Klaus W. Albegger

β-trace protein test: new guidelines for the reliable diagnosis of cerebrospinal fluid fistula

OBJECTIVE Cerebrospinal fluid (CSF) fistulas need to be reliably diagnosed for the optimal management. Recently, in preference to beta2-transferrin, another CSF protein, beta-trace protein (betaTP), is similarly used with a new method for CSF diagnosis. This study evaluates the sensitive interpretation and limits of this new betaTP test for use in routine CSF fistula diagnosis. METHODS Nephelometric detection of betaTP has been made in nasal secretion, serum, and CSF samples from healthy individuals as well as patients with reduced glomerular filtration rate and with bacterial meningitis. Additionally, 53 patients with suspected CSF rhinorrhea are also analyzed. RESULTS The betaTP test can also be used to reliably diagnose CSF rhinorrhea even slightly better than the beta2-transferrin test. It should not be used for patients with renal insufficiency and bacterial meningitis as they substantially increase serum and decrease CSF betaTP values, respectively. CONCLUSION Quantitative measurement of betaTP is a noninvasive, highly sensitive, quick, and inexpensive method that can be used for the detection of CSF rhinorrhea in nasal secretions. However, in cases where there is doubt about the interpretation, the results should be proved with beta2-transferrin test or sodium-fluorescein test.

A common curriculum in Europe for ORL-HNS specialization and subspecialist training programs: we are on the right way!

We read with great interest the article “Sub-specialty training in head and neck surgical oncology in the European Union” by A. Manganaris, M. Black, A. Balfour, C. Hartley, J-P. Jeannon and R. Simo. Since some development has occurred after this article was written we would like to comment on a few aspects. We fully agree that harmonization of specialist education within EU is crucial since the free movement of labor has signiWcantly increased the movement of ENT specialists from one country to the other. For this purpose the UEMS-ENT Section has adapted the generic UEMS charters on specialization, visitation of training centers, CME/ CPD, etc. to the speciality of Otorhinolaryngology–Head and Neck Surgery (ORL–HNS) (http://orluems.com). The logbook for the main specialty has recently been revised and it is available also as an online version in several languages. We regret that many countries have still chosen to use their own logbook like UK, which UEMS-ENT section representatives have been heavily involved in the formulation of the UEMS-ENT section logbook. Even more, there are other European countries that are still not using any logbook till date. Only a few countries have a compulsory exit exam at the end of the specialist training in ORL-HNS. Therefore, the UEMS-ENT section in collaboration with the European Academy of Otorhinolaryngology–Head and Neck Surgery (EAORL–HNS) arranged the Wrst European Board Examination (EBE), which was held during the Wrst meeting of the EAORL–HNS in collaboration with EUFOS, 27–30 June 2009 in Mannheim. The examination was well received and the majority of the candidates passed this theoretical part of the EBA. In the UEMS-ENT section meeting in October the next site location of the EBE will be decided and the oral (viva) part of the exam will be planned. In this regard, the EBE would hope to beneWt from those colleagues and countries such as UK, Ireland, Germany and Poland who have many years’ experience of conducting oral examination. It is true that the specialist training in ENT-HNS in Europe varies somewhat in duration and content, the information on this can be found at http://orluems.com. However, we are pleased to see, that many countries, that previously had a relatively short specialization time, have used the European harmonization process in order to convince their National Authorities of the need to adapt the European standards of a 6 years training period. The other extreme seems to be UK ORL Training, where even after the Calman Reforms in 1997, training remains at a minimum of 8 years, but usually longer than so, is required including pre-registration house oYcer (1 year), senior house oYcer (2 years minimum), then specialist registrar = Higher Surgical Training (HST) in ORL/H&N (5–6 years) service. With this background it is understandable that the authors state “The accredited UK trainee appears to be the best trained, with a wide clinical and surgical repertoire...”. On the other hand, it is obvious ORL-HNS is such a wide specialty that a thorough knowledge in all parts of it is impossible for one individual to R. Grénman (&) Department of Otorhinolaryngology, Head and Neck Surgery, University of Turku and Turku University Hospital, Turku, Finland e-mail: Reidar.grenman@tyks.fi

The development and design of the European Board of Otorhinolaryngology-Head and Neck Surgery Examination (EBEORL-HNS).

The UEMS Otorhinolaryngology-Head and Neck Surgery section is a dedicated body formed to promote the standardisation and harmonisation of European Otorhinolaryngology (ORL). The European Examination Board of Otorhinolaryngology and Head and Neck Surgery was created to establish a supranational final exam and accreditation for ORL Surgeons. It is open to candidates both from the European Union and outside the EU. The exam is composed of a written examination to assess mainly the theoretical knowledge of Otorhinolaryngological diseases. The second part, a viva voce examination, is designed to test the clinical application of knowledge based on case scenarios and clinical conditions presented to the candidates. The inaugural examination written component took place in Mannheim/Germany in 2009 and the inaugural Viva Voce examination in Vienna/Austria in 2010. Up to and including the year 2013, 858 participants have attempted one of the two exam components. Of the 858 participants, 305 were successful in both examinations and obtained the accreditation of the European Diploma (European Board Certification). The historical origins, development of the examination, its formal arrangements and the format of the examination are presented in this article.

Michael G. Stewart and Samuel H. Selesnick (eds): Differential diagnosis in Otolaryngology: head and neck surgery

This relatively small book is a very practical resource for rapid and accurate diagnosis and differential diagnosis in Otorhinolaryngology—head and neck (including facial plastic) surgery. This comprehensive manual uses an innovative format what ORL-specialists need in their daily practice. Each chapter is symptom based, with the patient’s presentation followed by an easily accessible list of potential diagnoses—the differential diagnosis. Supplementary data on the features of different diseases help the user to correctly identify the underlying problem. As the main chapters are organized by signs and symptoms and not by disease, this book becomes a ready clinical reference. With the key information, one can then assess a variety of complaints. The diagnostic evaluations discussed include all classical methods as well as new and forthcoming technologies in Allergy and Immunology, Genetics, Audiology [auditory steady state responses (ASSR)] and vestibular testing [vestibular-evoked myogenic potentials (VEMPs)], MRI and PET/CT. In detail, the authors present symptom-orientated evaluations in Neurotology, Rhinology, Upper Aerodigestive Tract, Voice, Facial Plastic and Reconstructive Surgery, as well as Allergy and Immunology, with special focus on head and neck imaging and positron emission tomography. The differential diagnosis (DD) in Neurotology, Rhinology/sinus disease, skin/face and neck disorders are separated for adult and pediatric patients, whereas the DD for oral cavity, larynx/trachea, pharynx/esophagus include adults and children. There is also a chapter on DD in cosmetic and plastic surgery, trauma and reconstruction. The book closes with future prospects in new technologies for DD. Numerous cross references throughout the text clearly link different symptoms and diseases to provide a solid basic understanding of each diagnosis. Eighty-two highquality illustrations and clinical photographs, including 52 in full color, clearly demonstrate many lesions and diseases. Well-organized tables of rare diseases and syndromes enhance a rapid overview. DD in Otolaryngology is a ‘‘missing link’’ in the ORLHNS literature. It is a recommended reference and refresher for experienced ORL-HNS specialists, who need to update their knowledge of their own and other subspecialty fields in ORL-HNS. But it is also a must-have for ORL residents and a very valuable tool for younger fellows when they prepare for daily practice or study for exams.

Die circadiane Speichelsekretion

SummaryA circadian biochemical pattern for the salivary secretory process is well documented, but this is not the case for the morphology. Informations up to now concerning the morphology of secretion processes are based on investigations in wich secretion is artificially stimulated or inhibited without taking any consideration of the organisms circadian system. To solve this problem we used male Wistar rats, which were standardized on a light-dark-cycle with light from 07.00–19.00, with food and water ad libitum. During an 24 h time span sub-groups of 5 animals were sacrificed at 4 h intervalls and the salivary glands were quickly removed for light- and electron microscopic investigations. It is demonstrated, that the volume of all components of all salivary glands (parotid, sublingual, submandibular gland) change in a characteristical manner, especially on the ultrastructurel level. It is therefore shown, that the salivary glands have a time-structure, i.e. a time dependent morphology, which reflects the rhythmic activity, namely production, storage and extrusion of secretory material.