Milan Stankovic

Applicability of autologous incus: the influence of age and localization of cholesteatoma

There is a correlation between macroscopic and histologic changes of incus in chronic otitis with cholesteatoma. The incidence and types of damage of auditory ossicles in chronic otitis media were extensively studied, but except some studies on reoperations there are no morphometric studies of human auditory ossicles in chronic otitis media. In order to define the rate of ossicular applicability for tympanoplasties in different macroscopic forms of damage, we analysed histologic changes of human incudes in correlation to their macroscopic alterations. Histomorphometric study of 82 intraoperatively removed human incudes, from chronic otitis media with cholesteatoma (attic, sinus, tensa cholesteatoma), was performed. They were divided according to the age of patients and localization of cholesteatoma. Erosions, vitality, vascular areas, osteomyelitic zones, and applicability of ossicles were measured. Progressive increase of erosions, decrease of vitality, dilatation of vascular spaces and osteomyelitic areas, and decrease of rate of potential applicability for tympanoplasties were found. Residual osteomyelitis was present in incudes with advanced external osteitis and ossicular defect. Macroscopic changes of incudes in cholesteatoma and their histologic structure correlate. Localisation of cholesteatoma is important for ossicular damage. Defects of long process with external osteitis of incudes and more intense pathological changes demand their removal and use of other reconstructive materials for tympanoplasties in order to avoid tympanoplasty failure.

Primary and salvage total laryngectomy. Influential factors, complications, and survival.

S hearing impaired people have intense problems especially when arriving in a public medical center, which must be considered with great prudence. Besides a propper arrangement of spatial arrays and organisational processes, there is a wide spectrum of interdisciplinary diagnostics, therapeutic approaches, rehabilitation offers and long term after care, which has to be included within a comprehensive center. The Wuerburg CHC was established in 2009 and gradually linked to all necessary partners including physicians, audiologists, psychologists, genetisists, radiologists as well as care attendants, medical engineers and health care professionals. Now the CHC offers the complete spectrum starting with newborn hearing screening, early hearing aid fitting and genetic counselling, including all kind of otosurgical procedures like classical middle ear surgery, cochlea and other hearing implants or acoustic neurinoma surgery and finally the necessary rehabilitation programs. Regular board meetings for difficult cases, new technological developments as well the integration of research programs enable a continuous adjustment to the rapidly developing field of hearing restoration. Patients feed back demonstrated, that the decoupling of the center from the general duty of a large university ENT clinic, succeeded in a better quality of patient care for hearing impaired people.C facial plastic surgery is based on achieving best possible results not only in correction of facial deformities but also in reconstruction of defects after tumor resection. It is not always an easy goal and sometimes it is necessary to perform multi stage surgical procedures to satisfy high aesthetic criteria of modern society. In corrective surgery of primary and secondary facial deformities, the most difficult task is to obtain natural look which will be socially accepted and will afford the patient normal life. Almost same criteria are in use when reconstructive surgery is in question. Doing this, at all times we have in our minds function, which should be unimpaired if not improved and aesthetic that will dominate in outside look and not interfere with function. These two main principles should be our ultimate goals in facial plastic and reconstructive surgery.D is a symptom observed in about half of the patients admitted to an acute clinic of geriatric medicine. Dysphagia can be caused by a multitude of illnesses and its consequences such as malnutrition, cachexia, dehydration and aspiration pneumonia are noted in a high percentage of geriatric in-patients. The male patient (80 years old) presented in this case study was admitted to our geriatric clinic because of a persistent cough and severe weight loss. He had had a 16 months long history of consultations at several hospitals and medical specialists: A bronchoscopy, an X-ray of the lungs and a laryngeal examination including stroboscopy at an ENT clinic had been conducted. Finally the patient had been diagnosed with a beginning fibrosis of the lungs and compulsive throat clearing. The latter was treated to little effect by a speech and language therapist. Bedside evaluation of the patient’s swallowing performance including the Daniels Test suggested severe dysphagia which was confirmed by a video endoscopic evaluation of swallowing. The endoscopy revealed great amounts of pharyngeal residues with a high risk of post deglutitive aspiration of pudding and silent aspiration of fluids. Further medical diagnostic procedure comprised a neurologic examination, an MRT of the brain stem and blood tests which suggested scleroderma as the underlying pathology. This was later confirmed by a clinic for entorology. Severe dysphagias caused by reduced opening of the upper esophagus sphincter and beginning fibrosis of the lungs were the first symptoms of scleroderma in this patient. In general, an examination of persistent cough should include screening for dysphagia and scleroderma should be considered as differential diagnosis.PURPOSE In this retrospective study we analysed patients with advanced squamous cell carcinoma of the larynx and hypopharynx treated with primary total laryngectomy (PTL) between 1990 and 2007. METHODS The patients were treated by classical PTL, radiotherapy 60-70 Gy, concomitant radio and chemotherapy (cisplatin and 5-fluorouracil) or salvage total laryngectomy (STL). They were followed up for 5 years and complications, survival, residual/recurrent disease and metastases were registered. RESULTS STL after previous radiotherapy (STL-pRT), and after chemoradiotherapy (STL-pCTRT) caused more frequent local complications than PTL. Five-year disease-free survival (DFS) rate was significantly influenced by TNM stage and localization of the primary laryngeal tumor. For laryngeal cancer it was: 61.3% for PTL, 54.1% for STL-pC-TRT, and 47.6% for STL-pRT. Incomplete responders to initial treatment had low survival rate. PTL for hypopharyngeal carcinoma and particularly salvage laryngectomy after chemoradiotherapy were associated with more frequent local complications. The 5-year DFS for hypopharyngeal cancer was lower than for laryngeal cancer. CONCLUSION PTL still offers the best survival rate with low complications for advanced laryngeal and hypopharyngeal squamous cell carcinoma. STL causes more frequent local complications, especially after chemoradiotherapy. Addition of chemotherapy to radiotherapy increases the survival. Five-year DFS rate depends on TNM stage and localization of the primary tumor.

Changes in auditory ossicles in rheumatoid arthritis: scanning electron microscopic study

The aim of this study was to define the existence of surface changes on auditory ossicles caused by rheumatoid arthritis. The study comprised of nine pairs of auditory ossicles (mallei and incudes) from autopsy of patients with rheumatoid arthritis, and five pairs of ossicles from persons without RA, taken during autopsies. The specimens were studied with JEOL JSM 5300 type scanning electron microscope. Surface changes of auditory ossicles were defined, affected areas were calculated, and expressed in percentage of total surface. Changes in auditory ossicles in patients with rheumatoid arthritis are significantly higher than in control ossicles, both on ossicular surface and articulations. Increased lysis of incudes, especially in the region of long propagation, corresponds to vascular damage. Articular degeneration is also present, indicating specific rheumatoid alteration. Both changes are statistically more intense in cases with longer duration of disease. In conclusion, rheumatoid arthritis reduces vascularity of auditory ossicles and causes degeneration of articular surfaces.

Stridor as initial clinical presentation of tracheal chondroma

Chondromas are benign cartilaginous tumours that are uncommon in the head and neck region. Only few cases of chondroma have been reported in the trachea. We present a 70-year-old patient who presented clinically with severe dyspnoea requiring urgent tracheotomy. An oval, expansive, well-delineated tracheal tumour was evident on magnetic resonance imaging. The mass was removed surgically in its entirety, preserving tracheal rings, and the histopathological diagnosis was chondroma. The patient was decannulated after 2 months, and was followed for 3 years. Urgent tracheotomy is an unusual initial clinical manifestation of this infrequent tumour. Surgical options and the choice of therapy in this case are discussed.

Survival after Salvage Total Laryngectomy: The Influence of Previous Treatment

Purpose: To compare the complications and survival rate after different treatment modalities of advanced laryngopharyngeal cancer. Methods: Retrospective study included 619 advanced laryngopharyngeal carcinoma, treated with either primary total laryngectomy (PTL), or salvage (STL) after partial laryngectomy, radio, chemoradiotherapy. Complications and survival rate were documented. Results: Five years disease free survival rate amounted 60.9% for PTL, 54.3% for STL after partial laryngectomy, 50% for STL after radiotherapy and 43.8% for STL after chemoradiotherapy. Histologically positive neck was highly significantly associated with worse prognosis, much more than recurrence within larynx. Conclusion: PTL gives the best survival rate with low complications for advanced laryngopharyngeal squamous cell carcinoma. Complications and survival rate of STL significantly depend on previous treatment of laryngopharyngeal cancer.

The Learning Curve of Cholesteatoma Surgery: Follow up of AudiologicalResults

Objective: To review the effect of learning curve on the audiological results of patients surgically treated for cholesteatoma. Study design: Retrospective review of patients records in tertiary referral center. Patients: Retrospective study of 758 patients operated by one surgeon for acquired middle ear cholesteatoma divided into two periods. The patients were divided into three age groups: children, adolescents, and adults. The localization of cholesteatoma was classified as: attic, sinus, or tensa. Audiological results were followed during shortterm and long-term period. Interventions: Patients were treated with single canal wall up or wall down, according to the propagation of disease and condition of middle ear. Reoperations were performed when needed. Main outcome measures: Preoperative and postoperative air bone gap (ABG) was compared in different groups. Results: In short term follow up the surgical experience was found significant for: attic and sinus tympani site, adult patients, absent manubrium mallei, closed technique, unilateral cholesteatoma, and primary surgery. During long tem follow up experience resulted in better audiological results for: all sites of cholesteatoma, adolescents and adults, all types of ossicular damage, uni- and bilateral cholesteatoma, for closed technique, and both for primary and revision operations. Conclusion:Obtained experience during surgical treatment for cholesteatoma was significantly influential on the improvement of audiological results of different aspects of cholesteatoma elimination, particularly for difficult and advanced cases, such as attic cholesteatoma, bigger ossicular damage, and closed surgical technique.

Linfangioma cavernoso laringofaríngeo extenso causante de obstrucción de las vías aéreas superiores

Lymphangiomas represent malformations of lymphatic system that frequently affect head and neck region. They are usually seen at birth or in early childhood. According to the size of the lymphatic cavities lymphangiomas are classified as microcystic (capillary), macrocystic (cavernous) and cystic hygromas. According to progression of disease staging system was proposed: stage I--unilateral infrahyoid disease, stage II--unilateral suprahyoid, stage III--unilateral supraand infrahyoid disease, stage IV--bilateral suprahyoid, and stage V--bilateral suprahyoid and infrahyoid disease. For laryngeal and hypopharyngeal site the radiographic differential diagnosis includes: retention cyst, ectopic thyroid, dermoid cyst, thyroglossal duct cyst or hemangioma. The histologic differential diagnosis includes hemangioma, and metastatic papillary cyctic thyroid carcinoma. Extensive cavernous lymphangioma occurs in 3%--18%. Advanced lymphangioma can cause airway or feeding