Klaus Bumm

Minimally Invasive Head Holder to Improve the Performance of Frameless Stereotactic Surgery

Frameless stereotactic procedures crucially depend on the firmness of immobilization. Once registered, shifting of the patient leads to inaccuracy, and the patient registration has to be realigned. To overcome the drawbacks of conventional invasive fixation for neurosurgery and the widely accepted fixation with surgical tape in ENT, the Vogele‐Bale‐Hohner (VBH) head holder has been developed. It permits rigid, noninvasive fixation of the head by using an individualized dental cast attached to the upper jaw by vacuum. Oral intubation is uncomplicated. In addition, a special registration device providing well defined reference points can be mounted to the mouthpiece. We report the first promising clinical applications of this device.

Sialoscopy in Cases of Unclear Swelling of the Major Salivary Glands

OBJECTIVE: Sialoscopy has developed into an important diagnostic and therapeutic tool for diseases of the major salivary glands. STUDY DESIGN AND SETTING: We evaluated 103 patients with chronic swelling of the major salivary glands. Routine diagnostic measures revealed no clear diagnosis. The findings of 109 sialoscopies are described. A semi-rigid endoscope (with a diameter of 1.1 mm and 2 integrated working channels) was used for sialoscopy, 51.5% of the cases in Warthons duct and 48.5% in Stensens duct. RESULTS: Pathologic findings resulted in 83.0% of the submandibular and in 96% of the parotid ducts. Obstruction neither due to sialolithiasis nor stenosis was observed in 56.3%, whereas sialolithiasis was observed in 20.3% of the patients. In 36 (35%) patients, an interventional sialoscopy was performed. CONCLUSIONS: In cases of invisible salivary duct obstruction, especially in those with low mineralized calculi, strictures, stenoses, or postinflammatory changes, sialoscopy gives immediate and direct information about causal pathologies. Moreover, further therapy can be planned within the same procedure. EBM RATING: C

Sperm Protein 17 Is Expressed in Human Somatic Ciliated Epithelia

It was once believed that sperm protein 17 (Sp17) was expressed exclusively in the testis and that its sole function was to bind to the oocyte during fertilization. However, immunohistochemistry of the human respiratory airways and reproductive systems show that it is abundant in ciliated cells but not in human cells with stereocilia and microvilli. The high degree of sequence conservation throughout its N-terminal half, and the presence of an A-kinase anchoring protein (AKAP)-binding motif within this region, suggest that Sp17 plays a regulatory role in a PKA-independent AKAP complex in both male germinal and ciliated somatic cells.

The distinct gene expression profiles of chronic lymphocytic leukemia and multiple myeloma suggest different anti-apoptotic mechanisms but predict only some differences in phenotype.

We compared gene expression in purified tumor cells from untreated patients with chronic lymphocytic (CLL) (n=24) and newly diagnosed multiple myeloma (MM) (n=29) using the Affymetrix HuGeneFL microarray with probes for approximately 6800 genes. Hierarchical clustering analysis showed that CLL and MM have distinct expression profiles (class prediction). Gene and protein expression (measured by flow cytometry) correlated well for CD19, CD20, CD23, and CD138 in CLL and MM, but not for immunoglobulin light chain, CD38 and CD79b in CLL, or CD45 and CD52 in MM. CLL and MM differentially expressed 18% of 130 apoptosis related genes, suggesting differences in mechanisms of cell survival.

Surgical Application of a New Robotic System for Paranasal Sinus Surgery

The applicability of a robotic system for fully automated surgical procedures approaching the sphenoid sinus is evaluated. An integrated robotic system, A73, for computer navigation-guided, fully automated, and telemanipulation robotic performance is described. Details of the system comprising newly designed surgical instruments for robotic operations and preoperative planning protocols are provided. Experiments with an operational accuracy of less than 1 mm were followed by surgical tests, in which the results of fully automated and telemanipulation performances on 5 cadaveric heads are seen. The A73 system has been successfully used for a reproducible and accurate resection of the anterior wall of the sphenoid sinus. Therefore, we conclude that this system is suited for further testing toward approaching fully automated and more complex procedures of paranasal surgery.

Salivary simulation with ascorbic acid enhances sonographic diagnosis of obstructive sialadenitis

High‐frequency ultrasound (US) is routinely used to evaluate various diseases of the salivary glands. Normally, the duct network of the submandibular and parotid glands is not visible during US assessment. In obstructive sialadenitis of the parotid and submandibular glands, localization of the obstacle is often difficult.

Localization and infliction pattern of iatrogenic skull base defects following endoscopic sinus surgery at a teaching hospital

OBJECTIVE Aim of this study is to evaluate the incidence, infliction patterns and management of dural injuries with cerebrospinal fluid (CSF) rhinorrhea following endoscopic sinus surgery at a teaching hospital. We present our results of over 14 years of experience from endoscopic repair of CSF rhinorrhea with long-term follow-up. METHODS A retrospective study was performed by screening 14 years of sinus surgeries for iatrogenically inflicted CSF leaks of the anterior skull base. Obtained data were analyzed to determine the infliction pattern and location of CSF leaks, surgical closure techniques and outcomes. All incidences were further evaluated with regards to the surgeons training status. RESULTS 144 patients out of 6908 sinus surgeries were diagnosed with CSF rhinorrhea and underwent subsequent surgical repair. 52 patients had iatrogenic CSF leaks with 32 of the defects inflicted by the departments physician personnel. Average follow-up was 62 months, with a range of 10-168 months. The side distribution was 56.3% to the patients right side and in 40.6% to the patients left side. 68.7% became apparent during the initial surgery whereas 31.3% only after surgery. The most common defect location was the anterior ethmoid at the attachment of the medial concha base with 43.7%, followed by the junction between the ethmoid and sphenoid sinus with 21.9%, the frontal sinus aditus with 18.7% and the medial ethmoid region with 9.4%. With increasing training status, surgeons were more prone to cause defects at the frontal sinus aditus whereas surgeons with lesser training status caused more defects at the anterior ethmoid at the medial concha base. The posterior ethmoid and sphenoid sinus was equally prone to defects over all stages of surgical training. Initial endoscopic repair was successful in 87.5% of patients and 95% after revision surgery. CONCLUSION The obtained data confirm the safety of the endonasal sinus surgery according to Wigands technique. The incidence of iatrogenic CSF leaks at a teaching hospital is not higher than at specialized rhinology departments. We observed a distinct pattern of inflicted skull base defects with different hot-spot areas, prone to damage in various stages of the surgeons status of expertise.

Tumor-associated antigenic pattern in squamous cell carcinomas of the head and neck – Analysed by SEREX

Most immuno-therapeutic approaches are based on tumor-associated antigens and many newly identified proteins have led to trials exploiting their possible therapeutic applicability. So far only limited information on the antigenic profile of head and neck squamous cell carcinomas (HNSCC) exists. Serological analysis of tumor antigens by recombinant cDNA expression cloning (SEREX) was used to identify the immunogenic patterns in our HNSCC patient collective. A cDNA expression library derived from a pharynx HNSCC case was screened with autologous and heterologous sera. Thirty-seven positive clones coding for 17 immunoreactive gene products, which elicited an in vivo tumor response, were found. Results were confirmed and extended by expression analysis using RT-PCR and in situ-hybridisation. The protein-sequence of five clones exists so far only hypothetically. Of all identified proteins only KIAA0530 has previously been associated with a HNSCC related immune response. All other proteins have not yet been described in a context with HNSCC antigenic patterns. Antibodies against a heat shock transcription factor 2 (HSF2) were found in 2 out of 10 sera from HNSCC patients. In summary, using the SEREX technique, we isolated 17 immunogenic antigens in HNSCCs and confirmed the clinical relevance of KIAA0530. Further analysis concerning their feasibility as target structures for an immunotherapy approach is currently conducted.

rAAV/Her-2/neu Loading of Dendritic Cells for a Potent Cellular-Mediated MHC Class I Restricted Immune Response Against Ovarian Cancer

Recent studies demonstrate that recombinant adeno-associated virus (rAAV)-based antigen loading of dendritic cells (DCs) generates, in vitro, significant and rapid cytotoxic T-lymphocyte (CTL) responses against viral antigens. We used the rAAV system to induce specific CTLs against tumor antigens for the development of ovarian cancer (OC) gene therapy. As an extension of the versatility of the rAAV system, we incorporated a self-antigen, Her-2/neu, which is expressed in many cancers, including breast and ovarian. We analyzed two different vectors containing a short (157-612) and long domain (1-1197). Our rAAV vector induced strong stimulation of CTLs directed against the self tumor antigen, Her-2/neu. We then investigated the efficiency of the CTLs in killing Her-2/neu-targeted cells. A significant MHC class I-restricted, anti-Her-2/neu-specific CTL killing was demonstrated against Her-2/neu-positive OC cells after one in vitro stimulation. In summary, single peripheral blood mononuclear cell (PBMC) stimulation with rAAV/157-612- or rAAV/1-1197-pulsed DCs induces strong antigen-specific CTL generation. The CTLs were capable of lysing low doses of peptides pulsed into target cells or OC Her-2/neu(+) tumors. These data suggest that AAV-based antigen loading of DCs is highly effective for generating human CTL responses against OC antigens.

New endoscopic instruments for paranasal sinus surgery

BACKGROUND: Minimally invasive endoscopic and microscopic procedures represent state of the art paranasal sinus surgery techniques in both diagnostic and surgical fields. To combine favorable aspects of both techniques, we evaluated the clinical applicability and effectiveness of multifunctional microendoscopes, providing multiple features to ensure highest accuracy and surveillance when performing crucial steps in paranasal sinus surgery. METHODS: The study included both anatomic experiments on cadaveric heads and clinical tests on patients undergoing routine paranasal surgery. The systems applicability was evaluated in procedures approaching the frontal and sphenoid sinus. Three different endoscopes, 2 straight and the other 1 with a 90° angle, were tested. They integrate canals for flushing and suction and a working canal for either drilling or obtaining biopsies with a miniaturized forceps. For stereotactic feedback, the applicability in combination with a computer-navigation system was evaluated. RESULTS: Anatomic tests were performed to optimize illumination and to test drilling features and forceps biopsies. In all cases, the frontal sinus ostium and the sphenoid sinus anterior wall was easily identified and enlarged by drilling under visual and stereotactic control. Continuous suction and irrigation ensured a constant visual surveillance by removing drilling debris and blood. Best suited for multifunctional endoscopic surgery were drill heads with a cylinder shape, for placing bore holes along the Z axis, and spherical drill heads, for furbishing and enlarging drill holes. CONCLUSION: These new instruments have proven their applicability in paranasal sinus surgery. Multifunctional endoscopic procedures were deemed best suited for maneuvers requiring highest precision, such as the surgery of the frontal and sphenoid sinus.