Tobias Kroll

Cone beam computed tomography (CBCT) sialography—an adjunct to salivary gland ultrasonography in the evaluation of recurrent salivary gland swelling

OBJECTIVE Cone beam computed tomography (CBCT) sialography could help improve the visualization of the ductal system of salivary glands. The aim of this retrospective investigation was to monitor the use of CBCT sialography for the diagnosis of pathologies within the intraglandular ductal system when ultrasonography was inconclusive. STUDY DESIGN Fourteen consecutive patients suffering from recurrent swelling of a major salivary gland were evaluated. In 12 patients (8 female; 4 male; average age 46 years), a radiopaque contrast agent could be injected into the ductal system, followed by a routine CBCT. Four blinded examiners evaluated the acquired data sets retrospectively. RESULTS CBCT revealed seven stenosis, two salivary stones, one complete duct atresia, one intraglandular duct ectasia, and one regular duct system. Three of the detected pathologies were strictly intraglandular. CONCLUSIONS CBCT sialography shows promise as a supplementary noninvasive diagnostic tool for the visualization of the intraglandular ductal system of the major human salivary glands. Controlled studies to further validate this method should be undertaken.

Extracardiac juvenile rhabdomyoma of the larynx: a rare pathological finding.

The extracardiac juvenile rhabdomyoma is extremely rare in the field of Otorhinolaryngology. The tumour usually arises from the soft tissue of the face or from mucosal sites, especially the oropharynx and the oral cavity but only sporadic endolaryngeal cases have been described in literature so far with predominance of young males. Here, we describe the very rare case of endolaryngeal extracardiac juvenile rhabdomyoma in a 42-year-old male. Clinical examination showed a mass of the right vocal cord, resembling a cystic lesion. Microlaryngoscopy revealed a non-encapsulated lesion and histopathology including immunohistochemistry which consecutively led to the correct diagnosis. This case suggests that the endolaryngeal extracardiac juvenile rhabdomyoma can be easily confused with a vocal cord cyst. Malignant transformations have not been reported but recurrences have been described. When total excision cannot be accomplished, reoperation or narrow follow-up is indicated to prevent advanced revision surgeries.

Intraindividual homogeneity of 18F-FDG PET/CT parameters in HPV-positive OPSCC

OBJECTIVES 18F-FDG PET/CT is widely used in clinical oncology. Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) represents an emerging disease that differs from HPV-negative OPSCC in clinical behavior and tumour biology. In these tumours, HPV-oncogenes might lead to distinct alterations in metabolic pathways. Therefore, we compared metabolic parameters using 18F-FDG PET/CT in HPV-positive and HPV-negative OPSCC in relation to histopathological findings. MATERIALS Eighty-six patients with OPSCC received pre-therapeutic 18F-FDG PET/CT. Standardised uptake volume (SUV), total lesion glycolysis (TLG) and metabolic tumour volume (MTV) were analysed for the primary tumour. SUVmax was determined for neck lymph nodes. HPV-status was determined; overall survival rates (OS) were estimated. RESULTS 32/86 patients (37.2%) had HPV-related OPSCC. Overall, PET-parameters in primary tumours of both groups did not differ significantly. Comparing early with locally advanced primary tumours, there was a significant increase in 18F-FDG uptake in HPV-negative patients (p<0.001). Positive nodes of HPV-related OPSCC showed significantly higher SUVmax values (p=0.039) compared to HPV-negative OPSCC. Strikingly, there was a higher intraindividual homogeneity of 18F-FDG uptake between primary and respective positive nodes in HPV-related primary OPSCC (p=0.001). SUV-max and -mean values did not correlate with OS in HPV-related OPSCC. CONCLUSION The intraindividual homogeneity of 18F-FDG uptake in HPV-related OPSCC could reflect the more homogenously, HPV-triggered carcinogenesis compared to the mutation-driven carcinogenesis in the HPV-negative OPSCC with heterogenic 18F-FDG uptake.

Praxis der Tumorendoskopie an deutschen HNO-Kliniken

BACKGROUND Second primary carcinomas (SPC) essentially influence therapy and the outcome in head and neck cancer. This study presents the current status of tumour endoscopy in German ENT-clinics. MATERIAL AND METHODS A standardised questionnaire regarding indication, time of event, examined anatomical region and technique of tumour endoscopy was compiled, sent to all German ENT-clinics (n=159) and subsequently analysed. RESULTS In 94-100% of the clinics, tumour endoscopy is being conducted when primary carcinoma lies within oral cavity, pharynx, larynx or is a CUP-syndrome. In 80%, 2-stage surgical procedure is preferred. Nasal cavity and tracheobronchial system (47%, 74%) are often not included in the examination. When primary cancer is seen, in 7% of the clinics a standardised biopsy of unsuspicious anatomic areas is conducted. In CUP-syndrome, unsuspicious surfaces within the pharynx do not undergo routine biopsy in 10-20% of the clinics. In tracheobronchoscopy (63.0%) and esophagoscopy (93.3%) rigid scopes are mainly used. 65% of the clinics conduct endoscopy as follow-up care. CONCLUSION Practice of tumour endoscopy in German ENT-clinics is widespread but does not follow standardised mechanisms. Current international literature shows that there is no common consensus on value and techniques of tumour endoscopy, however, due to highly developed radiological diagnostics, risks of rigid endoscopies and unknown incidence of second primary tumours it is discussed more and more negative. To establish future guidelines, controlled studies or analysis of large populations seem to be necessary.

Contrast-agent enhancement in ex vivo flat-panel computed tomography of locally advanced laryngeal cancer

Abstract Conclusion: Visualization of cartilage invasion in ex vivo laryngectomy specimens was improved by flat-panel volumetric computed tomography (fpvCT) after diffusion of contrast agents. A prospective study to assess the specificity and sensitivity of this new method is warranted. Objectives: Cartilage invasion is a criterion for staging laryngeal squamous cell carcinoma. Contrast-enhanced CT is routinely used for assessing cartilage invasion. However, the sensitivities and specificities given for this method in the literature vary, and there is a need for improvement of this staging method. The objective of our pilot study was to determine cartilage invasion with fpvCT after contrast agent diffusion. Methods: Three patients underwent preoperative CT and total laryngectomy. The excised larynges were immediately scanned with an fpvCT scanner, without contrast enhancement. Additional fpvCT scans were performed after incubation of the larynges in one of three different contrast agents for 24 and 48 h. The results from presurgical conventional scans, fpvCT scans, and histological examination – as the gold standard – were compared. Results: We demonstrated the feasibility of ex vivo contrast enhancement of laryngeal tissues by diffusion, with a subsequent increase in contrast enhancement and improved visualization of cartilage invasion in fpvCT scans. Histology confirmed the fpvCT results.

Rigid Triple Endoscopy Improves Clinical Staging of Primary Head and Neck Cancer

Background: Correct pre-therapeutic staging of the first primary carcinoma (FPC) and detection of simultaneous second primary carcinomas (SSPCs) decisively influence therapy and prognosis of head and neck squamous cell carcinomas (HNSCC). The aim of this study was to determine the benefit of pre-therapeutic triple endoscopy for detection of SSPC and pre-therapeutic T category. Methods: A cohort of 234 HNSCC patients with completed triple endoscopy was reviewed, focusing on pre-therapeutic T category and SSPC. Risk stratification for different subsites was evaluated. Results: The risk for SSPC was 5.56%. FPC of the oral cavity and oropharynx had the highest prevalence of SSPC (46.15%, 38.46%); most SSPCs were found in the hypopharynx. No SSPCs were found in the oral cavity, nasopharynx and oesophagus. Significant results in correct pre-therapeutic T staging have been achieved for the larynx (p = 0.021) and the oropharynx (p = 0.001). Conclusions: Triple endoscopies seem to be inadequate for SSPC detection in HNSCC patients. Endoscopies of the trachea and oesophagus should be reconsidered. Alternatively, risk-directed endoscopies of the hypopharynx might be performed in patients with oral cancer. For evaluation of resectability, conducting triple endoscopy could be reduced to a single endoscopy because the complication rate is low and pre-therapeutic T staging can be improved.

The 8th edition AJCC/UICC TNM staging for p16-positive oropharyngeal carcinoma: is there space for improvement?

The 8th edition of the AJCC/UICC TNM-staging system for p16[HPV]-positive OPSCC manages to improve prediction of prognosis and will essentially influence choice of therapy in future. Nonetheless, adjustments of the current version are needed. The surrogate marker p16 alone is inadequate for HPV detection, the role of ECS in HPV-positive OPSCC is not fully understood, and the patient’s characteristics as well as molecular signatures and genetics have not been taken into consideration yet.

Spontane Knochenregeneration nach keratozystischem odontogenem Tumor@@@Spontaneous bone regeneration following ceratocystic odontogenic tumor

ZusammenfassungEin Patient stellte sich mit einem keratozystischen odontogenen Tumor des linken Sinus maxillaris vor. Radiologisch fanden sich ausgedehnte druckbedingte knöcherne Atrophien der Kieferhöhlenwände. Es erfolgte eine endoskopische Zystektomie des Tumors und die anschließende klinische Nachsorge. Im Verlauf wurde eine erneute radiologische Untersuchung durchgeführt, in der sich eine nahezu vollständige Rekonturierung der Kieferhöhlenwände zeigte. Knöcherne Rekonstruktionen im Rahmen von schonenden Ersteingriffen, wie der Enukleation, sollten bei der Möglichkeit spontaner Knochenregeneration zurückhaltend indiziert werden.AbstractA patient presents with a keratocystic odontogenic tumour of the left maxillary sinus. In computed tomography scans, extensive pressure-induced osseous atrophy of the sinus walls is detected. Endoscopic cystectomy of the tumour was performed, with subsequent clinical follow-up. A second computed tomography scan revealed almost complete regeneration of the sinus walls. Where spontaneous regeneration of osseous structures is possible, restraint should be exercised when assessing indications for bony reconstruction during initial conservative surgery such as enucleation.A patient presents with a keratocystic odontogenic tumour of the left maxillary sinus. In computed tomography scans, extensive pressure-induced osseous atrophy of the sinus walls is detected. Endoscopic cystectomy of the tumour was performed, with subsequent clinical follow-up. A second computed tomography scan revealed almost complete regeneration of the sinus walls. Where spontaneous regeneration of osseous structures is possible, restraint should be exercised when assessing indications for bony reconstruction during initial conservative surgery such as enucleation.

Spontaneous bone regeneration following ceratocystic odontogenic tumor

ZusammenfassungEin Patient stellte sich mit einem keratozystischen odontogenen Tumor des linken Sinus maxillaris vor. Radiologisch fanden sich ausgedehnte druckbedingte knöcherne Atrophien der Kieferhöhlenwände. Es erfolgte eine endoskopische Zystektomie des Tumors und die anschließende klinische Nachsorge. Im Verlauf wurde eine erneute radiologische Untersuchung durchgeführt, in der sich eine nahezu vollständige Rekonturierung der Kieferhöhlenwände zeigte. Knöcherne Rekonstruktionen im Rahmen von schonenden Ersteingriffen, wie der Enukleation, sollten bei der Möglichkeit spontaner Knochenregeneration zurückhaltend indiziert werden.AbstractA patient presents with a keratocystic odontogenic tumour of the left maxillary sinus. In computed tomography scans, extensive pressure-induced osseous atrophy of the sinus walls is detected. Endoscopic cystectomy of the tumour was performed, with subsequent clinical follow-up. A second computed tomography scan revealed almost complete regeneration of the sinus walls. Where spontaneous regeneration of osseous structures is possible, restraint should be exercised when assessing indications for bony reconstruction during initial conservative surgery such as enucleation.A patient presents with a keratocystic odontogenic tumour of the left maxillary sinus. In computed tomography scans, extensive pressure-induced osseous atrophy of the sinus walls is detected. Endoscopic cystectomy of the tumour was performed, with subsequent clinical follow-up. A second computed tomography scan revealed almost complete regeneration of the sinus walls. Where spontaneous regeneration of osseous structures is possible, restraint should be exercised when assessing indications for bony reconstruction during initial conservative surgery such as enucleation.

Concerning: Subtotal facial nerve decompression in preventing further recurrence and promoting facial nerve recovery of severe idiopathic recurrent facial palsy (Wu SH et al., Eur Arch Otorhinolaryngol. 2015;272(11):3295–8. doi:10.1007/s00405-014-2991-9. Epub 2014 Mar 12)

With interest we read the article of Wu et al.: Subtotal facial nerve decompression in preventing further recurrence and promoting facial nerve recovery of severe idiopathic recurrent facial palsy (Wu SH et al., Eur Arch Otorhinolaryngol. 2015;272(11):3295–8. doi:10.1007/ s00405-014-2991-9. Epub 2014 Mar 12). The authors report on patients with recurrent Bell’s palsy that were selected upon neurography results, however, neurography is known to be unable to predict the outcome of patients with Bell’s palsy (Laryngoscope 1998;108(8):1177–80). Surgery has been offered to all patients; however, surgery cannot be regarded as standard treatment, ethical approval is lacking in the methods section of the article. 10 patients refused surgery and had a poor outcome according to Table 2 (further recurrent episodes of facial palsy and worse final facial nerve function). Tables 1 and 2 suggest preoperative facial nerve palsy episodes (FPE) between two and seven times in the respective groups, and post FPE in the surgery group 0/12 vs. 5/10 in the non-surgery group. The abstract gives different results (40 % in the non-surgery group). It must be mentioned that the outcome might be influenced by recurrence and not independently by the surgical intervention. Additionally, the facial nerve function before the last episode is crucial, but the variable ‘‘initial FNF’’ in Table 1 and 2 probably describes the grade of palsy immediately before surgery? The surgery group underwent subtotal decompression including geniculate ganglion and the tympanic segment. To our experience removing the incus and replacing it leads to conductive hearing loss, not very much depending on surgical skills. Additionally, the paper is missing detailed information on how the incus has been replaced (replaced as before? fixated with cement? with interposition on stapes?). The possibility of middle fossa approach for decompression of the geniculate ganglion and the meatal segment of the facial nerve and the geniculate ganglion to prevent hearing deterioration might also be discussed. The discussion implies that facial nerve decompression surgery in general can be recommended for patients with Bell’s palsy. Numerous studies are available concluding that transmastoid decompression surgery cannot be recommended for Bell’s palsy (Cochrane Database Syst Rev 2011: CD007468). To our opinion, the author’s conclusion that facial nerve decompression surgery is effective in recurrent Bell’s palsy, therefore, just cannot be drawn from their published data.