H.-G. Kempf

Management of choanal atresia in cases of craniofacial malformation.

ObjectiveTo report the method and results of endonasal endoscopic approach in congenital choanal atresia in cases of craniofacial malformation.PatientsThe pathology of unilateral and bilateral choanal atresia and the treatment results in seven children treated between 1999 and 2006 are presented. 5 infants suffering from bilateral atresia also had severe malformations (Charge syndrome [2 patients], trisomy 18, microcephalus, central cranioschisis, cleft lip and anophthalmia 9). The surgical intervention was carried out immediately after birth. 2 patients with unilateral atresia were treated in their second and sixth year of life respectively. CT scan was the diagnostic procedure of choice. Intraoperative endoscopy showed both membraneous and osseous atresia.Surgical procedureTrocars of different sizes were used to open the atresia plate, while the osseous parts were removed with diamond drills. Silicone tubes were inserted transnasally and remained in place for several months to improve the infants’ability to breath and drink.ResultsIn all cases of bilateral atresia the tubes either had to be changed repeatedly or replaced with larger tubes due to dislocation and head growth. The septum was perforated in one case. No further stenoses were detected following the removal of the tubes (after 3–6 months).ConclusionThe transnasal access is particularly suited to newborns and infants because it induces a minor surgical trauma and carries a low risk of bleeding if endoscopes are used. The results show that the risk of restenoses can be minimised with sufficient fixating and in-patient care.

Diagnostic and Clinical Outcome of Neurogenic Tumours in the Head and Neck Area

A retrospective analysis of diagnostic procedures and clinical outcome of patients with neurogenic tumours of the head and neck region was performed. There were 25 patients - 16 with neurinoma, 5 with neurofibroma and 4 with neurogenic sarcoma - who presented with a mass in the head and neck area. In 13 patients, the neurinoma originated from the facial nerve, 2 of them were located in the middle ear and mastoid and showed facial palsy. Four patients presented with neurofibromatosis type 1. Twenty-three patients were operated on to remove the tumorous masses. Eighteen tumours were assigned intraoperatively to a cranial nerve main trunk, whereas 7 tumours originated from small branches or showed diffuse growth in neurofibromatosis. All benign neurogenic tumours were removed totally without relapse. One of 2 auricular nerve autografts in middle-ear facial nerve neurinoma resulted in a sufficient muscle tonus of the face. Three patients with malignancies died within 12-24 months showing local recurrencies (n = 1) and/or pulmonary metastasis (n = 2). As expected, neurogenic tumours are unusual neoplasms of the head and neck regions. On the other hand, neurogenic malignancies exhibit diagnostic problems as well as uncertain chances for long-term survival. Tumour staging, determined by extension and critical for treatment decisions, is well evaluated by CT scan and MRI. A multimodal therapy regimen with operation and radiation is recommended for neurogenic sarcoma also when developing in neurofibromatosis. However, in main trunk neurinomas, nerve autografting with interposition is the therapy of choice with a good chance of functional recuperation.

Der Er:YAG-Laser in der Ohrchirurgie: Anwendungsgebiete, Vorteile und Limitationen

Das hohe Mas an Prazision in der Ohrchirurgie sowie die Vulnerabiltat der meisten Strukturen im Bereich des Mittelohres haben immer wieder neue genauere Operationstechniken verlangt. Der Laser bietet dem Chirurgen die Moglichkeit, beruhrungsfrei und mit groser Prazision zu arbeiten. Die bisher verwandten Wellenlangen wie Argon, KTP, Nd:YAG, Ho:YAG haben sich aufgrund der tiefreichenden und damit schwer abschatzbaren thermischen Wirkungen nicht durchsetzen konnen. Der CO2- Laser unterscheidet sich hier durch seine deutlich geringere Eindringtiefe (JOVANOVIC). Die bis heute noch nicht abschlieisend untersuchten Fremdkorperreaktionen auf Karbonisate und ihre moglichen Folgen haben aber eine weitergehende Verbreitung bisher ebenso verhindert. Der seit kurzem verfugbare Er:YAG-Laser hat mit 2,94 μm sein Absorptionsmaximum im Wasserbereich und hat somit durch die Photoablation als Hauptbestandteil der physikalischen Reaktion einen sehr karbonisations- und koagulationsarmen Wirkmechanismus. Basierend auf den grundlegenden experimentellen und klinischen Arbeiten von PFALZ und Mitarbeitern hat die Fa. Carl Zeiss ein Forschungsgerat entwickelt, welches in unserer Klinik seit 2/96 zunachst in vitro im Labor, spater in vivo im Operationssaal bei Mittelohreingriffen eingesetzt werden konnte.