J.C. Luers

Carcinoma ex pleomorphic adenoma of the parotid gland. Study and implications for diagnostics and therapy

Background. Carcinoma ex pleomorphic adenoma (CXPA) is a rare parotid malignancy and until today no standardized concept exists for its therapy apart from recommendations for parotid carcinoma in general. Prognosis is thought to be poorer than for other parotid malignancies. We sought to describe a general diagnostic and therapy strategy and assess factors predicting the outcome. Methods. We retrospectively analysed the courses of 22 patients with a CXPA of the parotid gland treated at a tertiary medical care centre for otorhinolaryngology. We examined parameters of medical history, diagnostics, surgical and adjunctive therapy and analysed overall and disease-specific survival. Results. About half of the patients had evidence of a parotid mass of up to 1 year only while maximum of the others was 48 years. Nine patients were primarily operated without suspicion for malignancy. Both 5-year disease-specific and overall survival were 60%. Recurrence-free survival rate after 5 years was 85%. Any patients with a stage I or II disease had an uneventful follow-up. To date, no patient with a stage IV disease has survived longer than 5 years. Conclusion. Surgical therapy (total or radical parotidectomy) is the method of choice for CXPA of the parotid gland. Stage I tumors have a very good and stage IV tumors a bad prognosis.

Methylene blue for easy and safe detection of salivary duct papilla in sialendoscopy.

Sialendoscopy is one of the new challenges in treating salivary gland diseases, mainly sialolithiasis. It is an unpleasant situation if the sialendoscopy operator experiences problems in finding the papilla or during introduction of the endoscopic devices, especially because the intervention is usually performed under local anesthesia. One key step in performing sialendoscopy is the safe, atraumatic entering of the papilla with the endoscope, which is much more difficult for the submandibular gland than for the parotid. The ostium represents the narrowest part of the Wharton duct with mean diameters between 0.5 and 1.5 mm. The small, single-device sialendoscope measures 1.3 mm (Karl Storz Company, Tuttlingen, Germany). Thus, before a sialendoscopy can be performed, the ostium needs to be dilated with a cone-shaped dilatator and probes. Damage to the orifice can result in failure of the whole procedure. Therefore, a smooth probe implementation into the duct is the key, which makes secure detection of the ostium necessary. The surgeon should also be familiar with the exact anatomy of the individual, especially when the duct must be incised. At intraductal sialolithiasis with stones close to the orifice, incision of the duct should start preferably from the position of the caruncula, which therefore needs to be localized first. Especially if the gland and duct are inflamed or if the sialolith is of a significant size, the entire floor of the mouth can be edematous, making the duct entrance invisible. Because we are dealing with a salivary duct, it would be advantageous to identify the ostium by observing its secretion. A helpful method is massaging the gland, but even then some glands express only a little saliva; hence, the secretion may not be visualized on the smooth reflecting mucosa (Fig 1). To overcome this problem, we suggest tipping methylene blue (1% methylthioninium chloride; Neopharma GmbH & Co.KG, Aschau, Germany) onto the area of the caruncula. Then massaging the gland followed by a slow sweeping of the duct in a distal direction should express at least minor amounts of saliva. In contrast to no use of dye, after meth-

Young age is a positive prognostic factor for residual hearing preservation in conventional cochlear implantation.

Objective To investigate the prognostic significance of various factors in hearing preservation after traditional cochlear implantation (CI). Study design Retrospective case review. Setting Academic tertiary referral center. Patients A total of 153 implantations with mean patient age at implantation of 36 years (from 10 mo to 83 yr) and residual hearing at the frequencies 250, 500, and 1,000 Hz on the unaided preoperative pure-tone audiometry were included. Intervention(s) CI with a conventional full-length electrode. Main outcome measure(s) The changes on the residual hearing 3 months after implantation were analyzed regarding patients’ demographic factors, shape of the preoperative threshold curve, type of the electrode carrier, and approach of electrode insertion in the cochlea. Preservation of residual hearing was defined as measurable postoperative threshold at the frequencies 250, 500, and 1,000 Hz. Results Preservation of residual hearing was observed in almost half of the cases (47%). In more than half of these patients (54%), a maximal to complete hearing preservation (0–10 dB loss) was achieved. About one-third of these implantations (29%) showed a moderate preservation of residual hearing (11–20 dB loss). In the remaining 17%, the preservation of hearing was marginal (>21 dB loss). Hearing preservation and its extent were significantly better in children and adolescents compared with those in adults. Conclusion The preservation of residual hearing after conventional CI is possible. Young age seems to have a positive impact on hearing preservation.

Vibrant Soundbridge Rehabilitation of Conductive and Mixed Hearing Loss

The Vibrant Soundbridge is the worlds most often implanted active middle ear implant or hearing aid. During the last few years, the device indications have expanded from sensorineural hearing loss to conductive and mixed hearing loss. Titanium couplers have led to improved contact of the floating mass transducer with the middle ear structures. The resulting hearing gain is satisfying for most patients, but so far, there is no clear audiologic advantage over conventional hearing aids. Currently, the indications are mainly related to intolerance of conventional hearing aids (eg, chronic otitis externa), severe mixed hearing loss with a destructed middle ear and certain medical diagnosis (eg, congenital atresia).

Implantable hearing aids

ZusammenfassungImplantierbare Hörgeräte im engeren Sinne sind technische Systeme, die ein akustisches Signal nach entsprechender Verarbeitung durch direkte mechanische Stimulation der Ossikelkette oder der Cochlea bereitstellen. Gegenüber konventionellen Hörgeräten weisen sie Vorteile bezüglich des Tragekomforts und der generellen Akzeptanz auf. Da bis heute allerdings keine überzeugenden audiologischen Vorteile vorliegen, sind die Indikationen zur Verwendung implantierbarer Hörsysteme momentan vorrangig medizinischer Natur. In Deutschland sind heutzutage die Systeme Vibrant Soundbridge®, Carina® und Esteem® verfügbar. Die Leistung der verschiedenen implantierbaren und nichtimplantierbaren Hörsysteme in Verbindung mit verschiedenen Operationsverfahren unterliegt aktuell großen Veränderungen, sodass zukünftig auch rein audiologische Indikationen möglich sein könnten.AbstractStrictly speaking, implantable hearing aids are technical systems that process audiological signals and convey these by direct mechanical stimulation of the ossicular chain or cochlea. They have certain benefits over conventional hearing aids in terms of wearing comfort and general acceptance. As current studies lack convincing audiological results, the indications for implantable hearing aids are primarily of medical or cosmetic nature. To date, three systems are available in Germany: Vibrant Soundbridge®, Carina®, and Esteem®. Because the performance of the different implantable and nonimplantable hearing systems together with various surgical procedures are currently undergoing major changes, audiological indications may also develop in the future.Strictly speaking, implantable hearing aids are technical systems that process audiological signals and convey these by direct mechanical stimulation of the ossicular chain or cochlea. They have certain benefits over conventional hearing aids in terms of wearing comfort and general acceptance. As current studies lack convincing audiological results, the indications for implantable hearing aids are primarily of medical or cosmetic nature. To date, three systems are available in Germany: Vibrant Soundbridge®, Carina®, and Esteem®. Because the performance of the different implantable and nonimplantable hearing systems together with various surgical procedures are currently undergoing major changes, audiological indications may also develop in the future.

Characterizing the active opening of the eustachian tube in a hypobaric/hyperbaric pressure chamber.

Objective Active and passive opening of the Eustachian tube (ET) enables direct aeration of the middle ear and a pressure balance between middle ear and the ambient pressure. The aim of this study was to characterize standard values for the opening pressure (ETOP), the opening frequency (ETOF), and the opening duration (ETOD) for active tubal openings (Valsalva maneuver, swallowing) in healthy participants. Design/Participants In a hypobaric/hyperbaric pressure chamber, 30 healthy participants (19 women, 11 men; mean age, 25.57 ± 3.33 years) were exposed to a standardized profile of compression and decompression. The pressure values were recorded via continuous impedance measurement during the Valsalva maneuver and swallowing. Based on the data, standard curves were identified and the ETOP, ETOD, and ETOF were determined. Results Recurring patterns of the pressure curve during active tube opening for the Valsalva maneuver and for active swallowing were characterized. The mean value for the Valsalva maneuver for ETOP was 41.21 ± 17.38 mbar; for the ETOD, it was 2.65 ± 1.87 seconds. In the active pressure compensation by swallowing, the mean value for the ETOP was 29.91 ± 13.07 mbar; and for the ETOD, it was 0.82 ± 0.53 seconds. Conclusion Standard values for the opening pressure of the tube and the tube opening duration for active tubal openings (Valsalva maneuver, swallowing) were described, and typical curve gradients for healthy subjects could be shown. This is another step toward analyzing the function of the tube in compression and decompression.

Experimental study on admissible forces at the incudomalleolar joint.

Hypothesis The forces that cause rupture of the incudomalleolar joint during the fixation of stapedial prostheses can be determined by means of load-deflection measurements at the long process of the incus. As in other tissues, 3 ranges of forces can be defined: micro rupture, rupture, and short-term maximum. Background A crucial step in stapes surgery is the attachment of the stapedial prosthesis to the long process of the incus. It is unknown which forces occur during the crimping process that increase the risk of damage to the incudomalleolar joint or incus luxation. The goal of this study was to assess the admissible range of forces at the long process of the incus that would be tolerable before damaging the structures and to compare them with the forces occurring during surgery. Methods Load-deflection curves in the lateral-medial and anterior-posterior direction were measured in 9 freshly frozen or fresh temporal bones. The force was measured with a load cell, and displacement was taken from the encoder information of the electrically driven translation stage on which the load cell was mounted. The long process of the incus was coupled to the load cell via a customized needle. We also monitored with video recordings for visual confirmation of findings. Results The rupture force at which the middle ear was found to be severely injured was 894 (724–1018) mN in the anterior-posterior direction and 695 (574–771) mN in the lateral-medial direction. Micro-ruptures occurred at forces around 568 (469–686) mN in the anterior-posterior direction and in the lateral-medial direction at 406 (254–514) mN. Short-term maximum forces of 1,321 (1,051–1,533) mN were measured in the anterior-posterior direction and 939 (726–1,132) mN in the lateral-medial direction. Conclusion Rupture forces of the incudomalleolar joint could be defined with high accuracy. These results were used to calculate risks of incus luxation or subluxation during stapes surgery. Compared with the use of clip and SMA prostheses, the risk of damage from a crimping procedure is significantly higher.

Insertion of Cochlear Implant Electrode Array Using the Underwater Technique for Preserving Residual Hearing.

Objective: To describe a method of cochlear implantation in which the opening of the cochlea and the electrode array insertion are performed under water (underwater technique). Study Design: Retrospective patient review. Setting: Academic tertiary referral center. Patients: Fifteen implantations in children and adult patients with residual hearing at the frequencies 250, 500, and 1000 Hz on the unaided preoperative pure-tone audiometry were included in this study. Intervention(s): Cochlear implantation with a conventional full-length electrode, in which the opening of the cochlea and the electrode array insertion are performed after the tympanic cavity was filled with body-temperature Ringer solution. Main Outcome Measure(s): Changes on residual hearing 6 to 8 weeks after surgery and at subsequent follow-up appointments were analyzed. Preservation of residual hearing was defined as measurable postoperative threshold at the frequencies 250, 500, and 1000 Hz. Results: Overall postimplant hearing preservation 6 to 8 weeks after implantation was achieved in 13 of the patients (87%). Subsequent follow-up was performed on average 15.2 months after surgery (range, 7–32) in 14 out of 15 patients. At this late postoperative evaluation preservation of hearing was recorded in nine patients (64%), whereas in the remaining five patients (36%) no residual hearing was measured. Conclusion: The underwater technique offers a reliable nontraumatic method for electrode array insertions during cochlear implantation. The method respects the physiology of the cochlea und minimizes the pressure variations during cochlear opening and implantation.

Impact of xylomethazoline on eustachian tube function in healthy participants.

Introduction The use of decongestants is common in otitis media eustachian tube (ET) dysfunction. However, the underlying mechanism and the type of action on the complex middle ear pressure equalization system are poorly understood. Here, by use of the pressure chamber, we investigated the impact of intranasal decongestive therapy (xylomethazoline) on ET function. Materials and Methods Thirty healthy participants (60 ears) were exposed to a predetermined profile of phases of compression and decompression in a hypobaric and hyperbaric pressure chamber. ET opening pressure, ET opening duration, ET opening frequency, and ET closing pressure were determined before and after intranasal application of xylomethazoline. Results A significantly higher number of ET openings (ET opening frequency) in passive equalization condition could be measured after application of decongestants than before. No significant difference could be found in the values of ET opening pressure, ET opening duration, and ET closing pressure parameters before in comparison with the values after application of xylomethazoline. Conclusion We conclude that xylomethazoline might only have a minor effect during active and passive middle ear pressure equalization. Larger cohorts and targeted application of decongestants should be tested to confirm these preliminary data and to find new evidence on the effects of decongestants.

Comparison of digital volume tomography and high-resolution computed tomography in detecting superior semicircular canal dehiscence - a temporal bone study

Abstract Conclusion: In detecting a thin bony coverage of a superior semicircular canal (SSC), digital volume tomography (DVT) scans in Poeschl projection seem to be superior to high-resolution computed tomography (CT) scans. Still, a definite diagnosis of SSC dehiscence (SSCD) is not possible with any radiologic imaging technique. Objective: To compare CT and DVT to find out whether DVT is equal, better or worse in showing a thin bony layer on top of an SCC. Methods: In 11 human temporal bone specimens, the SSC was microscopically blue-lined leaving a thin bony coverage on top of it. All specimens were assessed with both high-resolution CT and DVT. After reconstructing the images in Stenvers and Poeschl projections, all images were evaluated by five independent examiners experienced in radiologic imaging of the temporal bone using a four-point ordinal scale, from 1 (distinct dehiscence) to 4 (distinct coverage). Results: The mean score for all CT scans was 2.58 compared with 3.22 for DVT scans (p = 0.000). Poeschl projection showed a mean score of 3.25 compared with 2.55 for Stenvers projection (p = 0.000). The best imaging modality was found to be DVT scans in Poeschl projections, with a mean score of 3.60.