A. Gurr

The common pig: a possible model for teaching ear surgery

Anatomical dissection of the human temporal bone is an essential element in the education of ear surgeons. Unfortunately, the acquisition of human temporal bones can be difficult. As an alternative, temporal bones of animals might help. The temporal bones of ten common pigs taken out of a butcher’s daily routine were drilled and dissected under clinical aspects. The resulting anatomy was analyzed and measured. Especially, the mastoid, the external ear canal and the middle ear were incorporated. The preparation was done following a strict order of steps relevant to typical work of an ENT surgeon. Our results were compared with known data of the human temporal bone and effectiveness concerning surgical training was verified. We could see that the temporal bone of the pig had a totally different appearance compared to the human one, especially regarding the length and location of the external ear canal. Also, the mastoid is difficult to identify. It is hidden by the atlanto-occipital joint and has no pneumatization. The anatomical landmarks as the arcades and the facial nerve are congruent to the human anatomy although not all structures are accessible via the mastoid. The pigs’ middle ear showed to be very similar to the human one. The incus showed a shortened long process. This study showed that the temporal bone of the pig might be an alternative regarding some aspects of surgical training in ENT education. A complete replacement is not possible. After some modification, it might be an efficient model for endaural techniques and ossicular manipulation.

Human β-Defensins in different states of diseases of the tonsilla palatina

Tonsils are believed to play an important role during the development of the immune system. Although diseases of the tonsils like hypertrophy of the tonsil, acute tonsillitis, chronic tonsillitis or peritonsillar abscess are common, little is known about the underlying pathophysiology. Little is known about antimicrobial peptides produced by the tonsils. The human β-Defensins 1-3 (hBD1-3) are naturally produced “antibiotics” with antimicrobial activity against different bacteria, fungi, and viruses. The objective of the study was to determine the concentrations for hBD1-3 in different states of diseases of the tonsilla palatina. After tonsillectomy and tissue fixation in formalin, total proteins were isolated from 38 samples (11 hypertrophy of the tonsil, 8 acute tonsillitis, 11 chronic tonsillitis, 8 peritonsillar abscesses). The protein concentration was determined and ELISA for hBD1-3 were performed. We also conducted immunofluorescence double stainings for the co-expression of streptococcus group A and hBD1-3. We could verify a significant difference for the mean hBD1 score of the acute tonsillitis in comparison to the hyperplastic tonsil, the chronic tonsillitis, and the peritonsillar abscess. There was no statistically significant difference in the hBD2 and hBD3 concentrations between the four groups. The immunofluorescence stainings showed that hBD1-3 and the streptococcus group A in the same place. We conclude that in the hyperplastic tonsilla palatina hBD1-3 play an important role. The mouth is constantly faced with a high bacterial load. During a tonsillitis, the hBD1 concentration is lower than in the non-acute infected tonsil because hBD1 is being consumed for fighting the bacterial infection. But, the existence of hBD1-3 in the tonsil cannot prevent the tonsillitis to become chronic.

Human antimicrobial proteins in ear wax

The external auditory canal is vulnerable to bacterial infections, but little is known about thechemical compositions of ear wax regarding antimicrobial peptides. We, therefore, studied the proteinconcentrations of ten well-known human antimicrobial peptides from ear wax.Twenty ear wax samples from healthy individuals were analysed using enzyme-linked immunosorbent assay (ELISA) to determine theprotein concentrations of the antimicrobial peptides hBD1-3, lactoferrin, LL-37, BPI, hSLPI and HNP1-3. All ten antimicrobial peptides are present in ear wax. Some of these proteins seem to be merelycell-bound in ear wax. Antimicrobial peptides in ear wax prevent bacteria and fungi from causing infections inthe external auditory canal. The role and importance of these proteins for the blind-ending ear externalcanal is discussed. If this local defence system fails, infections of the external auditory canal may result.The knowledge about the presence of antimicrobial peptides in cerumen may lead to new concepts ofthe local treatment of external auditory canal diseases in the future.

Complications in 312 cases of nasal and auricular reconstruction via autologous rib cartilage

BACKGROUND We present the results and complications with autologous rib cartilage in comparison to other materials in nasal and auricular reconstruction using a large patient collective from our clinic. MATERIAL AND METHODS The retrospective study included all cases of auricular and nasal reconstruction via rib cartilage between 2001 and 2009. The outcome was analysed by subjective and objective parameters. RESULTS 51/321 patients underwent plastic reconstructive surgery of the nose, 270/321 received a partial or complete auricle reconstruction with autologous rib cartilage. The complication rate e.g. of hematomas, lesions of the pleura, postoperative pain and keloids at the donation site was small. Concerning the aesthetic results of the nose and auricles 273 of 321 (85%) were satisfied after the first operation. Only 3/51 nasal reconstructions underwent a second operation. In case of complete auricular reconstructions, all patients underwent at least 2 operations for the three-dimensional look. CONCLUSIONS The use of autologous rip cartilage is still a good option in the auricular and nasal reconstruction. Depending on the expertise of the surgeon the postoperative aesthetic results are good with a low complication rate. However concerning the bigger effort in several aspects for the surgeon as the patient it should be reserved to specific indication criterias.

Stellenwert des Nervenmonitorings für die Schilddrüsenchirurgie

Aim of this study is to investigate the influence of nerve monitoring for protection of recurrent nerve function in thyroid surgery. We analysed retrospectively the data of 369 patients, who underwent thyroid surgery at our clinic between 2000 and 2006. In 129 cases (35%) a hemithyroidectomy and in 236 cases (64%) a total thyroidectomy were performed. A single node in the isthmus was removed in 4 patients. In thyroidectomy we strove for identification of the recurrent nerve. This was performed successful in 96% (577 of 601) of the cases. In 94% of all thyroid surgeries nerve monitoring (NIM-Response/Medtronic) to watch the recurrent nerve were used. In 5 cases (0.83%) a permanent recurrent laryngeal nerve paralysis occurred. There was temporary recurrent laryngeal nerve paresis in 11 cases (1.84%). The use of nerve monitoring could not significantly lower the risk for laryngeal nerve paralysis or paresis (Fischers exact test, p>0.05). As expected we found no influence of nerve monitoring on other surgical complications. The apply of intraoperative nerve monitoring is a useful tool in thyroid surgery and is described to lower the risk of recurrent laryngeal nerve damage, but to our opinion it does not replace the intraoperative preparation of the recurrent laryngeal nerve. Sound anatomical knowledge of the head- & neck region is an important requirement for save thyroid surgery.

Principles of cholesteatoma surgery

As a potentially life-threatening disease, cholesteatoma of the petrous bone generally requires a surgical approach. Surgery aims to produce an ear that is easy to care for and is free of recurrent or residual cholesteatoma. Hearing improvement is of secondary importance. Nevertheless the sound conduction system is generally reconstructed as a single-stage procedure. There are various possible methods of dealing with a cholesteatoma: (i) preserving or reconstructing the posterior meatal wall with an aerated mastoid (closed technique) or obliteration of the mastoid completely or partially after removal of the posterior wall (closed technique); and (ii) leaving the cavity open for inspection (open technique). In our opinion any technique where the mastoid is not open for inspection should be called a closed technique. Both techniques have their specific advantages and disadvantages.

Protein isolation from ear wax made easy.

Cerumen is a waxy substance with a mixture of different lipids and and not yet identified proteins. Analysing ear wax can be quite laborious because of the different and sometimes interfering components. Therefore, time-consuming techniques such as chromatography or spectrometry were used to gain informations about the components of ear wax. Conclusions were drawn from immunohistochemical detections of special proteins within the skin or the glands of the external ear canal about the existence of these proteins within the ear wax. But directly analysing the proteins within the ear wax was difficult. We, therefore, worked out a method to isolate proteins from ear wax. Ear wax was collected from 16 adults with no infections of the external ear canal. The protein isolation was conducted using the Qproteome™ Mammalian Protein Prep Kit by Qiagen in two different kind of ways (cell and lysat fraction). Afterwards, we performed a quantification of the total protein concentration using the BCA method. There was a statistical significant difference in the total protein concentration between the two different (cell and lysat fraction) described ways. Furthermore, it is a fast and easy method to extract proteins from ear wax. The benefit of the described method and the field of application will be discussed.

Approaches to the Middle Ear

The decision as to perform transcanal, endaural or a retroauricular approach should be based on the preoperative evaluation. The expected extent of surgery, the necessity of opening the mastoid, the given anatomical findings, e.g. a narrow or angled external ear canal and a bulging anterior external ear canal wall, all have to be considered. The position of the sigmoid sinus and the depth of the dura are further aspects to be taken into account. Smaller central perforations and fresh traumatic perforations can be closed through a transcanal approach using a speculum. The transcanal approach is the least traumatic approach and can be used for office procedures and small perforations. The endaural approach is generally used for surgery within the middle ear. It mainly comprises the region which can be seen by examining the patient preoperatively with the speculum, i.e. before stapes surgery and tympanoplasties without work in the mastoid.

Prinzipien der sanierenden Cholesteatomchirurgie

As a potentially life-threatening disease, cholesteatoma of the petrous bone generally requires a surgical approach. Surgery aims to produce an ear that is easy to care for and is free of recurrent or residual cholesteatoma. Hearing improvement is of secondary importance. Nevertheless the sound conduction system is generally reconstructed as a single-stage procedure. There are various possible methods of dealing with a cholesteatoma: (i) preserving or reconstructing the posterior meatal wall with an aerated mastoid (closed technique) or obliteration of the mastoid completely or partially after removal of the posterior wall (closed technique); and (ii) leaving the cavity open for inspection (open technique). In our opinion any technique where the mastoid is not open for inspection should be called a closed technique. Both techniques have their specific advantages and disadvantages.

Treatment of tympanosclerosis

ZusammenfassungDie Tympanosklerose ist ein Narbenprozess des Mittelohrs mit anschließender Verkalkung als Folge chronischer Entzündungen, der meist mit einer Schallleitungsschwerhörigkeit einhergeht. Die Behandlung richtet sich nach den Prinzipien der Tympanoplastik mit Entfernung der tympanosklerotischen Veränderungen, Verschluss der Trommelfellperforation und Rekonstruktion des Schallleitungsapparats. Besondere Anforderungen ergeben sich insbesondere bei ausgedehntem Befall des Trommelfells und der Stapesregion. Am Trommelfell kann die Entfernung großer tympanosklerotischer Platten zu ausgedehnteren Rekonstruktionsmaßnahmen zwingen. Bei Arbeiten an der Steigbügelfußplatte ergibt sich die Gefahr der Eröffnung des Innenohrs mit einer hohen Ertaubungsgefahr. Rekonstruktionen der Schallleitungskette bei fixierter Fußplatte erfordern somit meist nach primärem Trommelfellverschluss einen 2. operativen Eingriff. Befunde ohne klinische Symptomatik sollten belassen werden. Eine Hörgeräteversorgung stellt die Alternative zum operativen Vorgehen dar.AbstractTympanosclerosis is a scarring process with a remarkable variability in its localization within the middle ear. It can lead to conductive hearing loss in many cases. It is usually caused by recurrent chronic inflammation of the middle ear. It is generally accepted that functionally relevant tympanosclerotic findings of the middle ear structures should be treated by surgery. Depending on the extent of the surgical resection, the tympanic membrane and the ossicular chain must be reconstructed individually. In cases of isolated myringosclerosis with no hearing loss, no surgery is required. When the ossicular chain is affected by the sclerosis, sound conduction can often be restored only by interposition of grafts. Stapes footplate fixation can be treated by a stapesplasty. Tympanosclerosis of the oval window combined with other chronic inflammation usually requires two-stage surgery. Tympanosclerotic findings without any clinical symptoms should not be removed. The fitting of conventional or implantable hearing aids is the only treatment if chain reconstruction fails or is impossible.Tympanosclerosis is a scarring process with a remarkable variability in its localization within the middle ear. It can lead to conductive hearing loss in many cases. It is usually caused by recurrent chronic inflammation of the middle ear. It is generally accepted that functionally relevant tympanosclerotic findings of the middle ear structures should be treated by surgery. Depending on the extent of the surgical resection, the tympanic membrane and the ossicular chain must be reconstructed individually. In cases of isolated myringosclerosis with no hearing loss, no surgery is required. When the ossicular chain is affected by the sclerosis, sound conduction can often be restored only by interposition of grafts. Stapes footplate fixation can be treated by a stapesplasty. Tympanosclerosis of the oval window combined with other chronic inflammation usually requires two-stage surgery. Tympanosclerotic findings without any clinical symptoms should not be removed. The fitting of conventional or implantable hearing aids is the only treatment if chain reconstruction fails or is impossible.