A. Schröck

Endovascular Treatment of Epistaxis: Indications, Management, and Outcome

ObjectiveEpistaxis is a common clinical problem, and the majority of bleedings can be managed conservatively. However, due to extensive and sometimes life-threatening bleeding, further treatment, such as superselective embolization, may be required. We report our experience with endovascular treatment of life-threatening epistaxis.MethodsAll patients presenting with excessive epistaxis, which received endovascular treatment at a German tertiary care facility between January 2001 and December 2009, were retrospectively identified. Demographic data, etiology, origin and clinical relevance of bleeding, interventional approach, therapy-associated complications, and outcome were assessed.ResultsA total of 48 patients required 53 embolizations. Depending on the etiology of bleeding, patients were assigned to three groups: 1) idiopathic epistaxis (31/48), 2) traumatic or iatrogenic epistaxis (12/48), and 3) hereditary hemorrhagic telangiectasia (HHT) (5/48). Eleven of 48 patients required blood transfusions, and 9 of these 11 patients (82%) were termed clinically unstable. The sphenopalatine artery was embolized unilaterally in 10 of 53 (18.9%) and bilaterally in 41 of 53 (77.4%) procedures. During the same procedure, additional vessels were embolized in three patients (3/53; 5.7%). In 2 of 53(3.8%) cases, the internal carotid artery (ICA) was occluded. Long-term success rates of embolization were 29 of 31 (93.5%) for group 1 and 11 of 12 (91.7%) for group 2 patients. Embolization of patients with HHT offered at least a temporary relief in three of five (60%) cases. Two major complications (necrosis of nasal tip and transient hemiparesis) occurred after embolization.ConclusionsEndovascular treatment proves to be effective for prolonged and life-threatening epistaxis. It is easily repeatable if the first procedure is not successful and offers a good risk–benefit profile.

Sudden sensorineural hearing loss after heroin injection

Sudden sensorineural hearing loss is a symptom of cochlear injury. Potential aetiologies are vascular diseases, viral infections, allergic reactions, autoimmune disorders, and traumatic rupture of the intralabyrinthe membrane. Unlike in unilateral cases bilateral sensorineural hearing loss is often associated with specific disease entities. We report a case of sudden bilateral deafness after intravenous heroin abuse. The putative pathophysiological mechanisms are discussed.

Sex determining region Y-box 2 (SOX2) amplification is an independent indicator of disease recurrence in sinonasal cancer.

Objectives The transcription factor SOX2 (3q26.3-q27) is an embryonic stem cell factor contributing to the induction of pluripotency in terminally differentiated somatic cells. Recently, amplification of the SOX2 gene locus has been described in squamous cell carcinoma (SCC) of different organ sites. Aim of this study was to investigate amplification and expression status of SOX2 in sinonasal carcinomas and to correlate the results with clinico-pathological data. Materials and Methods A total of 119 primary tumor samples from the sinonasal region were assessed by fluorescence in-situ hybridization and immunohistochemistry for SOX2 gene amplification and protein expression, respectively. Of these, 59 were SSCs, 18 sinonasal undifferentiated carcinomas (SNUC), 10 carcinomas associated with an inverted papilloma (INVC), 19 adenocarcinomas (AD) and 13 adenoid cystic carcinomas (ACC). Results SOX2 amplifications were found in subsets of SCCs (37.5%), SNUCs (35.3%), INVCs (37.5%) and ADs (8.3%) but not in ACCs. SOX2 amplification resulted in increased protein expression. Patients with SOX2-amplified sinonasal carcinomas showed a significantly higher rate of tumor recurrences than SOX2 non-amplified tumors. Conclusion This is the first study assessing SOX2 amplification and expression in a large cohort of sinonasal carcinomas. As opposed to AD and ACC, SOX2 amplifications were detected in more than 1/3 of all SCCs, SNUCs and INVCs. We therefore suggest that SNUCs are molecularly closely related to SCCs and INVCs and that these entities represent a subgroup of sinonasal carcinomas relying on SOX2 acquisition during oncogenesis. SOX2 amplification appears to identify sinonasal carcinomas that are more likely to relapse after primary therapy, suggesting that these patients might benefit from a more aggressive therapy regime.

Fibroblast growth factor receptor-1 as a potential therapeutic target in sinonasal cancer

Despite multimodal treatment, sinonasal malignancies have an unfavorable prognosis. The purpose of this study was to elucidate if these tumors harbor amplifications of the fibroblast growth factor receptor 1 (FGFR1) gene, which has recently been identified as a potential therapeutic target in squamous cell lung cancer.

Transarterial endovascular treatment in the management of life-threatening intra- and postoperative haemorrhages after otorhinolaryngological surgery

Management of life-threatening postsurgical bleeding is complex. If conservative or surgical therapy is demanding, an endovascular treatment can be considered. The goal of this study was to evaluate the outcome of endovascular approaches in the diagnosis and therapy of otherwise intractable postoperative haemorrhages with a study design of outcomes research. Charts of all patients with postsurgical bleedings receiving endovascular treatment were reviewed for clinical outcome, complications, and demographic data. 15 patients were identified. They had rhinosurgery (12/15), tonsillectomy (2/15) or transoral tumour debulking (1/15) prior to the endovascular procedure. In more than 70%, the source of bleeding was directly located angiographically and subsequently superselectively embolized. The remaining patients suffered from post-rhinosurgical epistaxis and underwent a bilateral embolization of the sphenopalatine artery. All bleedings were successfully controlled and no procedure-related complication was noted. In conclusion, endovascular treatment of life-threatening postsurgical haemorrhages should be considered if the source of bleeding is unknown or if surgery is difficult and may result in devastating postoperative complications.

Targeting DDR2 in Head and Neck Squamous Cell Carcinoma with Dasatinib

Squamous cell carcinoma of the head and neck (HNSCC) is the tenth most common tumor entity in men worldwide. Nevertheless therapeutic options are mostly limited to surgery and radio‐chemotherapy resulting in 5‐year survival rates of around 50%. Therefore new therapeutic options are urgently needed. During the last years, targeting of receptor tyrosine kinases has emerged as a promising strategy that can complement standard therapeutical approaches. Here, we aimed at investigating if the receptor tyrosine kinase DDR2 is a targetable structure in HNSCC. DDR2 expression was assessed on a large HNSCC cohort (554 patients) including primary tumors, lymph node metastases and recurrences and normal mucosa as control. Subsequently, DDR2 was stably overexpressed in two different cell lines (FaDu and HSC‐3) using lentiviral technology. Different tumorigenic properties such as proliferation, migration, invasion, adhesion and anchorage independent growth were assessed with and without dasatinib treatment using in‐vitro cell models and in‐vivo zebrafish xenografts. DDR2 was overexpressed in all tumor tissues when compared to normal mucosa. DDR2 overexpression led to increased migration, invasion, adhesion and anchorage independent growth whereas proliferation remained unaltered. Upon dasatinib treatment migration, invasion and adhesion could be inhibited in‐vitro and in‐vivo whereas proliferation was unchanged. Our data suggest treatment with dasatinib as a promising new therapeutic option for patients suffering from DDR2 overexpressing HNSCC. Since dasatinib is already FDA‐approved we propose to test this drug in clinical trials so that patients could directly benefit from this new treatment option.

Histologie nach Tonsillektomie

BACKGROUND The necessity to rule out clinically occult malignancies by routine histological examination of all tonsillectomy specimens is a controversial topic. METHODS Clinical and histological findings of all patients who underwent tonsillectomy at the University of Bonn, Germany from January 2002 to March 2007 were retrospectively reviewed. A meta-analysis of PubMed literature regarding the histological results of tonsil specimens was performed. The incidence of clinically occult tonsil malignancy was recorded and potential risk factors for malignancy were analyzed. A cost-effectiveness ratio of microscopic analysis of all specimens was also performed. RESULTS Clinically occult tonsil malignancies were detected in 2 out of the 1,523 patients (0.13%) in this study. In the meta-analysis of 24 studies (61,550 patients) 6 cases of clinically occult tonsil malignancies (0.01%) were identified. Statistically 7,694 tonsils have to be histologically examined to detect 1 case of occult malignancy which corresponds to an average cost per case of 385,000 EUR. DISCUSSION Considering economical aspects we recommend that histological examination should be performed when the following risk factors are present: a history of cancer, tonsil firmness or lesions, tonsillar asymmetry, swelling of neck lymph nodes, constitutional symptoms, anamnestic unilateral symptoms and prior peritonsillar abscess.

Histology after tonsillectomy

BACKGROUND The necessity to rule out clinically occult malignancies by routine histological examination of all tonsillectomy specimens is a controversial topic. METHODS Clinical and histological findings of all patients who underwent tonsillectomy at the University of Bonn, Germany from January 2002 to March 2007 were retrospectively reviewed. A meta-analysis of PubMed literature regarding the histological results of tonsil specimens was performed. The incidence of clinically occult tonsil malignancy was recorded and potential risk factors for malignancy were analyzed. A cost-effectiveness ratio of microscopic analysis of all specimens was also performed. RESULTS Clinically occult tonsil malignancies were detected in 2 out of the 1,523 patients (0.13%) in this study. In the meta-analysis of 24 studies (61,550 patients) 6 cases of clinically occult tonsil malignancies (0.01%) were identified. Statistically 7,694 tonsils have to be histologically examined to detect 1 case of occult malignancy which corresponds to an average cost per case of 385,000 EUR. DISCUSSION Considering economical aspects we recommend that histological examination should be performed when the following risk factors are present: a history of cancer, tonsil firmness or lesions, tonsillar asymmetry, swelling of neck lymph nodes, constitutional symptoms, anamnestic unilateral symptoms and prior peritonsillar abscess.

Seltene Ursache eines pulssynchronen Tinnitus

Atypische Teilung der A. carotis interna (ACI) links, unmittelbar distal der Karotisbifurkation in ein kaliberschmales mediales (. Abb. 3) und kaliberstärkeres laterales Gefäß. Beide Gefäße verlaufen zunächst parallel nach kranial, das kaliberstarke laterale Gefäß verläuft unmittelbar ventral der V. jugularis interna und vereinigt sich nach einem lateralkonvexen Bogen erneut mit dem kaliberschwächeren Gefäß zu einer normalkalibrigen A. carotis interna im horizontalen Abschnitt des petrösen Segments. Der weitere Verlauf der ACI links ist regelrecht.

Maligne Erkrankungen des Sinunasaltrakts

BACKGROUND With a worldwide annual incident rate of 1/200,000 sinonasal tract malignancies are a relatively rare disease. MATERIAL AND METHODS All patients with sinonasal malignancies (n = 177) treated between 1996 and 2010 at the Department of Head and Neck Surgery, University of Bonn, Germany were analyzed retrospectively. Data on age, gender and incidence were available for all patients but other demographic data, treatment regimes and outcome were only analyzed for carcinomas. RESULTS Carcinomas were the most frequent histological diagnosis (58%). Unspecific sinonasal symptoms lasted on average for 4.7 ± 5 months before primary diagnosis. Interestingly, 64% of patients with sinonasal carcinoma presented with locally advanced disease (T3-4) but only 15% displayed corresponding regional lymph node metastases. The overall 3-year survival rate was 61%. Patients solely needing surgical treatment displayed a better survival rate than patients receiving combined surgery and adjuvant treatment or definitive radio(chemo)therapy. Multivariate analysis revealed a T-stage classification as the only independent prognostic factor for 3-year survival. CONCLUSIONS Due to unspecific symptoms most sinonasal malignancies are diagnosed at an advanced stage of the disease and despite multimodal therapies these tumors still have an unfavorable prognosis.ZusammenfassungHintergrundMaligne sinunasale Tumoren sind mit einer jährlichen Inzidenz von weltweit 1/200.000 selten.Material und MethodenEs wurden retrospektiv alle Patienten erfasst (n = 177), welche im Zeitraum 1996–2010 an der HNO-Universitätsklinik Bonn aufgrund sinunasaler Malignome therapiert wurden. Inzidenz, Alter und Geschlecht waren für alle Entitäten vorhanden. Weitere demographische Daten, Therapie und Follow-up wurden ausschließlich für Karzinome analysiert.ErgebnisseDie häufigste Entität war das Karzinom (58%). Unspezifische Beschwerden vor Erstdiagnose dauerten 4,7 ± 5 Monate an. Obwohl 64% der Karzinompatienten ein lokal fortgeschrittenes Tumorleiden (T3–4) aufwiesen, zeigten nur 15% lokoregionäre Lymphknotenmetastasen. Die Gesamt-3-Jahres-Überlebenswahrscheinlichkeit lag bei 61%. Patienten mit ausschließlich operativer Therapie hatten eine deutlich bessere Prognose als Patienten nach kombinierter oder primärer Radio(chemo)therapie. Das T-Stadium konnte als unabhängiger prognostischer Faktor identifiziert werden.SchlussfolgerungAufgrund unspezifischer Beschwerdesymtomatik werden sinunasale Malignome meist erst in fortgeschrittenem Tumorstadium diagnostiziert. Trotz multimodaler Therapieansätze ist die Prognose schlecht.AbstractBackgroundWith a worldwide annual incident rate of 1/200,000 sinonasal tract malignancies are a relatively rare disease.Material and methodsAll patients with sinonasal malignancies (n = 177) treated between 1996 and 2010 at the Department of Head and Neck Surgery, University of Bonn, Germany were analyzed retrospectively. Data on age, gender and incidence were available for all patients but other demographic data, treatment regimes and outcome were only analyzed for carcinomas.ResultsCarcinomas were the most frequent histological diagnosis (58%). Unspecific sinonasal symptoms lasted on average for 4.7 ± 5 months before primary diagnosis. Interestingly, 64% of patients with sinonasal carcinoma presented with locally advanced disease (T3–4) but only 15% displayed corresponding regional lymph node metastases. The overall 3-year survival rate was 61%. Patients solely needing surgical treatment displayed a better survival rate than patients receiving combined surgery and adjuvant treatment or definitive radio(chemo)therapy. Multivariate analysis revealed a T-stage classification as the only independent prognostic factor for 3-year survival.ConclusionsDue to unspecific symptoms most sinonasal malignancies are diagnosed at an advanced stage of the disease and despite multimodal therapies these tumors still have an unfavorable prognosis.