxysmal vertigo, together with hearing impairment and noises in the ear, is typical of Menière's disease. Persistent vertigo often occurs after the loss of a peripheral vestibular end organ (e.g. after trauma of infection). In the case of positional and postural vertigo, a differentiation must be made between benign paroxysmal positional vertigo due to "wandering" otoliths, and orthostatic vertigo, which occurs on changing rapidly from a lying to a sitting position. The diagnosis is verified by Epley or Semont positional maneuvers. Confirmation of a cervical vertigo is provided by the de Kleijn and Nieuwenhuyse test. Brief episodes of vertigo (transient vertigo) occur after transient ischemia, for example when craning to look at a high building. In the acute stage, treatment of vestibular vertigo consists in the damping of the threshold for vestibular stimuli with antiemetics. For long-term treatment, antihistaminics and histamine-like substances have proven of value.

Abstract: BACKGROUND: The inverted papilloma of the nasal cavity and the paranasal sinuses is a benign but locally aggressive neoplasm with a high recurrence rate and an unknown risk of malign transformation. This unsteadiness of biological behaviour requires a permanent control of the outcome of the available surgical treatments to ensure the utmost reliability for the patients. METHODS: In our investigation we analysed the surgical results in 54 patients with inverted papilloma of the last 30 years with an average followup of 55 months. 25 of them were endoscopically treated. The other group of 29 patients was treated by traditional surgical techniques using an extra-nasal approach. RESULTS: Using the endonasal-endoscopic technique we observed a recurrence rate of 48% whereas the other group treated by an extra-nasal approach reached a recurrence rate of only 24% and did not show any multiple recurrences. A malign transformation was found in two patients (< 5%) within the first 8 months after the first resection. CONCLUSION: In consequence patients with inverted papilloma have to be informed of the different surgical techniques and their recurrence rates. Especially an endonasal-endoscopic treatment of the maxillary sinus has to be carefully considered.

Abstract: In this study, the effect of endotoxin on the guinea pig cochlea has been examined electrophysiologically and immunohistochemically. Bacterial lipopolysaccharide (LPS, 5 mg/ml, 0.2 ml) was injected into the middle ear trans-tympanically. The electrocochleograms were measured before, immediately upon, and 3, 6 and 12 h after the injection continuously with an electrode inserted into the facial canal. After each measurement, some of the animals were killed with an intracardiac perfusion of fixative, temporal bones were removed and were immunohistochemically examined for inducible nitric oxide synthase (iNOS/NOS II). On serial paraffin section, iNOS could be detected first after 3 h in the lateral wall, the supporting cells of the organ of Corti and in cells of the spiral ganglion and was observed up to 12 h. After the injection of LPS, the threshold of compound action potential became significantly worse after 12 h in the LPS group. These changes became evident first at higher frequency (8 kHz). These results suggest that iNOS-generated NO is involved in the cochlea dysfunction under inflammatory conditions.

Abstract: Immunohistochemical investigations of the guinea pig cochlea, using a specific antibody to the inducible isoform of NO synthase (iNOS/NOS II), have been performed 3 weeks after closure of the right endolymphatic duct (n=7). Endolymphatic hydrops, the morphological substrate of Meniere's disease, became evident by distension of the Reissner's membrane. iNOS expression could be noted in endothelium, spiral ganglion cells, in nerve fibers, in supporting cells of the organ of Corti and cells of the spiral ligament. Temporal bones of non-operated controls (n=6) as well as of sham-operated animals (n=3) did not show structures positive to iNOS. These findings imply that iNOS-generated NO could be involved in the pathophysiology of cochlear dysfunction in Meniere's disease.

Abstract: The pathogenetic mechanisms of acute cochleo-vestibular lesions are still unknown, but viral infections and vascular phenomena with impairment of microvascular perfusion are thought to play a major role. Between 1 July, 1986 and 28 February 1998, 1501 patients were treated with an infusion protocol using cortisone, dextrane 40 and pentoxifylline. Group 1 contained 1001 patients with sudden hearing loss, group 2a 107 patients with isolated tinnitus and group 2b 393 patients with labyrinthine disorders (among which were 81 patients with cochleovestibular dysfunction). The records were evaluated retrospectively. In group 1 complete hearing recovery occurred in 44.8%, partially in 40.4%, no change in 12.1% and worsened in 2.6%. In group 2a with isolated tinnitus 17.9% had a complete recovery, 43.9% partial recovery, 35.5% no change and 2.8% worsened symptoms. In group 2b vertigo disappeared in 56.8%, had partial recovery in 21.0% and did not change in 7.4%. In the 1501 patients treated, no significant side-effects were found to the medical interventions used. From these results we conclude that the infusion protocol is safe and effective in the treatment of cochleo-vestibular disorders.

Abstract: Cisplatin is known to cause inner ear damage. The role of nitric oxide (NO) in the cochlea of the guinea pigs after injections of cisplatin or a combination of cisplatin and NO synthase (NOS) inhibitor [N(G)-nitro-L-arginine methyl ester (L-NAME)] i.p. was examined by means of immunohistochemistry. Three days after injection, the cochleas were examined immunohistochemically for single-stranded DNA (ssDNA). We found that ssDNA was expressed in the stria vascularis and spiral ganglion cells of the cisplatin-treated cochlea. In the L-NAME/cisplatin-treated cochlea, the number of cells that exhibited positive staining for ssDNA was markedly reduced. High NO levels lead to inner ear dysfunction under pathological conditions. Our results indicate that NO mediates the ototoxicity of cisplatin.

Abstract: beta-Trace protein is an immunological marker for the detection of cerebrospinal fluid traces. The aim of the study was to evaluate the predictive value of the beta-trace protein test. We investigated 145 specimens for cerebrospinal fluid using beta-trace protein. All case notes were retrospectively reviewed and tabulated for indication and procedure with focus on outcome. The specimens were analyzed by immunoelectrophoresis. beta-Trace protein was detected in 62 specimens and was absent in 83. In correlation with the clinical course, the clinical findings, the results of high-resolution computed tomography of the paranasal sinuses or petrous bone, computed tomographic cisternography, magnetic resonance imaging, indium 111-pentetic acid radionuclide cisternography, intraoperative findings, and visualization using sodium-fluorescein, there were no false-positive results. In 6 cases, a false-negative result occurred. The overall accuracy was 95.68%. The beta-trace test has a specificity of near 100% and a sensitivity of 91.17%. Analysis of beta-trace protein is a valuable test and has some advantages in comparison with the beta2-transferrin assay.

Abstract: To date few reports have discussed the presence and function of nitric oxide (NO) in structures of the facial nerve. We performed nicotinamide adenine dinucleotide phosphate (NADPH-d)-diaphorase-histochemistry and immunohistochemistry on the intratemporal portion of the facial nerve, including the geniculate ganglion, of guinea pigs using specific antibodies to the three known isoforms of NO synthase and soluble guanylyl-cyclase (sGC). Normal facial nerves were compared to those treated intratympanically with bacterial lipopolysaccharides (LPS) and tumor necrosis factor-alpha (TNF-alpha). Both constitutive NOS isoforms and sGC could be detected in the bipolar ganglion cells of normal animals, while the inducible isoform (iNOS or NOS II) was not found. Endothelial NOS (NOS III) and sGC were present in blood vessels and were predominantly found in the perineurial sheath and less in the endoneurium. sGC could be detected in all fibers in a cross section of the facial nerve. LPS and TNF treatment led to the detection of iNOS in the perikaryia of the geniculate ganglion and the perineural sheath. These findings imply that NO may be involved in neurotransmission at least in the visceroafferent system. NO regulates vascular tone of nutrient blood vessels in the perineural sheath and endoneurium. The presence of sGC indicates that NO acts via its second messenger cGMP. NOS II expression may be a contributing factor to facial nerve palsy via two different mechanisms: NOS II-generated NO may lead to an overstimulation of the visceroefferent nerve fibers and motor fibers of the facial nerve. Dysregulation in facial nerve blood vessels could lead to edema and elevated pressure on the nerve within its osseous canal.

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Abstract: In a prospective, randomized, controlled, double-blind trial we compared the effectiveness of endonasal irrigations with Ems salt solution to that with sodium chloride solution in the treatment of adult patients with chronic paranasal sinus disease. Subjects (n = 40) were randomly allocated to treatment either with isotonic Ems salt solution or with isotonic sodium chloride solution. The treatment consisted of endonasal irrigation twice daily and additional nasal spray as required. Nasal endoscopy, plain radiography of the paranasal sinuses, olfactometry, anterior rhinomanometry, and a saccharin-clearance test were carried out on days 1 and 7. Patients recorded rating scales of general discomfort, nasal airway obstruction, agreeableness of the irrigation, duration of improved nasal resistance after each irrigation, and the amount of additional nasal spray in a diary. Nasal air flow was not improved significantly. Subjective complaints, endonasal endoscopy, and radiography results revealed a significant improvement in both groups (P = 0.0001). In comparison, the two groups were not significantly different in outcome. Endonasal irrigations with salt solutions are effective in the treatment of chronic sinusitis, and a significant difference between Ems salt and sodium chloride was not observed.

Abstract: BACKGROUND: The esthesioneuroblastoma is a rare tumour of neuroectodermal origin, which arises usually in the area of the olfactory epithelium and invades the paranasal sinuses, the orbit and the brain. The low incidence of this disease makes a development of standardised clinical and histological classification difficult. Up to now this tumour is considered to be slow progressive but strained by a high rate of local recurrences. Metastasis are usually seen late at an advanced stage. PATIENTS: In the last 18 years 7 patients with an esthesioneuroblastoma were treated in our department. This relatively large number of patients allows a retrospective evaluation of the different already existing classifications concerning treatment and prognosis. RESULTS AND CONCLUSIONS: In all cases of a disease limited on the paranasal sinuses the patients were successfully treated either by a combination of resection and radiation (4 cases) or resection alone (1 case). No patient underwent a chemotherapy. Two cases with lethal outcome showed an extremely aggressive tumour progression. In such cases of extensive disease an additional chemotherapy has always to be taken into account. Our experiences and the analysis of the literature gives some indications that middle-aged patients have a worse prognosis than young or old patients.

Abstract: Successful use of non-biologic implants in reconstructive head and neck surgery is dependent on tissue compatibility and epithelization. This is true not only for epithelial cells, but also for mesenchymatic cells. Therefore we tested several substrates with human fibroblasts or keratinocytes from the oral mucosa in cell culture. In tissue culture keratinocyte outgrowth from small mucosal flaps onto the surface was observed. Preparations were evaluated by histology and scanning electron microscopy. Cellulose-ester, polyvinylidene-difluoride and polyglactin developed monolayers of fibroblasts and keratinocytes in cell cultures. In tissue culture mucosal flaps showed good adherence to the surface of these materials and a fine outgrowth of keratinocytes. Expanded polytetrafluor-ethylene (ePTFE) was partially covered by a layer of fibroblasts and keratinocytes in cell culture, but cell adherence was not sufficient. In tissue culture the mucosal flaps failed to attach on ePTFE. These results illustrate that the mesenchymatic and epithelial component of cell and tissue cultures show different qualities of cellular adherence and growth on the surface of non-biologic implants. We propose our method for the development of an in-vitro model for the epithelization of non-biologic implantation materials.

Abstract: Cisplatin is known to cause inner ear damage (ototoxicity). The role of inducible nitric oxide synthase (iNOS) in the cochlea of guinea pigs after injections of cisplatin or a combination of cisplatin and NOS inhibitor (NG-nitro-L-arginine methyl ester, L-NAME) i.p. was examined electro-and immunohistochemically. The auditory brain stem responses (ABR) were measured prior to injection and 3 days after the injection. Three days after injection, the cochleas were examined immunohistochemically for iNOS. We found that iNOS was expressed in the cisplatin- and L-NAME/ cisplatin-treated cochlea. The threshold shift of ABR was significant in the cisplatin group, whereas it was decreased in the L-NAME/cisplatin group. iNOS catalyzed high NO levels lead to inner ear dysfunction. Our results indicate that iNOS mediates the ototoxicity of cisplatin.

Abstract: Growth factors, such as vascular endothelial growth factor (VEGF) and neurotrophins, recently identified in the inner ear of guinea pigs, exert their proliferative properties partly through activation of mitogen-activated protein kinase/extracellular signal-regulated kinase (MAPK/ERK1/2). In order to demonstrate presence of ERK1/2 in the inner ear we performed immunohistochemical analysis using specific antibodies to inactive and activated ERK1/2 on paraffin-sections of temporal bones from guinea pigs (n=5). In the cochlea clear immunoreactivity to inactive ERK1/2 was predominant in the spiral ligament, in the organ of Corti (intensive staining in supporting cells, faint staining in sensory cells) and limbus epithelium, while spiral ganglion cells and nerve fibres revealed weak staining. Activated ERK1/2 could be detected sparely in the spiral ligament exclusively. In the vestibule inactive ERK1/2 was located in the sensory epithelium, in nerve fibres and in vascular endothelium, while activated ERK1/2 could be detected in few nerve fibres and synaptic endings (buttons and calyces) on hair cells of the maculae and crests and in the endothelium of few blood vessels. These findings provide evidence that activated ERK1/2, as a general downstream signal of growth factors, may be contributed in the inner ear physiology.

Abstract: Vertigo is not a uniform symptom. The basis for a differentiated diagnosis is the history, which should record the frequency and duration of attacks. Further diagnostic investigations serve to differentiate between non-vestibular and vestibular (peripheral) forms of vertigo. Of essential importance is the determination of nystagmus with the aid of Frenzel lenses, with distinction being made between voluntary nystagmus and provoked nystagmus. These orientating examinations, which can be carried out by the family doctor, set the points for the further course. On account of the need for special equipment, such studies as the caloric tests, the swivel chair test, optokinetic tests or the tilting stage test, remain the domain of the specialist. They enable a definitive differentiation of an ENT illness from a neurological disorder.

Abstract: In order to demonstrate the safety and efficacy of transnasal orbital decompression for malignant Graves' ophthalmopathy, we carried out a retrospective chart review and clinical follow-up examination of 78 consecutive patients who were operated on for compressive optic neuropathy (CON) with loss of visual acuity or visual field defects. The intervention - strictly transnasal, endoscopically controlled, bilateral decompression of the medial and inferomedial wall of the orbit - was performed when medical and radiation therapy had failed. A total of 145 endonasal decompressions were performed on 78 patients (63 female, 15 male, 52. 2 +/- 10.5 yrs.) over 9 years. Of these, 65 were operated bilaterally, 15 required only unilateral decompression; 4 had repeated surgery. Visual acuity increased from an average of 0.50 +/- 0.27 (range, 0.01 - 1.25) to 0.75 +/- 0.21 (range, 0.01 - 1.25). Proptosis decreased by an average of 3.94 +/- 2.73 mm (range, -1.0 - 11.0 mm), from a mean preoperative Hertel measurement of 22.19 +/- 3. 13 mm (range, 15 - 34 mm) to a mean postoperative Hertel measurement of 18.3 +/- 2.65 mm (range, 10 - 26 mm). Ocular motility was corrected by recession of the medial rectus muscle in 58 cases, in 26 cases immediately after decompression in the same surgical session. The transnasal orbital decompression procedure improved vision, decreased proptosis in a range comparable to more invasive techniques and had favorable cosmetic results without additional disfiguring by scars. Post-decompression strabismus was successfully managed by recession of both medial orbital muscles in the same surgical session.

Abstract: Endotoxin-treated cochleas of the guinea pig were examined electrophysiologically and immunohistochemically concerning the expression of inducible nitric oxide synthase (iNOS/NOS II). One mg of bacterial lipopolysaccharide (LPS, 5 mg/ml) or mixed solution of 1 mg of LPS plus 1 mg of N(G)-nitro-L-arginine methyl ester (L-NAME, 5 mg/ml) (L-NAME/LPS) was injected into the middle ear of guinea pigs transtympanically. The electrocochleograms were measured prior to, immediately and 48 h after the injection. Immunohistological studies for iNOS followed after fixation, embedding and sectioning of the temporal bones. The threshold and amplitude of the compound action potential (CAP) became significantly worse in the LPS treated group. In contrast, the changes of the threshold and amplitude of CAP were decreased in the L-NAME/LPS group. iNOS was expressed in the stria vascularis, the spiral ligament, the organ of Corti and the spiral ganglion in the LPS group. These immunoreactivities in the L-NAME/LPS group were less intense than that in the LPS group. These results indicate that LPS has an ototoxic effect on the cochlea and that this effect could be mediated by iNOS produced high nitric oxide under inflammatory conditions.

Abstract: The endonasal surgery has a branch in the transnasal orbital surgery. For this transnasal approach the anterior skull base, the medial and infero-medial orbita, the orbital apex with the optical nerve and the sphenoid sinus are within reach. In all primary and secondary malignant lesions with extension into the orbita, the transnasal biopsy is of importance for diagnosis, particularly in metastasis to the orbit and pseudo-tumors. Benign lesions like mucoceles and osteomas are accessible and fully removable. Good results have been obtained in endonasal orbital decompression and inhomogeneous space occupying intraorbital lesions like bleedings. Among the orbital traumatism, with restrictions fractures of the medial orbital wall, medial orbital floor and foreign bodies could be operated. The transnasal approach is not indicated in all diseases, which are situated mostly intraconally, supraorbitally and lateral of the bulbus as well as in tumors with intracranial extension. In summary, the transnasal orbital approach has its place as helpful addition to the transfacial and transcranial techniques and can even replace them in certain selected indications.

Abstract: It is well known that the anti-cancer drug cisplatin has an ototoxic property; however, the details are not yet evident. In this study, the expression of inducible nitric oxide synthase (INOS/NOS II) in the vestibule of guinea pigs after i.p. injections of cisplatin was examined immunohistochemically. Three days after the injection of cisplatin (10 mg/kg) or placebo, animals were sacrificed. Then the temporal bones were removed and subjected to Immunohistochemical studies for iNOS. In the cisplatin group, INOS was detectable, whereas the tissue in the control group was negative for iNOS. The vestibule, the wall of blood vessels and the vestibular ganglion cells showed immunoreactivity for iNOS. It is known that INOS catalyzes an inadequate quantity of NO under pathological conditions. Increased NO levels lead to inner ear dysfunction. Therefore, our results indicate that iNOS could also mediate the vestibulo-toxicity of cisplatin.

Abstract:

Abstract: Nitric oxide (NO) can play an important role in the regulation of vascular tone and neurotransmission, as well as in non-specific immunoreactions and inflammation in a variety of tissues. Increased quantities of nitric oxide in respired air can be measured during inflammatory processes. However, the exact role and precise sources of NO under physiological and pathophysiological conditions within the airways remain to be defined. Three isoforms of NO-synthases can be distinguished: two constitutive (neuronal and endothelial) Ca(2+)-dependent cNOS and one inducible Ca(2+)-independent iNOS (NOS II). Constitutive NOS (NOS I and III) release a basal amount of NO under physiological conditions. The inducible form once expressed can catalyse the generation of large quantities of NO. Many kinds of cells, such as macrophages, neutrophils, endothelium and smooth muscle cells, are capable of expressing NOS II. Since all isoforms of NO-synthase seem to be present in nasal tissues and the expression of iNOS under inflammatory conditions seems to be responsible for excessive production of NO, the distribution of NOS-isoforms (especially NOS II) in normal and inflammatory nasal tissue, as well as the exact requirements for expression of iNOS remain to be proven. Non-inflamed fresh human nasal mucosa from the middle turbinate was compared immuno-histologically with nasal mucosa having the typical findings of chronic polypoid rhinosinusitis (i.e., polypoid middle turbinates and polyps of the middle nasal duct). In order to gain more information about the mechanisms of acute inflammation, non-inflamed vital turbinates were incubated in vitro with the proinflammatory substances bacterial lipopolysaccharides (LPS) and tumor necrosis-factor (TNF) for 30, 60, 90, 120, 180 and 240 min. Subsequent to exposure to NADPH-diaphorase and immunostaining with specific antibodies to each NOS-isoform, clearly increased or initiated expressions of inducible NOS (iNOS) in blood vessels, glands, macrophages and epithelium of chronically inflamed and LPS-incubated nasal tissue became apparent in comparison to the non-inflamed controls. In contrast, NOS III/NOS I seemed to be not affected. The onset of immunohistochemically recognizable NOS II expression was observed after 90 min incubation with of LPS/TNF-alpha. Polypoid tissue showed a strong increase in submucosal thickness and a high infiltration of iNOS-positive leukocytes (granulocytes and macrophages) compared to the LPS-incubated non-inflamed specimens. These findings implicate NOS II generated nitric oxide as a key agent for causing swelling, secretion and obstruction in patients with acute and chronic polypoid or allergic rhinitis. These findings also suggest that molecular NO has to be considered in the pathophysiology of chronic polypoid rhinosinusitis.

Abstract: Beta-trace protein is a lipocalin that was recently identified as prostaglandin D synthase and represents a major constituent of human cerebrospinal fluid. Beta-trace protein, similar to beta 2-transferrin, has been used as an immunological marker for the detection of cerebrospinal fluid. Between 1982 and 1999, 130 specimens from 101 patients with suspected cerebrospinal fluid leaks of the anterior or lateral skull base have been investigated for beta-trace protein. The specimens were analyzed by one-dimensional immunoelectrophoresis using Laurrell's electroimmunoassay. In all, beta-trace protein could be detected in 57 specimens and was absent in 73. All case notes were studied retrospectively. In correlation with the clinical course and the findings of CT of the paranasal sinuses, high resolution CT of the petrous bones, CT cisternography, NMR, 111In-DTPA radionuclide cisternography, intraoperative findings, visualization of sodium-fluorescein stained cerebrospinal fluid using endoscopic blue light or testing for glucose, there was no false-positive result. A false-negative result occurred in two cases. These findings show that the beta-trace test has a sensitivity of 97.3% and a specificity of nearly 100%. Our findings show that analysis of beta-trace protein can be a valuable test for detecting CSF leakage and has certain advantages in comparison with the beta 2-transferrin assay.

Abstract: Since NO is believed to be involved in cochlear physiology, presence of the constitutive isoforms of nitric oxide synthase (NOS), and the target enzyme of NO, soluble guanylyl cyclase (sGC) in structures of the mammalian cochlea have been demonstrated. To date, no reports have been published regarding the detection of the inducible isoform (NOS II) in the cochlea. In order to show the capability of iNOS expression in cochlear tissue, a mixture of proinflammatory bacterial lipopolysaccharides (LPS) and tumor necrosis factor alpha (TNF-alpha) was injected into the tympanic cavity of guinea pigs, vs. saline-solution as control. Paraffin sections of LPS/TNF-alpha treated and saline-treated cochleae (6 h) were examined immunohistochemically with specific antibodies to neuronal, endothelial and inducible NOS and to sGC. Initiated expression of iNOS in the cochlea was observed in the wall of blood vessels of the spiral ligament (SL) and the modiolus, in supporting cells of the organ of Corti, in the limbus, in nerve fibers and in a part of the perikarya of the spiral ganglion after LPS/TNFalpha-treatment. iNOS was not detected in saline-treated control tissue. Expression of both constitutive NOS-isoforms (endothelial and neuronal NOS) and of sGC showed no significant differences in both experimental groups. Endothelial eNOS and neuronal bNOS were detected co-localized in ganglion cells, in nerve fibers, in cells of the SL and in supporting cells of the organ of Corti, but not in sensory cells. Strong labeling for bNOS became evident in the endosteum of the cochlea, while in the endothelium of blood vessels and in the epithelium of the limbus only eNOS could be labeled. sGC could be detected in SL, in supporting and sensory cells of the organ of Corti, in nerve fibers, ganglion cells, in the wall of blood vessels and in the limbus-epithelium. While small amounts of NO, generated by bNOS and eNOS, seem to support the cochlear blood flow and auditory function as well as neurotransmission, high amounts of iNOS-generated NO could have dysregulative and neurotoxic effects on the inner ear during bacterial and viral infections of the middle and inner ear.

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Abstract: Facial nerve schwannomas are rare benign tumors, when occurring, they are located most frequently in the distal fallopian canal and present as extracranial masses. The predominant symptom is a progressive facial nerve paralysis. We report a 20-year-old woman with an intracranial schwannoma originating from the greater superficial petrosal nerve that had wide extension into the pterygopalatine fossa. The motor facial nerve including the geniculate ganglion was not affected. The patient presented with vertigo, progressive hearing loss and mild facial nerve synkinesis but without a lacrimation deficit. The tumor was detected by computed tomography and magnetic resonance imaging. The schwannoma was completely removed using an intracranial, extradural middle fossa approach during which complete preservation of the motor facial nerve was possible. To our knowledge this is the first reported case of an isolated schwannoma of the greater superficial petrosal nerve without involvement of the motor facial nerve.

Abstract: Immunohistochemical investigations of the guinea pig vestibular system, using a specific antibody to the inducible isoform of NO-synthase (iNOS/NOS II), have been performed 3 weeks after surgical closure of the right endolymphatic duct (n = 7). Endolymphatic hydrops (ELH) of the right temporal bone became evident by excavation of the Reissner's membrane in all seven animals. Those animals revealed iNOS-expression in ganglion cells, in the wall of blood vessels and in nerve fibers of the right vestibular system, while the corresponding left temporal bones and temporal bones of non-operated controls (n = 6) as well as of sham-operated animals (n = 3) did not show any iNOS-positive structures. iNOS-generated NO could be involved in the pathophysiology of vestibular dysfunction in Meniere's disease.

Abstract: Sjögren's syndrome is an important autoimmune disease in the head and neck. Patients have an increased arrival risk of up to 6% per year for developing B-cell lymphomas, including mucosa-associated lymphoid tissue (MALT) lymphomas. The following case report shows this relation and the difficulty of differentiating clinically recurrent swelling of the parotid gland in Sjögren's syndrome from malignant lymphoma. A 64-year-old woman had a 2-year history of indolent, recurrent swelling of both parotid glands. Blood examination showed elevated ESR and a hypergammaglobulinemia. Immunosuppressive therapy produced no improvement. Two years after the diagnosis of Sjögren's syndrome, swelling of the left parotid gland persisted. Superficial parotidectomy of the left side was performed and histopathological examination revealed a MALT-related lymphoma. Subsequent parotidectomy of the right side also showed infiltration of the gland by a MALT lymphoma. Postoperative radiation therapy was given. During the follow-up period no recurrence or systemic disease was detected. Patients with Sjögren's syndrome should be examined regularly by the otolaryngologist. If a lymphoma cannot be ruled out, open biopsy must be considered for histological diagnosis. Prognostic factors for developing a lymphoma are possibly a high ESR and hypergammaglobulinemia. Further prognostic factors have to be evaluated.

Abstract: Laser magnetic resonance spectroscopy (LMRS) is a sensitive and isotope-selective technique for determining low concentrations of gaseous free radicals with high time resolution. We used this technique to analyze the nitric oxide (NO) concentration profile while simultaneously measuring the flow and expired volume during several single breathing cycles. Eight healthy, nonallergic volunteers were investigated. An initial NO peak was found in all breathing cycles before the NO concentration dropped to a relatively stable plateau in the late phase of expiration. The nasal NO peak was significantly higher than the oral NO peak. The nasal NO plateau was always higher than the oral NO plateau. The height of the initial nasal and oral NO peak rose with increasing duration of breath hold, whereas the late expiratory NO plateau changed only little for either the nasal or the oral breathing cycles. Our findings demonstrate, in line with other reports using other techniques, that the nose is the primary source for NO within the airways.

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Abstract: The presence of nitric oxide synthase (NOS) in substructures of the cochlea of guinea pigs is an issue of current focus. Moreover, information concerning the localization of cells effected by the NO/cGMP-pathway are rare. Paraffin sections of guinea pig cochlea were incubated with specific antibodies to the three known NOS isoforms, soluble guanylyl cyclase (sGC) and cyclic guanosine-monophosphate (cGMP), the second messenger system of NO. While detection of inducible iNOS failed in all cochlear structures, expression of endothelial eNOS was found in the spiral ligament, in the stria vascularis, in cells of the organ of Corti, in nerve fibers and in some perikaryia of the spiral ganglion. The cochlear nerve showed an accentuated affinity for immunostaining in distal, basal segments of the cochlea. Neuronal bNOS was found predominantly in the endosteum of the modiolus and cochlea and was less intensively present in all perikaryia of the spiral ganglion and in the spiral ligament. Supporting cells of the organ of Corti and cells in the limbus spiralis displayed only modest immunostaining, while bNOS was not found in outer and inner hair cells. NOS detection was accompanied by immunoreactivity to sGC and to cGMP. The presence of NOS and its second messenger system gives evidence for a possible involvement in neurotransmission, regulation of the cochlear amplifier and in homeostasis.

Abstract: The exact distribution of nitric oxide-synthases (NOS) and the NO-target enzyme soluble guanylyl cyclase (sGC) in the cochlea and vestibular organ is an issue of current discussion. The existence of NOS-isoforms in the cochlea of the guinea pig has been described recently, while information about the vestibular system are still rare and non-satisfying. In order to gain more information, immunostaining was performed, using specific antibodies to NOS I-III and to sGC, on paraffin sections of complete temporal bones from mice. NOS III could be detected in cochlea and vestibular ganglion cells, in nerve fibres, in outer hair cells of the cochlear and in the sensory epithelium of the maculae. Also, the spiral ligament and the limbus epithelium was positive to NOS III. NOS I was found in the sensory epithelium of the maculae and cristae ampullares, outer and inner hair cells of the cochlea, in nerve fibres and in ganglion cells. In contrast to that NOS II could not be detected at all. Furthermore, a strong NOS I immunoreaction was displayed on the endosteum of the bone, while the periosteum was lacking of NOS. NOS detection was accompanied by immunoreactivity to sGC. The findings imply that NOS I and III-generated NO is involved in neurotransmission and other regulative processes in the vestibulocochlear system.

Abstract: We report on 10 patients with severe malignant "mixed-type" obstruction of the proximal trachea or distal trachea plus both main stem bronchi. They had far-advanced inoperable tumors (esophageal cancer in 4 patients, lung cancer in 3, and recurrent laryngeal, uvular, and thyroid cancers in 1 each). Emergency treatment consisted of a dilating bougie maneuver followed by the insertion of a large one-way (4 patients) or Y-shaped (6) silicone prosthesis. Subsequent to the intervention, there was long-lasting clinical improvement. The median survival from stent insertion was 8 months for all patients irrespective of tumor type; it was 5 months for lung carcinoma patients and 8 months for those with esophageal cancer. The results are in accordance with those of other studies using different therapeutic modalities. Stent exchange proved necessary in 5 patients. The main reasons were continuing tumor growth beyond the proximal and distal boundaries and recurrent productive bronchial infection. Patients died of pneumonia (4 patients), pulmonary lymphangitic spread (1), heart failure (2, one of whom also had pneumonia), and fatal hemorrhage (1). As of December 1995, 3 patients were still alive, 2, 5, and 8 months after stent implantation. As evidenced by clinical efficacy and length of palliation, endoscopic placement of silicone-based one-way and bifurcated prostheses in far-advanced tumor of the central airways is technically feasible and ethically justifiable.

Abstract: We describe the case of a young woman with pain on turning her head attributable to a malformation of the hyoid bone. Diagnosis was established using spiral computed tomography with the patient's neck in the position of greatest discomfort and with 3-dimensional reconstruction of the hyoid bone. Prior conventional radiography and magnetic resonance imaging did not aid in finding a diagnosis. After surgical removal of both greater cornua of the hyoid bone there was a complete relief of symptoms.

Abstract: The exact distribution of nitric oxide-synthases (NOS) in the vestibular system has not been described satisfying yet. Immunostaining, using specific antibodies to the three known NOS-isoforms, to cyclic guanosine monophosphate (cGMP) and soluble guanylyl-cyclase (sGC), the second messenger system of nitric oxide (NO), was performed on paraffin sections of temporal bone from guinea pigs. eNOS could be detected in vestibular ganglion cells and in nerve fibres, including the calyces, surrounding the type 1 hair cells (HC). bNOS was found in the sensory epithelium, ganglion cells and in bone, while iNOS could not be found. NOS-detection was accompanied by reactivity to sGC and to cGMP. This finding implies that b- and eNOS-generated NO is involved in regulative processes in neurotransmission and regulation of blood flow.

Abstract: BACKGROUND: Soft tissue sarcoma represent approximately 7% of all neoplasms in children up to 14 years. The most common type (approx. 50%) among them is the rhabdomyosarcoma (RMS). Within the head and neck, which accounts for approx. 35% of all RMS, the tumor can be found ubiquitiously. Preferred localizations are the orbita, the paranasal sinuses, and the soft tissue of cheek and neck. The prognosis of RMS was formerly poor but has markedly improved since defined multimodal therapy was established in the Seventies (for example the Intergroup Rhabdomyosarcoma Study, IRS, in 1972; the International Society of Paediatric Oncology, SIOP, in 1975, or the German "Cooperative Weichteil-Sarkom-Studien", CWS, in 1981). The therapy of choice for RMS, according to the CWS, is chemotherapy because very often a good remission of the tumor is achieved. The main role of surgery is first to obtain biopsy specimens for histological diagnosis, and second aim is the complete resection of the primary and resectable metastases, for example by a neck dissection. Severe mutilation by radical surgery, especially in childhood, should be avoided in favor of multidrug chemotherapy and radiation in the interest of patient well-being. PATIENTS: Our retrospective study shows the treatment and results of 11 patients with a rhabdomyosarcoma of the head and neck within 25 years (1972-1997). RESULTS: Five of the 11 patients, who were treated in the years 1972-77, died (average 13 months, range 3-72 months). Five of the six patients, who were treated since 1991, have survived to date, one had a relapse of the tumor. Four special cases of patients are discussed in greater detail. CONCLUSION: Although the achieved mean survival time is encouraging nowadays (a 5-year survival rate of approx. 70% for all RMS is described) fatal cases are typical for this malignancy. Early diagnosis, localization, histological subtype, and prompt initiation of adequate treatment is decisive for a successful outcome.

Abstract: In order to demonstrate the involvement of nitric oxide synthases (NOS)--in particular the inducible isoform (iNOS)--in inflammatory processes within the nasal airways, we used organ-bath incubation to study isolated inferior turbinates and mucosa of the maxillary sinus of guinea pigs. The pattern of the expression in various substructures of the nasal mucosa was of special interest. Mucosa was incubated for 6 h with lipopolysaccharides (LPS) produced by E. coli, interleukin II (IL-2) or tumor necrosis factor-alpha (TNF-alpha). Saline was used as the control solution. Following incubation the specimens were fixed in buffered 4% formaldehyde solution over a period of 4 h. Tissues were next exposed to nicotinamide adenine dinucleotide phosphate (NADPH)-diaphorase-reaction and immunostained with specific antibodies to iNOS. Results then showed a clearly increased or initiated expression of iNOS in epithelium, glands, leucocytes and blood vessels of treated tissues in comparison to the control specimens. The inflammatory mediator LPS and the cytokines Il-2 or TNF-alpha alone were found to be capable of increasing the expression of iNOS, although the effects of LPS clearly exceeded those of the cytokines. This finding implicates iNOS-generated nitric oxide as a key factor for causing nasal swelling, secretion and obstruction during nasal infections and allergic episodes.

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Abstract: Central airway malignant stenosis. Malignant stennsis of the central airways (i.e. larynx, trachea, main stem bronchi) may be caused by primary tnmors of these structures or by malignant lesions invading the airways from the neighborhood, like thyroid carcinoma or esophageal malignancies. Airway t,bstrnction niay be cansed by endolartnrtal tumsmor growth, by external airway compression, by airway malacia, or by bilateral recurrent laryngeal nerve paralysis. Effective management of these lesions reqnires an individualized approach. A variely of therapeutic options are now available to the physician. These ineltmde, among others. endotracheal intubation. tracheostomiea, endolaryngeal procedures for bilateral vocal cord paralysis, tnmor desobliteration. and stenting of the trachea or the main stem bronchi, Endoseopie procedures are highly effective, even if the nnderlying condition cannol delinitively be treated for cure, They prevent asphyxation and increase the qtmality nt life. Therefore, these procedures should �tow be readily available in all oncological centers dealing with malignant airway tumors.

Abstract: Central airway malignant stenosis. Malignant stennsis of the central airways (i.e. larynx, trachea, main stem bronchi) may be caused by primary tnmors of these structures or by malignant lesions invading the airways from the neighborhood, like thyroid carcinoma or esophageal malignancies. Airway t,bstrnction niay be cansed by endolartnrtal tumsmor growth, by external airway compression, by airway malacia, or by bilateral recurrent laryngeal nerve paralysis. Effective management of these lesions reqnires an individualized approach. A variely of therapeutic options are now available to the physician. These ineltmde, among others. endotracheal intubation. tracheostomiea, endolaryngeal procedures for bilateral vocal cord paralysis, tnmor desobliteration. and stenting of the trachea or the main stem bronchi, Endoseopie procedures are highly effective, even if the nnderlying condition cannol delinitively be treated for cure, They prevent asphyxation and increase the qtmality nt life. Therefore, these procedures should �tow be readily available in all oncological centers dealing with malignant airway tumors.

Abstract: Recanalization-techniques for benign stenosis of tile larynx and the subglottis. Benign stenosis of the larynx and the subglottic airways can be Caused by inflammation, searing, malacia and tumors. Beside the classical surgical interventions for resection and recanalittion, stcnting techniques become more and mnre impurtant also to prevent reslenosis. Beside balloon- and self-expanding metal stents the silicone-based flexible stents are favored due to their easy removal and their physical properties. The development of more sophisticated stents is ongoing and will improve Ireatment of benign airway disease in the future.

Abstract: BACKGROUND: Although widely established in the management of malignant airway lesions, currently available tracheobronchial prostheses made of silicone have their drawbacks resulting from rigidity and wall thickness. Therefore we present clinical follow-up data obtained with a novel thin-walled expandable prototype silicone airway stent (Polyflex stent, Willy Rüsch AG, Kernen, Germany) in 19 patients. METHODS: Seventeen of 19 patients had tracheobronchial complications of infiltrating cancer: five had respiratory-digestive fistulas, 14 had mixed-type obstructions (mucosal infiltration plus extrinsic compression), and two had diffuse tracheal hemorrhages from the tumor surface (three patients had more than one complication). Two of 19 patients had benign postintubation stricture and malacia. Overall, 33 stents were implanted either simultaneously or in a consecutive manner. Scanning electron microscopy was performed both on prototype stents and on other available silicone stents for comparison. RESULTS: The treatment improved the patients' clinical condition substantially. The mechanical properties of the new prosthesis were excellent. Important stent-associated side effects were early mucus retention (n = 7), infolding of the inner silicone layer (n = 2), and stent dislodgment (n = 2). As of February 1997, 10 patients have died of causes unrelated to stent placement. Seven patients with malignant airway disease are still alive from 2 weeks up to 7 months after initial treatment. Scanning electron microscopy of explanted and unused prototypes suggested that an extremely ragged luminal microstructure may contribute to the firm adhesion of secretory material and that technical smoothing of the surface avoids such complications. CONCLUSIONS: The novel self-expandable silicone airway stent may be a promising addition to commonly used stent types. Short-term and medium-term management of fistulas, tumor surface bleeding, and strictures (malignant and benign) is satisfactory. Scanning electron microscopy of stents provides information on peculiar features of microstructure and material that may be of use in clinical research and technical innovation.

Abstract: Until now reports of factitious disease have not been found in the ENT literature. In contrast, the dermatologic literature estimates an incidence from 0.01 to 0.26%. In order to achieve effective treatment for these patients, knowledge of the characteristic symptoms is fundamental. The present paper describes the variety of disease possible, using three cases treated between 1992 and 1994 in the ENT Department of Cologne. According to the literature, females are involved in a ratio of 9:1, with the majority working in medically related professions. Depression and anorexia are typical symptoms. When a factitious disease is suspected, psychiatric consultation is essential. Confrontation of a suspect patient by the otolaryngologist is not often considered because several reports quote suicidal behavior in up to 25% of self-manipulating patients and tendencies to refuse to follow psychiatric treatment are considerable.

Abstract: Tonsillectomy tissue can be used as a routine source for cultures of oropharyngeal keratinocytes. In so doing, a peritonsillar strip of unaltered mucosa was dissected in the upper submucosa. Subsequent trypsinization yielded 7.0 +/- 3.4 x 10(6) keratinocytes per bilateral tonsillectomy. Keratinocyte attachment and growth in primary culture were promoted by sublethally irradiated 3T3 murine fibroblasts. Three subcultures could be performed without a feeder layer and were characterized by a population doubling time of 4.5 days during log growth phase. Electrophoretic and immunoblot analysis of the third subculture revealed a strong expression of keratin pairs 5/14 and 6/16 as well as keratins 7 and 19, whereas keratins 8/18 were expressed less intensely. The lowest intensity, was found for keratin 13, which is known to be indicative of the differentiated mucosa. The culture technique thus provides an easily available in vitro model for morphological and functional studies on the epithelial compartment of human oropharyngeal mucosa.

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Abstract: OBJECTIVE: We evaluated the long-term prognosis of stents placed on an emergency basis in the trachea and its bifurcation for malignant stenosis. METHODS: We retrospectively analyzed all bronchologic treatments of obstructing airway lesions from January 1993 to December 1995. RESULTS: We report on 10 patients with severe malignant "mixed-type" obstruction of the proximal trachea or distal trachea plus both main-stem bronchi. They had far-advanced inoperable tumor (esophageal cancer: n = 4; lung cancer: n = 3; recurrent laryngeal, uvula, and thyroid cancer: n = 1 each). Emergency treatment consisted of a dilating bougie maneuver followed by the insertion of a large one-way (n = 4) or Y-shaped silicone prosthesis (n = 6). After the intervention, there was a long-lasting clinical improvement. Median survival from stent insertion was 8 months for all patients irrespective of tumor type; it was 5 months for patients with lung carcinoma and 8 months for those with esophageal cancer. The results are in accordance with other studies using different therapeutic modalities. Stent exchange was necessary in five patients. Main reasons were continuing tumor growth beyond the proximal and distal boundaries and recurrent productive bronchial infection. Patients died of pneumonia (n = 4), pulmonary lymphatic spread (n = 1), cardiac failure (n = 2), and fatal hemorrhage (n = 1). As of December 1995, three patients were still alive 2, 5, and 8 months after implantation. CONCLUSIONS: As evidenced by clinical efficiency and length of palliation, endoscopic placement of silicone-based one-way and bifurcational prostheses in far-advanced tumor of the central airways is technically feasible and ethically justifiable.

Abstract: A patient suffering from esophagorespiratory fistula after bougienage of a benign stricture at the site of the anastomosis between a jejunal interposition and the esophagus was referred for interventional treatment. A prototype nitinol stent centrally covered with Dacron was implanted under regional anesthesia and fluoroscopic guidance. The self-expanding prosthesis dilated the stenosis completely and closed the fistula, with consequent improvement in respiratory and nutritional status and thus the general quality of life. The patient was able to eat and drink normally until death 3 months later due to progression of his underlying malignant disease.

Abstract: AIMS: The efficacy of endoscopic endonasal orbital decompression in dysthyroid orbitopathy was analysed. METHODS: In 21 consecutive cases of bilateral operation short term (10 (SD 6) days after operation) and long term (156 (12) days after operation) results were recorded. RESULTS: Short term results showed that vision of the more affected eye improved from a mean of 0.35 to 0.59; vision improved in all but one eye which remained unchanged. In the fellow eyes mean visual acuity improved from 0.6 to 0.7; three of these eyes showed a decrease. Mean proptosis returned from 23.0 mm to 20.0 mm. As to motility the mean abductive capacity decreased from 5.5 mm to 4.0 mm of monocular excursion, whereas adduction increased from 7.5 mm to 8.5 mm. Upgaze and downgaze did not show any major change. The mean angle of horizontal squint shifted from 7.5 degrees of convergence to 15.5 degrees while no significant vertical or cyclorotational deviation was induced. These immediate postoperative results proved to be stable for the period of long term follow up with only slight changes. No significant bleeding or specific otorhinolaryngological complication without resolve occurred intraoperatively or perioperatively. CONCLUSION: This method is believed to be superior to non-endoscopic techniques because it avoids external scars and antral pain. With regard to the relief of intraorbital pressure, the technique gives good results for visual acuity improvement, but in proptosis reduction the method is not as efficient as external or combined procedures. There seems to be no difference when compared with other approaches in induction of horizontal squint. The method has a protective long term effect against the recurrence of compressive optic neuropathy.

Abstract: Claims for medical liability mostly arise when a patient believes that his sudden deafness was not accurately diagnosed, diagnosed too late or insufficiently or was not well treated. Guided by seven expert opinions potential problems in indemnity were depicted. A clear misdiagnosis of sudden hearing loss (e.g., a hearing loss taken for eustachian tube disorder) will lead to an accusation of malpractice if the doctor cannot prove an accurate otological examination and appropriate diagnostic studies. The burden of proof lies with the doctor. A further consequence of a missed diagnosis is a delay in treatment. In the literature the good prognostic factor of early treatment has been stressed but without delineating a clearcut line between "in time" and "too late". An accusation of malpractice by insufficient treatment (pills instead of infusions) has risen. Since an unequivocal treatment is not established and various modalities of therapy are still controversial, disputes could be settled more easily. The validity of "no treatment" may be considered but requires accurate diagnosis and the patient must give informed consent. Such a procedure is justifiable, even from an ethical standpoint, when the patient fully understands and agrees.

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Abstract: Die endolaryngeale Laserchirurgie hat einen festen Platz neben den konventionellen chirurgischen Kehlkopfeingriffen gefunden. Mit diesen Eingriffen ist eine deutliche Verkürzung der stationären Liegezeiten verbunden, so dass die Nachbehandlung überwiegend ambulant durchgeführt wird. Der Vorteil der endolaryngealen Laserchirurgie liegt in der Minimierung der intraoperativen Blutung und in dem gering invasiven Eingriff. Ein Nachteil liegt jedoch in der verlängerten Wundheilung. Der verstärkte Einsatz der postoperativen Feuchtinhalation und die richtige Auswahl der zu inhalierenden Substanzen kann die Wundheilungszeit abkürzen und zusätzliche Komplikationen verhindern. Eine bei hartnäckigen Fibrinbelägen in der Bronchologie angewendete Lösung aus einem gering resorbierbaren Antibiotikum, Kortison und α-Chymotrase zeigt auch in der postoperativen Phase nach Lasereingriffen im Kehlkopf gute Ergebnisse.

Abstract: A probable relation between prostaglandin formation and the pathophysiology of hearing loss led to the application of the potent vasodilator prostacyclin in the treatment of inner ear disorders. Two drugs may be administered to humans: (1) unstable natural prostacyclin (epoprostenol) with a strong biological potency but with a high first-pass effect, or (2) a prostacyclin analogue (taprostene) with less biological activity, but a longer biological half-life and intravenous application. Therefore, the purpose of this study was to investigate potential differences of both drugs in their effect on the inner ear. The therapeutic potency of both drugs was evaluated in a recently developed animal model consisting in the recovery of hearing after a temporary threshold shift obtained by two noise exposures at 100 dB. In addition, the ultrastructure of the stria vascularis was examined by electron microscopy after the application of the drugs. After administering epoprostenol (12 ng/kg body weight/min) and taprostene (25 ng/kg body weight/min) histomorphological alterations in the stria vascularis did not differ from the controls. In the repetitive low-level noise model, neither drug showed a significant difference in its effect on the recovery of the hearing threshold. The results indicate that in the guinea pig epoprostenol has the same effect on the hearing threshold as the stable analogue taprostene, as shown by auditory brain stem response.

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Abstract: Between 1991 and 1993, 9 cases of isolated medial orbital wall fractures were diagnosed with 8 patients, 8 of them complaining of horizontal diplopia due to medial rectus muscle entrapment. An endoscopic-controlled endonasal surgical procedure was performed in 7 patients. The endonasal procedure provided adequate exposure for removal of the incarcerated tissue as well as covering the defect. All 7 patients had good results with no restriction of lateral gaze and There were no surgical complications observed. The first step of the endonasal technique is a partial resection of the middle turbinate. During the following partial ethmoidectomy, the fracture of the ethmoid and medial orbital wall are exposed. This must be done carefully while avoiding any trauma to the herniated orbital contents. After repositioning the orbital fatty tissue, lyodura is introduced and fixed with fibrin glue. For larger defects, free graft of mucosa is recommended. The nasal packing is done between two silicon sheets in order to simplify the removal after 8 days. All 7 patients proved to be free of motility disturbances after the intervention. The endonasal method is limited to isolated medial wall fractures; in all other cases of midfacial fractures combined techniques have to be used.

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Abstract: Only a few case reports have been published about hearing impairment following lumbar puncture, and not all were thoroughly documented by audiograms. We present nine cases of hearing loss following myelography, lumbar puncture, and spinal anesthesia. We speculate that this rare complication arises only in persons with a wholly or partially patent cochlear aqueduct, and occurs via the release of perilymphatic fluid in the cerebrospinal space. Hearing loss was seen in eight of the nine patients in the lower frequencies, and in six of the nine patients on both sides. Recovery to normal hearing was noticed in six of the nine patients. Transient hearing loss may occur more often than it is generally assumed, and the symptom can remain unnoticed. Since not all of these hearing losses proved to be fully reversible, we suggest informing patients about this complication for medicolegal reasons.

Abstract: To elucidate the possible mediating role of prostaglandins as underlying mechanism of the acute audiologic effects of furosemide in patients with Ménière's disease, the hearing threshold shift after a 1 hour infusion of a commercially available prostaglandin E2 derivative (120 ng/kg body weight) was determined in 10 patients. Prostaglandin E2 produced a transient hearing improvement comparable to the effects obtained in the furosemide test with 1.2 mg/kg bw in the same patients. The effectiveness of a prostaglandin infusion on hearing levels may be a further sign of the involvement of this mediator in hearing processes.

Abstract: Als Mobius-Syndrorn wurde ursprunglich eine kongenitale Fazialis-Abduzens-Parese bezeichnet. Wegen der Seltenheit des Syndroms wurden in der Folgezeit meist nur kasuistische Beiträge veröffentlicht. Das <<ursprungliche Syndrom>> wurde dabei überwiegend im Zusammenhang mit zusätzlichen Paresen anderer Hirnnerven, äusseren Missbildungen an Gesichtsschädel und Extremitäten sowie psychomotorischen Defekten beschrieben, was zu einer immer verwirrenderen Vielfalt in der Zuordnung verschiedener Krankheitsbilder zum ursprunglichen Mobius-Syndrorn gefuhrt hat. Die Verschiedenheit der unter dem Begriff <<Mobius-Syndrorn>> publizierten Schadigungsmuster zeigt, dass es sich bei diesern kongenitalen neurornuskulären Syndrorn hinsichtlich Atiologie und Pathogenese urn sehr unterschiedliche Krankheitsbilder handelt. Trotz dieser Heterogenitat wirft das Syndrom em gemeinsames, wenn auch schwer lösbares therapeutisches Problem auf: die kosmetische und funktionelle Rehabilitation im Bereich der fachspeziflschen Hirnnerven und des Gesichtsschädels. Für die HNO-Heilkunde steht dabei die Korrektur der Fazialisparese im Vordergrund. Aufgrund der bei insgesamt 12 Patienten erhobenen klinischen und elektrophysiologischen Befunde konnte gezeigt werden, dass nervenplastische Massnahmen beim Mobius-Syndrom kontraindiziert sind. Auch muskuläre Zugelplastiken rnüssen sehr sorgfältig indiziert werden, da einige pathologische und neurologische Besonderheiten des Syndroms das angestrebte Behandlungsziel beeinträchtigen.

Abstract: Als Mobius-Syndrorn wurde ursprunglich eine kongenitale Fazialis-Abduzens-Parese bezeichnet. Wegen der Seltenheit des Syndroms wurden in der Folgezeit meist nur kasuistische Beiträge veröffentlicht. Das <<ursprungliche Syndrom>> wurde dabei überwiegend im Zusammenhang mit zusätzlichen Paresen anderer Hirnnerven, äusseren Missbildungen an Gesichtsschädel und Extremitäten sowie psychomotorischen Defekten beschrieben, was zu einer immer verwirrenderen Vielfalt in der Zuordnung verschiedener Krankheitsbilder zum ursprunglichen Mobius-Syndrorn gefuhrt hat. Die Verschiedenheit der unter dem Begriff <<Mobius-Syndrorn>> publizierten Schadigungsmuster zeigt, dass es sich bei diesern kongenitalen neurornuskulären Syndrorn hinsichtlich Atiologie und Pathogenese urn sehr unterschiedliche Krankheitsbilder handelt. Trotz dieser Heterogenitat wirft das Syndrom em gemeinsames, wenn auch schwer lösbares therapeutisches Problem auf: die kosmetische und funktionelle Rehabilitation im Bereich der fachspeziflschen Hirnnerven und des Gesichtsschädels. Für die HNO-Heilkunde steht dabei die Korrektur der Fazialisparese im Vordergrund. Aufgrund der bei insgesamt 12 Patienten erhobenen klinischen und elektrophysiologischen Befunde konnte gezeigt werden, dass nervenplastische Massnahmen beim Mobius-Syndrom kontraindiziert sind. Auch muskuläre Zugelplastiken rnüssen sehr sorgfältig indiziert werden, da einige pathologische und neurologische Besonderheiten des Syndroms das angestrebte Behandlungsziel beeinträchtigen.

Abstract: Sudden idiopathic hearing loss has occasionally been supposed to be caused by a disturbed microcirculation in the inner ear of unknown origin. Little is known about the regulation of cochlear blood flow and the effectiveness of drugs in cochlear microcirculation. Because animal experiments gave evidence that prostacyclin (PGI2) might be one biochemical substratum of local regulators in the flow of blood in the stria vascularis, 11 patients with sudden idiopathic hearing loss were treated once for 6 h with prostacyclin (10 ng/kg body weight/min) in a first open clinical trial. In most cases prostacyclin increased hearing level (mean value: 7.4 dB/frequency/day) more than a standard therapy with pentoxifylline. The substitution of PGI2 could be another indication of a rheologic disorder--whether per se or within a larger context of inflammation-like interaction--in the inner ear of patients with sudden hearing impairment.

Abstract: A placebo-controlled, double-blind study with the stable prostacyclin analog Taprosten (CG4203, Grünenthal, Aachen, FRG) on the treatment of sudden hearing loss was conducted in 22 patients in the ENT Department of the University of Cologne. The hospital ethical committee gave permission for the trial. After informed consent had been obtained, the patients (13 male, 9 female, age 21-74 yrs.) were treated with Taprosten (25 ng/kg bodyweight/minute intravenously) or with 30 ml saline solution (NaCl 0.9%) for 6 hours during 5 days. Hearing thresholds were controlled by pure tone audiometry and speech discrimination test each day before and after treatment. All the data obtained (dB hearing loss) by pure tone audiometry was averaged for 7 frequencies. Differences were calculated between the hearing loss before and after treatment. Differences were considered significant if p less than or equal to 0.01. No significant difference could be seen in hearing recovery after Taprosten and placebo during the 5 days of treatment. Evaluation of the individual frequencies showed no prevalence of higher or lower frequencies. Although the impression was that hearing loss recovered better within the first days of treatment with Taprosten, no statistical proof could be found. In both groups the percentage of complete recovery did not differ (about 70%). The reason for the lack of significant statistical differences was the high standard deviation of the averaged hearing loss and the very high spontaneous recovery. Even if, in this placebo-controlled study, we could not prove the efficacy of a prostaglandin treatment for sudden hearing loss, the need for multicentred placebo-controlled studies with more patients is evident.

Abstract: In the few case reports of hearing loss following spinal anesthesia, complete recovery of the hearing impairment has always been described. In nine cases with hearing loss following not only spinal anesthesia but also myelography and dural puncture, the hearing of three patients did not recover or only partly returned. Two cases went to court for malpractice. Their suits could be dismissed because it appears likely that this rare complication arises only in persons with a wholly or partially unobliterated aquaeductus cochleae due to loss of perilymphatic fluid into the cerebrospinal space. Hearing loss was seen in eight of nine patients in lower frequencies around 30-40 dB. In six patients there was impairment on both sides. Recovery of normal hearing occurred in six of the nine patients. Transient hearing loss may occur more often than is generally assumed, and the symptom may remain unnoticed when a severe post-dural puncture syndrome with headache, dizziness, and nausea dominates the attention of the patient. Not all cases of hearing loss proved to be fully reversible, but the individual risk for this complication is not predictable. The use of fine-gauge needles may reduce the leakage of cerebrospinal fluid through the dural puncture and thus lower the incidence.

Abstract: A placebo-controlled, double-blind study with Ems brine inhalations as postoperative treatment after endoscopic endonasal sinus surgery was conducted on 30 patients. After informed consent had been obtained, the patients were treated with either Ems brine or saline solution (200 ml) 3 times a day for 10 days. The parameters measured were rhinomanometry, X-ray films of the sinuses, endoscopy, saccharin clearance and a subjective evaluation by the physician and by the patient based on a visual analogue scale. The difficulty of choosing parameters for assessing the treatment was that comparable clinical studies and a single predictive parameter were not available. The bacteriological test and the saccharin clearance test were not significantly different between the two groups. Recovery, swelling, crusting, bleeding and signs of inflammation, opacity on sinus X-ray films, and nasal flow as measured by rhinomanometry were all significantly better in the group inhaling brine solution (P less than 0.05).

Abstract: The audiograms and CT scans of three children with a bilateral congenital mixed deafness are presented. Two children underwent an exploratory tympanotomy revealing a fixed stapes footplate: a perilymph gusher arose during platinotomy in both cases. The gusher was controlled successfully with a large fat graft in both children, and hearing remained unchanged. Two of the children were brothers: they had no other deformities except an enlarged fundus of the auditory canal on CT scans, and no clearly defined bony barrier to the vestibule, suggesting a cerebrospinal fluid fistula. Neither a patent nor an abnormal cochlear aqueduct could be detected in all three cases. It is likely that the three patients present an X-linked mixed deafness syndrome with fixation of the stapedial foot plate and perilymph gusher. A classification of congenital perilymph-CSF shunts is proposed.

Abstract: In 6 patients with endocrine ophthalmopathy, indications, surgical technique and results of the endoscopic controlled endonasal orbital decompression are described in comparison to the common surgical procedures. When medical and radiation therapy fail, indications for decompression are a) loss of visual acuity or visual field defects, b) increasing strabismus, c) severe keratopathy due to eyelid retraction. The endoscopic-controlled endonasal surgical decompression technique is proceeded in three steps. First, an endonasal ethmoidectomy with resection of the middle turbinate is performed and the medial wall of the maxillary sinus is widely opened. Second, the medial and inferior wall of the orbital walls are removed, preserving the infraorbital nerve. In the last step, the periorbital area is incised and the orbital fat herniates. The advantages of this procedure consist in the absence of exterior scars and the known morbidity of a Caldwell-Luc antrotomy. The results were documented by computed tomographic scans (CT), magnetic resonance imaging (MRI), Hertel measurements, evaluation of ocular motility and ophthalmoscopy. An average of 3-4 mm improvement in Hertel-measurements could be reached. All patients had a postoperative improvement of visual acuity. 2 patients developed more significant diplopia postoperatively, whereas in all other patients ocular motility either improved or rested unaffected. Therefore, the endoscopic controlled endonasal procedure allows to obtain comparable results to the common extranasal and transantral procedures without the disadvantages of the latter.

Abstract: Lesions of the lingual nerve and the glossopharyngeal nerve following tonsillectomy are rare but can be expected because of their anatomical course. What is extremely rare is a lesion of the hypoglossal nerve, whose course behind the carotid artery protects it from direct injury. The few cases described in the literature are thought to have been caused by inflammatory processes. It became necessary to look for other causes when, after a regular tonsillectomy, a hypoglossal palsy became evident in the absence of any inflammation. In an experiment, it was possible to demonstrate that both the insertion of a spatula and of an intubation spatula caused a strain of the hypoglossal nerve when the spatulas were inserted in the lateral lingual region. The nerve was distended by as much as 1.3 cm. The more the head was reclined, the more the nerve was distended. It would seem probable that this extension of the hypoglossal nerve causes its palsy following tonsillectomy.

Abstract: Lumbar puncture for myelography, spinal anaesthesia and aspiration of cerebrospinal fluid is a very common procedure. Although it has been known for a long time that hearing impairment may be a late complication, only a few case reports have been published, and not all have included audiograms. We present nine cases of hearing loss following myelography, lumbar puncture and spinal anaesthesia. It appears likely that this rare complication arises only in subjects with a wholly or partially patent cochlear aqueduct, allowing loss of perilymphatic fluid into the cerebrospinal space. Hearing loss was seen in eight of nine patients in the lower frequencies and in six of nine patients on both sides. Hearing recovered in six of nine patients. Transient hearing loss may occur more often than is generally assumed, and the symptom can remain unnoticed. Since not all of these hearing losses proved to be fully reversible, we suggest to inform patients about this complication for medico-legal reasons.

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Abstract: Osmotika sind hochmolekulare Substanzen, die in der Niere frei glomerulär filtriert, aber nicht tubulär rückabsorbiert werden. Sie binden freies Wasser intravasal und halten Wasser osmotisch im Harn zurück. Zu dieser Substanzgruppe gehören Harnstoff, Sorbit, Mannit und Glyzerin, aber auch Glucose in höherer Konzentration. Die Osmotika dienen in der Therapie zur Gewebeentwässerung und gehören formal zu den osmotisch wirksamen Diuretika. Sie stehen in ihrem gewünschten Therapieziel in Konkurrenz mit den Hyperonkotika und den übrigen Diuretika. Zu den Hyperonkotika zählen 7,5% Kochsalz-Lösung in Kombination mit 6% Hydroxyäthylstärke. Zu den Diuretika zählen weiterhin die Schleifendiuretika, kaliumsparende Diuretika, Aldosteronantagonisten und die Thiazide sowie deren Analoga. Die Gabe von Osmotika geht auf die Behandlung des Glaukoms zurück, später auf die Therapie des Schädel-Hirn-Traumas (Schädel-Hirn-Trauma) und hat sich weiterhin in der Behandlung des endolymphatischen Hydrops etabliert.

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Abstract: "This book integrates the basic science of the nose and face with clinical information on issues in rhinology, trauma, and aesthetics of the face. � the book would be of most benefit to residents and graduates in this field. � There are a plethora of charts, endoscopic photos, drawings, and photos in each chapter. This is an excellent resource and starting point for rhinologic and facial plastic surgery." (Jeffrey S. Rosenthal, Doody�s Review Service, November, 2009)

Abstract: Unter dem Druck zunehmender Arbeitsverdichtung wird die Ressource Zeit immer wertvoller: Dieses Buch ist die logische Konsequenz: Es ermöglicht dem Arzt eine zeitsparende Informationsaufnahme, ohne dabei jedoch auf die notwendige Tiefe zu verzichten. Im Mittelpunkt stehen detaillierte und differenzierte Empfehlungen zu Diagnostik und Therapie. Dabei wurde der Text stichwortartig gestaltet; auf jedes überflüssige Wort wurde verzichtet. Zahlreiche Tabellen, Algorithmen und schematische �bersichten ermöglichen einen schnellen �berblick. Unter Mitarbeit von Autoren aus ganz Deutschland: So konnte zu jedem Thema der jeweils anerkannte Experte sein Wissen weitergeben. Hervorragend geeignet für Assistenzärzte, Facharztkandidaten und Fachärzte. Ein unverzichtbarer Wissensspeicher für Klinik und Praxis.

Abstract: Unsere Sinnesorgane dienen der Wahrnehmung unserer Umwelt. Der Mensch ist als einziges Lebewesen fähig, Defizite in einem Bereich der Wahrnehmung durch seine Koordinationsfähigkeit auszugleichen. Dieses Buch entstand aus den Referaten etablierter Wissenschafter anlässlich eines Symposiums im September 2007 in Münster. Durch die interdisziplinäre Zusammenarbeit von Experten, die sich mit der Sinneswahrnehmung beschäftigen, gelang es erstmalig, aktuelle Forschungsergebnisse und neueste Entwicklungen aus den einzelnen Fachrichtungen ausführlich und umfangreich darzustellen. Der Schwerpunkt wurde auf Diagnostik und spezielle Therapieverfahren sowie innovative Behandlungs- und Rehabilitationsmöglichkeiten gelegt. Fundierte historische Abhandlungen runden dieses Buch ab. Das Buch richtet sich neben HNO-�rzten, auch an Augenärzte, Internisten, Neurologen, Orthopäden und Allgemeinmediziner. TOC:1. Die menschlichen Sinne.- 2. Klinik des Hörorgans. 1. Chirurgische Möglichkeiten der Verbesserung der Schalltransmission bei Hörstörungen. 2. Moderne Hörhilfen. 3. Erfahrungen mit Cochlea-Implantaten. 4. Sprech- und Sprachstörungen aus der Sicht des Phoniaters.- 3. Klinik des Riechorgans. 1. Klinik von Riech- und Schmeckstörungen. 2. Riechstörungen unter medicolegalen Gesichtspunkten. 3. Aerodynamik im Bereich des Riechorgans. 4. Pheromone: Spekulation oder Wissen? 5. The nose and beyond - no nose. 6. �sthetik des Riechorgans. 7. Rhinochirurgische Aspekte bei Visusminderung.- 4. Klinik des Sehorgans. 1. Optische Täuschungen. 2. Optische - entoptische Phänomene. 3. Die subjektive visuelle Vertikale aus augenärztlicher Sicht.- 5. Klinik des perihperen gleichgewichtsregulierenden Systems. 1. Klinik der vestibulären Gleichgewichtsstörungen. 2. Otolithenfunktion. 3. Labyrinthdysfunktion und Tubenventilationsstörung - Kausalität oder Koinzidenz. 4. Medikamentöse Therapie der Labyrinthfunktion vor dem Hintergrund haarzellphysiologischer Untersuchungen. 5. Vestibulär evozierte myogene Potenziale - Stellenwert eines neueren Untersuchungsinstruments zur Beurteilung der Sakkulusfunktion. 6. Schwindelbeschwerden im Zusammenhang mit dem Tauchen.- 6. Klinik der zentralen Gleichgewichtsregulation. 1. Posturographie - Evaluation neuer sensomotorischer Trainingsmethoden bei Patienten mit peripher-vestibulärer Störung. 2. Störungen des Stehens und Gehens aus der Sicht des Neurologen. 3. Klinik und Therapie von Herztrhythmusstörungen. 4. Differentialdiagnose: Kopfschmerz.- 7. Klinik der HWS unter besonderer Berücksichtigung von Tinnitus. 1. Juristische Grundbegriffe für die Begutachtung. 2. Schalldruckbelastung von PKW-Insassen durch Airbags. 3. Der unfallanalystische Beitrag zur interdisziplinären Begutachtung eines HWS-Schleudertraumas, Schutzhaltung RISP (Rear Impact Self Protection). 4. Das "HWS-Schleudertrauma" aus orthopädisch-traumatologischer Sicht. 5. Tinnitus nach HWS-Schleudertrauma. 6. Das chronische HWS-Beschleunigungstrauma.

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Abstract: Odonrogenic k-eratocysts are non-syndroniic decelopruenral cysts predominantlv found in the jaxv and to a lesser extinct in the maxillary hone arising from remnants of the denta! lam- ina. These cysts are known for their high tendency to recur and aggressive hehavior due to rapid grosvth and distortion of mdjacenm strtmctures. lnf]ainmnation can give rise to loca] pain. sv��elling and 1xiru!ent discharge or fistulisation. while some cysts remain asymptoniatic until a large expansion is reached. These cysts are wel! known hy oral�maxillofacia! surgeons for tik-ir diagnosuc and therapeutic chal!enge. A complete stirgical removal is the treatment of choice and aggressive enucleation. curettage, enucleation and peripheral ostectoniy, and resec� tion depending on the radiographic extension are descrihed in the literatt, re. A mininial invasive technique by combined onmi and nasa! endoscopic approach in .several patients is discussed for the removal of niaxillary odontogenic keratocysts (MOK). Because a part of these cysts can invade the maxillary bone and sinus, oro!arvngoiogists can he confronted too svith this cystic entity. Our own experience together \vith a review of the titerature of the clinical and prognostic features and treat� ment options for MOK are herehy presented.

Abstract: Odonrogenic k-eratocysts are non-syndroniic decelopruenral cysts predominantlv found in the jaxv and to a lesser extinct in the maxillary hone arising from remnants of the denta! lam- ina. These cysts are known for their high tendency to recur and aggressive hehavior due to rapid grosvth and distortion of mdjacenm strtmctures. lnf]ainmnation can give rise to loca] pain. sv��elling and 1xiru!ent discharge or fistulisation. while some cysts remain asymptoniatic until a large expansion is reached. These cysts are wel! known hy oral�maxillofacia! surgeons for tik-ir diagnosuc and therapeutic chal!enge. A complete stirgical removal is the treatment of choice and aggressive enucleation. curettage, enucleation and peripheral ostectoniy, and resec� tion depending on the radiographic extension are descrihed in the literatt, re. A mininial invasive technique by combined onmi and nasa! endoscopic approach in .several patients is discussed for the removal of niaxillary odontogenic keratocysts (MOK). Because a part of these cysts can invade the maxillary bone and sinus, oro!arvngoiogists can he confronted too svith this cystic entity. Our own experience together \vith a review of the titerature of the clinical and prognostic features and treat� ment options for MOK are herehy presented.

Abstract: ion scrutinizing the bacteriology of rhinosinusitis, in dept knowiedge of the commensal sinus flora. siudies in heaithy non�ENT�prone chiIdren (1�83�) high and rather polyniicrobiologicai cuiture iate oniinant potential pathogenic species. in healthy �ever cuiture mie of the middle meatus (MM) was ve with polymicrobial of merely 8% and inainly resiciential flora. Because of this striking dilference ve study was elaborated to eva bate the niiddle in the age group in hetween to consider the mi� ICS with age. MM sampies vere cuitured in about ctea healihy children hetween 7 and 17 years old. sarne residential flora was found as in aduits (Co� egative staphylococcus, S.aureus, Coiynebacterium still, however Iess prevalent, potential pathogenic H.influenza. tvi.catarrha!is. S.pneumonia), as found ddIe meatus of younger heaithy children. �this study )n can indeed he regarded as-�i transition community chiIdren and aduits. To the atithors this is the first ed study about the n icrohiology of the iii iddie nwatus aithy preteens and Leenagers population. The resuits )otheses for these observations are presented.