Carsten V. Dalchow

The sentinel node concept in head and neck cancer: solution for the controversies in the n0 neck?

The majority of patients with head and neck squamous cell carcinoma (HNSCC) who have a clinical N0 neck undergo neck dissection (ND) even though no lymph node metastases may be detected. With this background, our investigation critically analyzes the value of sentinel lymphadenectomy.

Digital volume tomography : Radiologic examinations of the temporal bone

OBJECTIVE We evaluated the clinical applicability and the value of digital volume tomography for visualization of the lateral skull base using temporal bone specimens. MATERIALS AND METHODS Twelve temporal bone specimens were used to evaluate digital volume tomography on the lateral skull base. Aside from the initial examination of the temporal bones, radiologic control examinations were performed after insertion of titanium, gold, and platinum middle-ear implants and a cochlear implant. RESULTS With high-resolution and almost artifact-free visualization of alloplastic middle-ear implants of titanium, gold, or platinum, it was possible to define the smallest bone structures or position of the prosthesis with high precision. Furthermore, the examination proved that digital volume tomography is useful in assessing the normal position of a cochlear implant. CONCLUSION Digital volume tomography expands the application of diagnostic possibilities in the lateral skull base. Therefore, we believe improved preoperative diagnosis can be achieved along with more accurate planning of the surgical procedure. Digital volume tomography delivers a small radiation dose and a high resolution coupled with a low purchase price for the equipment.

The value of digital volume tomography in assessing the position of cochlear implant arrays in temporal bone specimens.

Objectives: Radiological evaluation of the position of cochlear implant (CI) devices is an upcoming method for quality control after CI surgery. First, results of imaging of the middle and inner ear with digital volume tomography (DVT) show considerable advantages such as exceptional image quality, thin slice thickness, and low radiation dose. The aim of this study was to evaluate whether DVT is an appropriate method for postoperative imaging of CI patients and to identify the exact position of the implant array within the cochlear by multiple measurements. Design: Thirteen formalin-fixed temporal bone specimens were implanted with a CI array and scanned in DVT. To determine the exact electrode position, these specimens were ground and stained for microscopic measurements. The measurements on grindings acted as a referee and were compared with the measurements in DVT scans. The statistical analysis between the two measurement protocols was performed using the Bland-Altman method. Results: Best achievable agreement between DVT scans and histological reference was shown. Mean differences between DVT and grindings from −1.55 to −65.40 &mgr;m were calculated. All means are within the region of accuracy. General positioning of the implant into the cochlea could be verified in all specimens. The exact position of the implanted array within the cochlear scalae could be recognized correctly in 11 of 13 cases in DVT. It was possible to identify shiftings between the tympanic and vestibular scalae in all cases. Conclusion: DVT seems to be a convenient technique for postoperative position control after cochlear implantation.

Acute haemorrhage in patients with advanced head and neck cancer: value of endovascular therapy as palliative treatment option.

AIMS Acute or subacute haemorrhage is one of the most frightening complications in patients suffering from advanced head and neck cancer. Few articles report experience with superselective endovascular therapy for this purpose. Is endovascular therapy underestimated in the field of palliative head and neck cancer therapy? This study set out to investigate this question. PATIENTS AND METHODS A review was undertaken of the clinical courses of seven patients (six men, one woman) suffering from incurable, advanced head and neck cancer (four pharyngeal, two laryngeal, one neck) and treated with superselective endovascular strategies as an emergency procedure for acute bleeding. RESULTS All patients were successfully treated without evidence of neurological complication. Patients reached a median survival of 20 weeks (range eight-168 weeks). Following endovascular treatment all patients were discharged from the hospital within several days. Three patients survived almost free of symptoms for several weeks and were able to stay at home with their families until their death. CONCLUSION We conclude that in the field of palliative care, superselective endovascular therapy deserves to be considered alongside standard treatment options for the management of acute haemorrhage from advanced head and neck cancer.

A new instrument for minimal access surgery in cochlear implantation.

Objective: Evaluation of usefulness and benefits of a new hand-held retractor for minimal invasive technique in cochlear implantation. Setting: Tertiary medical center. Patients: Fourteen consecutive patients (age: 1-83; 4 = female and 10 = male) received a cochlear implant in minimal invasive technique using the new hand-held retractor. Intervention: Standardized operation procedure in minimal invasive technique for cochlear implantation. A short retroauricular incision is used to perform the mastoidectomy with posterior tympanotomy and cochleostomy. Results: The hand-held retractor allows drilling of the bony well for the receiver-stimulator package under direct vision from an anterior position of the surgeon. The sub-periosteal pocket is performed while maintaining continuous suction of irrigating fluids with no further assistance needed. Conclusion: With the new retractor, up to 70% of time to create the bony well is saved compared to previously used instrumentation. The retractor might be further useful in different fields of surgery where the operating field needs to be visualized with the integrated suction and light-device under protection of the surrounding tissue.

Malleostapedotomy – The Marburg Experience

BACKGROUND The surgical procedure for patients with otosclerosis routinely is incus stapedotomy. In case of otosclerosis with incus necrosis or a bony fixation of the malleus and incus, malleostapedotomy is performed. PATIENTS AND METHODS Between May 2002 and September 2003, malleostapedotomy was performed in 6 out of 34 patients with otosclerosis. In 2 primary cases, a middle ear dysplasia was found. The malleus was fixed in 2 further primary cases. Two revision surgeries were performed with incus necrosis present. A titanium piston was used, which was fixed at the malleus handle and introduced into an opening of the footplate. RESULTS The preoperative air-bone gap was reduced from 36 dB(A) to 13 dB(A) after surgery for an average checkup time of 3 months. The length of the prostheses varied from 6.3 to 7.5 mm. No patient showed a hearing loss or vertigo after surgery. CONCLUSION Malleostapedotomy is the technique of choice in case of an additional pathology of the ossicular chain in patients with otosclerosis. Larger numbers of patients and long-term investigations need to compare the results of malleostapedotomy with those of a conventional incus stapedotomy.

Early supraglottic cancer: how extensive must surgical resection be, if used alone?

OBJECTIVES Two centre based evaluations of oncologic results of endoscopic resection of supraglottic cancer without post-operative irradiation. PATIENTS AND METHODS Twenty-six patients with clinical T1 (n=5) or T2 (n=21) primary squamous cell carcinomas of the supraglottic larynx and with N0 (n=24) or N1 (n=2) neck disease were treated by endoscopic supraglottic laryngectomy coupled with neck dissection(s). Endoscopic resection was standardized whereas neck dissections (NDs) varied from classical modified radical ND to selective ND of levels I to IV. RESULTS Pathologically, three T2 patients were upstaged to T3, four N0 patients to N1 and one N2 patient down-staged to N1. Within an average of 42 months, there were no local failures and only one regional failure. CONCLUSIONS Endoscopic resection of T1 and T2 supraglottic cancer without post-operative irradiation achieved good oncological results. No patients with lateralized primary cancers were found to have contralateral cancer on pathological evaluation from bilateral dissections.

Cervicofacial and mediastinal emphysema after balloon eustachian tuboplasty (BET): a retrospective multicenter analysis

PurposeBalloon Eustachian tuboplasty (BET) is a new treatment modality addressing chronic obstructive dysfunction of the Eustachian tube (ET). So far, BET has been deemed a safe procedure under general anesthesia with only minor adverse effects. However, individual cases of postoperative emphysema have been reported. In the present retrospective multicenter analysis we determined the incidence rate of this potentially life threatening complication after BET.MethodsIn total we collected data from 3,670 BET procedures performed on 2,272 patients in four tertiary care ENT departments.ResultsTen cases of postoperative cervicofacial emphysema were documented, whereas only in 3 of them a pneumomediastinum was developed. None of the affected patients developed at any time serious clinical signs or symptoms besides cutaneous crepitations. A complete resolution and recovery of the emphysema occurred in all patients under antibiotic prophylaxis and abstinence from Valsalva maneuver within the first 2–6 postoperative days.ConclusionsPossible causes for the development of these postinterventional emphysemas are considered to be mucosal injuries of the ET during manipulations for the correct position of the insertion instrument, through a “kinking” of the balloon catheter or even due to the relative rigid catheter itself, although its form is regarded to be atraumatic. The complication rate of postoperative emphysema was 0.27% (95% CI 0.13–0.50%). The above facts in addition to only minor and transient overall complications after BET reported in literature, can label this procedure as a safe treatment with a low risk profile.

Er:YAG Laser Ablation of Bone versus Conventional Burrs in Otologic Surgery:

Objectives: The Er:YAG laser (EYL) provides an efficient means of precise and predictable bone ablation, without intense thermal injury associated with CO2 laser use. Use of the EYL in otology is possible, but must be undertaken with caution as ablation is associated with brief intense acoustic transients up to 120 dB. This study details the use of the EYL in otologic and neuro-otologic surgery and compares ablation using a commercially available EYL with customizable glass fiber tips versus diamond and cutting burrs by means of infrared thermal imaging (IRT) and environmental scanning electron microscopy (ESEM). Methods: Five 0.6 mm diameter cylindrical cuts to a depth of 0.6 mm were made in formalin fixed human squamous temporal bone using a 300 µs EYL with pulse energies of 250 and 400 mJ (corresponding fluence levels of 175 and 280 mJ/cm2) and 0.6 mm diameter cutting and diamond burrs. Copious irrigation was used for all cuts. IRT was used to determine temperature rise. Ablation regions were inspected with ESEM. Results: Peak temperature rises were similar for all methods of ablation, none exceeding the 12 °C threshold required for irreversible bone injury. ESEM revealed rough margins for cuts made using the cutting burr and smooth edges with no sign of microfracture for those made with EYL and diamond burr. Conclusions: EYL ablates bone efficiently and predictably with smooth margins without microfractures or clinically significant temperature rise. When used appropriately, EYL may be a valuable tool for the otologic surgeon.

First Clinical Results of the Dilatation of the Eustachian Tube in Patients with Tubal Dysfunction

Objectives: One of the main causes for chronic otitis media is a tubal dysfunction which can now be treated with the endonasal dilatation of the Eustachian tube with the help of a novel balloon catheter. Methods: Since July 2010, we treated patients with a tubal dysfunction with a balloon dilatation of the Eustachian tube with the help of an endoscope through an endonasal approach. Such a dilatation was done in patients in whom we found a tubal dysfunction in the tube manometry and impedance audiometry. In 55 patients, a single-sided and in 50 patients a bilateral treatment was performed by inserting a specially designed balloon catheter into the cartilage of the Eustachian tube and inflating it with 10 bar for 2 minutes. Results: Between July 2010 and November 2011, 105 patients (age 9-71; 45 female, 60 male) were treated because of a tybal dysfunction. The dilatation was performed under general anesthesia using an endoscope and a specially designed applicator. The postoperative check-up showed improved function in 69 patients, while 36 patients still showed a limitation of the tubal function. All patients reported a subjective improvement of middle ear pressure equalization. Conclusions: The endonasal dilatation of the Eustachian tube using the balloon catheter set to enlarge the cartilage is a safe and reliable method in patients with a tubal dysfunction. Our first clinical results confirm functional improvement after one year.