[Hearing impairment and dementia]

The World Health Organization (WHO) burden of disease study identified dementia and hearing problems as leading causes of loss of quality of life in the industrial world. The prevalence of dementia and hearing problems increases in aging societies. Comorbidity of these two diseases causes increasing demands on healthcare systems. The similarity and possible interaction of symptoms renders diagnosis and therapy of dementia and hearing loss a challenge for neurologists, psychiatrists, ear, nose and throat (ENT) and hearing specialists. Knowledge of both diseases enables an early intervention and helps preserve participation in society and thereby reducing the risk of developing dementia. This paper focuses on the characteristics of the diagnosis and therapy of hearing problems and dementia.

[Evaluation of the Freiburg monosyllabic speech test in background noise]

BACKGROUND

The Freiburg speech test has been the gold standard in speech audiometry in Germany for many years. Previously, however, this test had not been evaluated in assessing the effectiveness of a hearing aid in background noise. Furthermore, the validity of particular word lists used in the test has been questioned repeatedly in the past, due to a suspected higher variation within these lists as compared to the other word list used.

PATIENTS AND METHODS

In this prospective study, two groups of subjects [normal hearing control subjects and patients with SNHL (sensorineural hearing loss) that had been fitted with hearing aid] were examined. In a first group, 113 control subjects with normal age- and gender-related pure tone thresholds were assessed by means of the Freiburg monosyllabic test under free-field conditions at 65 dB. The second group comprised 104 patients that had been fitted with hearing aids at least 3 months previously to treat their SNHL. Members of the SNHL group were assessed by means of the Freiburg monosyllabic test both with and without hearing aids, and in the presence or absence of background noise (CCITT-noise; 65/60 dB signal-noise ratio, in accordance with the Comité Consultatif International Téléphonique et Télégraphique), under free-field conditions at 65 dB.

RESULTS

The first (control) group exhibited no gender-related differences in the Freiburg test results. In a few instances, inter-individual variability of responses was observed, although the reasons for this remain to be clarified. Within the second (patient) group, the Freiburg test results under the four different measurement conditions differed significantly from each other (p>0.05). This group exhibited a high degree of inter-individual variability between responses. In light of this, no significant differences in outcome could be assigned to the different word lists employed in the Freiburg speech test.

CONCLUSION

The Freiburg monosyllabic test is able to assess the extent of hearing loss, as well as the effectiveness of a fitted hearing aid, in the presence or absence of background-noise (CCITT-noise). The present study could not evidence statistically significant differences in outcome when using the different word lists in this test battery.

Matrix change of bone grafting substitute after implantation into guinea pig bulla

BACKGROUND

Many different surgical techniques have been developed to remove open mastoid cavities. In addition to autologous materials, alloplastic substances have been used. A very slow absorption of these materials and extrusion reactions have been reported. We investigated a newly developed, highly porous bone grafting material to eliminate open mastoid cavities, in an animal model. To characterise the transformation process, the early tissue reactions were studied in relation to the matrix transformation of the bone material.

MATERIAL AND METHODS

NanoBone (NB), a highly porous bone grafting material based on calcium phosphate and silica, was filled into the open bullae from 20 guinea pigs. The bullae were examined histologically. Energy dispersive X-ray spectroscopy (EDX) was used to investigate the change in the elemental composition at different sampling times. The surface topography of the sections was examined by electron microscopy.

RESULTS

After 1 week, periodic acid-Schiffs (PAS) staining demonstrated accumulation of glycogen and proteins, particularly in the border area of the NB particles. After 2 weeks, the particles were evenly coloured after PAS staining. EDX analysis showed a rapid absorption of the silica in the bone grafting material.

CONCLUSIONS

NanoBone showed a rapid matrix change after implantation in the bullae of guinea pigs. The absorption of the silica matrix and replacement by PAS-positive substances like glycoproteins and mucopolysaccharides seems to play a decisive role in the degradation processes of NB. This is associated with the good osteoinductive properties of the material.

[The new Siegle's otoscope - a step by step manual for converting a 0 degrees telescope into a pneumatic video-otoscope]

The simple technique of Siegle's otoscope has unfortunately passed out of date. Ever since, tympanometry gives a general view over pressure conditions in the middle ear in a fast way. Only with pneumatic otoscopy, the examiner gets more detailed information if the tympanic membrane is sclerotic or retracted. In a step by step manual we are able to show an easy and inexpensive way to convert a 0 degrees telescope into a pneumatic video otoscope only by using accessories one can find in any ENT clinic. Again the examination technique with the pneumatic otoscope is very simple, with the benefit of getting video images for analysis in slow motion and action replay and not at least for storage. Sample images of exemplary clinical findings are given to top off the instruction.

[Investigation of a new highly porous hydroxyapatite matrix for obliterating open mastoid cavities - application in guinea pigs bulla]

BACKGROUND

Many different techniques for obliterating open mastoid cavity have been described. The results after the application of alloplastic materials like Hydroxyapatite and Tricalciumphosphate were poor due to long-lasting resorption. Extrusion of those materials has been described. We investigated the applicability of a new high-porosity ceramic for obliterating large open mastoid cavities and tested it in an animal model (bulla of guinea pig).

METHODS

A highly porous matrix (NanoBone) bone-inductor fabricated in a sol-gel-technique was administered unilaterally into the opened bullae of 30 guinea pigs. In each animal the opposite bulla was filled with Bio-Oss, a bone substitute consisting of a portion of mineral bovine bone. Histological evaluations were performed 1, 2, 3, 4, 5 and 12 weeks after the implantation.

RESULTS

After the initial phase with an inflammatory reaction creating a loose granulation tissue, we observed the formation of trabeculare bone within the fourth week in both groups. From the fifth week on we found osteoclasts on the surface of NanoBone and Bio-Oss with consecutive degradation of both materials.

CONCLUSION

In our animal model study we found beneficial properties of the used bone-inductors NanoBone and Bio-Oss for obliterating open mastoid cavities.

[Myxoma of the middle ear-a rare cause of facial palsy]

In case of the co-occurrence of facial palsy and inflammation-like symptoms of the same ear, the differential diagnosis is focused on viral (herpes zoster) or bacterial diseases. We report a patient for whom the surgical exploration of the middle ear revealed a benign tumor: a myxoma. These neoplasias are rare tumors in the head and neck region. The typical tumor site is the atrium of heart. In the ear, the tumor grows slowly and remains asymptomatic unless it irritates structures such as the facial nerve or the vestibular organ. Histologically, the tumor presents a "myxoid" matrix that is rich in acid mucopolysaccarides. The treatment of choice is complete surgical resection. Using the case presented, we discuss the causality between the tumor and the facial palsy, although during the operation the bony canal of the nerve was found to be intact. In any cases with clinically and radiologically unclear findings of the ear in connection with facial palsy, surgical exposure should be considered.

Konfokalmikroskopische Untersuchungen des Kehlkopfepithels

BACKGROUND

To evaluate mucosal changes of the true vocal cord, e. g. leukoplakia, microlaryngoscopy is needed to obtain tissue for histopathologic investigation. But there is a discrepancy between the amount of representative tissue necessary for pathology and the postoperative voice function. Thus, a diagnostic procedure that enables the surgeon to differentiate inflammation from dysplasia and carcinoma in situ intra-operatively is urgently needed. We are now reporting on our results using laser scanning microscopy to visualize larynx epithelia.

METHODS

The laser scanning microscope used in this ex vivo study is a combination of the Heidelberg Retina Tomograph HRTII and the Rostock Cornea Module. A 63 x water immersion objective lens was used for imaging.

PATIENTS

Seven larynx preparations of patients (age 54 to 62 years) with a T4 larynx carcinoma who underwent laryngectomy between 2003 and 2006 were examined.

RESULTS

Areas of epithelia of the true vocal cord of macroscopically normal appearance supplied images of healthy, but also inflamed laryngeal epithelia. The corresponding histopathologic sections prepared horizontally confirmed the regularity and homogeneity of the mucosa. The different layers of the lamina propria can be separated. In contrast to healthy and inflamed laryngeal mucosa, dysplasia, precancerous lesions and carcinoma-atypical cells were visible. In the latter entity a loss of cellular junctions characterized by lack of visualization of the cell membrane was apparent.

CONCLUSIONS

LSM supplies information of healthy, inflamed, but also pre-malignant and malignant mucosa changes of the larynx. The pilot study shows that both hyperkeratosis and extensive hyperplasia confine the visualization of the basement cell layer. Research projects have been initiated with the objective to develop a rigid endoscope with integrated LSM technology.

Wirkung elektromagnetischer Felder des GSM-Mobilfunksystems auf auditives und vestibuläres Labyrinth und Hirnstamm

BACKGROUND

It is the subject of this study to investigate the biological effect of the HF radiation produced by the Global System for Mobile Communications-( GSM)-mobile phone on the inner ear with its sensors of the vestibular and auditive systems.

METHODS/PATIENTS

Thermographic investigations made on various model materials and on the human temporal bone should show whether mobile phone does induce any increases of temperature which would lead to a relevant stimulus for the auditive and vestibular system or not. We carried out video-nystagmographic recordings of 13 subjects, brainstem electric response audiometry of 24 ears, and recordings of distorsion products of otoacoustic emissions of 20 ears. All tests were made with and without a mobile phone in use. The data was then analyzed for variation patterns in the functional parameters of the hearing and balance system that are subject to the (non)existence of electromagnetic radiation from the mobile phone.

RESULTS

The thermographic investigations suggest that the mobile phone does not induce any increases of temperature which would lead to a relevant stimulus for the auditive and vestibular system. Video-nystagmographic recordings under field effect do not furnish any indication of vestibular reactions generated by field effects. Compared with the recording without field, the brainstem electric response audiometry under field effect did not reveal any changes of the parameters investigated, i. e. absolute latency of the peaks I, III, V and the interpeak latency between the peaks I and V. The distorsion products of otoacoustic emissions do not indicate, comparing the three measuring situations, i. e. before field effect, pulsed field and continuous field, any possible impacts of the HF field on the spectrum or levels of emissions for none of the probands.

CONCLUSION

The investigations made show that the electromagnetic fields generated in using the mobile phone do not have an effect on the inner ear and auditive system to the colliculus inferior in the brainstem and on the vestibular receptors in the inner ear and the vestibular system.

Untersuchungen zum Entstehungsmechanismus der isolierten Orbitabodenfraktur

BACKGROUND

Isolated orbital floor fractures make up a significant proportion of all facial injuries, but the mechanism involved in these injuries to the orbital walls (blow-out fractures) has not yet been completely defined. Two theories have been described, which seem to be mutually exclusive. According to the hydraulic pressure theory, the kinetic energy of the blow is transferred via the incompressible eye tissue to the floor of the orbita, which in turn fractures. The buckling force theory, in contrast, explains these fractures as the result of bending and shear stresses arising from kinetic energy act directly on the orbital rim.

MATERIALS AND METHODS

With the aim of elucidating the mechanism of injury, we constructed a simplified finite-element model of the human orbita by 3D optical scanning of a human skull obtained after an autopsy examination. We created a generic approximation model based on empiric data derived from femoral fractures and reported in the literature. Several experiments were conducted to test both the above hypotheses by direct and indirect application of kinetic energy.

RESULTS

We simulated different types of shear stress with the finite-element model of the skull. The calculated points of maximum pressure were all within the orbital floor.

CONCLUSION

The simulation showed that both mechanisms can lead to fractures, as also documented by recent studies. The generation of a finite-element model and simulation of stresses were initially useful in establishing a method. More detailed studies on the empiric data relating to the various structures and more extensive determination and measurement of different skull and/or orbita geometries are needed before we can achieve a model in which the mechanical attributes of the structures involved are reproduced with closer approximation to the real-life situation.

[Arrosion bleeding of the brachiocephalic trunc - a late complication after percutaneous dilatative tracheostomy in a patient with a cervical rib abnormality]

BACKGROUND

In the last years percutaneous dilatative tracheostomy was increasingly established in many intensive care units, mostly performed by the anesthesiologists. This method becomes problematic, when it is used in patients requiring long time intubation. It must always be kept in mind that in the course of further rehabilitation the patients may be treated by persons, who are not familiar with the altered anatomy of the upper airways. This bears the risk for severy complications, like bleeding from major vessels.

CASE REPORT

Letal arrosion bleeding of the brachiocephalic trunc was observed in a patient, 3 weeks after percutaneous dilatative tracheostomy (technique by Griggs). As an abnormality the patient had a cervical rib. The wrong position of the tracheostomy tube was not noticed because the patient had no dyspnoea, spontaneously breathing through the nose and mouth instead of through the tracheostomy tube.

CONCLUSIONS

Particularly in patients requiring long-time intubation it is essential that the tube can be changed safely. We advocate an "epithelialized" tracheostoma with tracheocutaneous anastomosis for these patients. If the position of the tracheostomy tube is not clear, endoscopic control has to be performed.

Die laterale Pharyngotomie – ein seltener Zugangsweg zur Fremdkörperentfernung im oberen Ösophagusdrittel

Esophageal foreign body impaction is a serious emergency. Diagnostic workup includes an exact history and physical examination as well as several imaging modalities. The extraction of an esophageal foreign body can be done using nonflexible or flexible esophagoscopy. We report on a 43-year-old patient with typical symptoms of esophageal foreign body impaction. The x-ray overview upon admission showed the adjustment wires of one component of a metal denture in the area of the upper esophagus. Extraction by nonflexible esophagoscopy was rendered impossible because parts of the denture had speared themselves into the esophageal wall. Safe and uncomplicated removal was then performed through a lateral pharyngotomy.

Isolierte Hammergriff-Fraktur

In very rare cases, acute hearing loss can be caused by a fractured long process of the malleus. Such fractures can be due to head traumas, direct injuries of the tympanic membrane or barotraumas. Clinical findings are: abnormal mobility of the manubrium mallei during the Valsalva maneuvre or pneumomassage of the ear drum, conductive hearing loss, abnormal high compliance in the type A tympanigram. We report on a 48 year old female patient who showed typical symptoms and clinical findings, and discuss possible pathogenic factors. In accordance with the literature, we presume that negative pressure in the external ear canal, caused by a rapidly extracted finger (!), might be responsible. At the very onset of hearing loss, the patient noticed a high frequency tinnitus in the affected ear. Surgically, we tried to re-fix the manubrium by splinting it and the adherent parts of the tympanic membrane with cartilage.

[Arterial aneurysms as cause of gushing post-tonsillectomy hemorrhage]

Aneurysms of the external carotid artery can be causally for threatening late hemorrhage secondary to tonsillectomy. On the bases of typical, extended and finally dramatic bleeding course in a child the "clinical look" and the sensitivity should be raised for this bleeding cause. Characteristic after apparently inconspicuous post-operative first phase is late signal bleeding with little loss of blood which are replaced after following intervals free of bleeding from bleeding as flood with massive loss of blood. Then vessel-imaging (Angio-MRI or CT) is urgently indicated. By confirmation of the suspicion diagnosis the interventional angiography is the therapy of the choice, although after successful embolisation a fine-meshed postcontrol is necessary, because therapy failures are possible how the described case points. The highest security offers the surgical exploration with aimed vessel stopping.

Konzept eines „endostealen” Cochlear Implant-Elektrodenträgers für Patienten mit Restgehör und Machbarkeitsstudie aus anatomischer Sicht

BACKGROUND

Many patients with severe hearing loss could benefit from a bimodal stimulation unilaterally: acoustically in the apical region of the cochlea with some residual low frequency hearing and electrically via a cochlear implant in the basal turn with lost high hearing in the high frequency range. As a new concept we introduce the idea of an "endosteal electrode" - to be inserted between spiral ligament and endosteum of the bony wall without opening the fluid-filled inner ear. In this paper the feasibility from the anatomical point of view is to be proven.

MATERIALS AND METHODS

In 10 human temporal bone specimens the bone covering the membraneous inner ear is carefully removed in the site of a typical cochleostomy. It should by proven whether or not the soft tissue layer covering the inner ear could be left intact and, furthermore, whether a "dummy-electrode array" could be inserted "endosteally".

RESULTS

In 10 of the 10 specimen the preparation could be carried out in the desired way, leaving the spiral ligament intact. The regular site of the "electrode" was morphologically proven after embedding the specimens for histological evaluation.

CONCLUSIONS

From the anatomical point of view, an "endosteal cochlear implantation" seems feasible. Further experiments including animal studies must show, whether this concept might succeed functionally.

Stapesfixation bei Kindern

BACKGROUND AND OBJECTIVE

The audiometric results after stapes surgery in children with isolated stapes footplate fixation were reason enough to analyze intraoperative findings and surgical procedures.

PATIENTS/METHODS

A total of 438 stapes surgeries were performed in the years 1985-2000, and a retrospective analysis was made of the anamnestic data, intraoperative findings and audiometric data from 12 children with isolated fixation of the stapes footplate. The average age of the children when operated was 10.2 years (the youngest was 7 and the eldest 13). A loss of hearing had set in 5 years earlier.

RESULTS

Taking the anamnestic data and the intraoperative into account, otosclerosis was found in 5 children. One child had a narrow oval window niche, in a further six children a congenital fixation of the stapes footplate was evident. Only 58% (n=7) of the 12 children operated showed acceptable postoperative hearing results. The best hearing results were found in children with juvenile otosclerosis. In three of six children with congenital stapes fixation, a worsening of both bone and air conduction was evident. The average conductive hearing loss was 30 dB at 1, 2 and 4 kHz.

CONCLUSIONS

When explorative tympanotomy is indicated, a thin-layer CT scan of the temporal bone should be made to assess the risk of a liquor pressure labyrinth developing.

Konfokale Laser-Scanning-Mikroskopie zur Beurteilung des Zungenepithels

BACKGROUND

Superficial changes of the epithelium of the tongue are diagnosed by biopsy. The aim of this in-vivo study was to show the normal epithelium, the subepithelial structures and the subepithelial vessels of the tongue using confocal microscopy.

METHODS

A digital confocal Laser-Scanning Microscope (LSM), a combination of the Heidelberg Retina Tomograph HRT II and the Rostock Cornea Module (Heidelberg Engineering GmbH) was used. This digital microscope makes computer-based external hydraulic z-scan possible and the automatic collection of patient-based video sequences and the 3D reconstruction of the structures of the fungiform papilla. 800-fold magnifications are possible using a water immersion lens (Zeiss, 63-fold). A parabolic plexiglass disc with holes and a video camera were used to stabilize the tongue and to control the contact between the tongue surface and the contact element of the lens.

PATIENTS

Confocal microscopy was performed on 17 healthy test volunteers aged 21 to 56.

RESULTS

First findings with confocal LSM as a contact procedure show that a precise identification of the fungiform and filiform papillae and 3D reconstruction of the pores is possible. Furthermore, different cell layers of the tongue epithelium, subcellular structures of the epithelium and the subepithelial vessels to depth of 50 microm can be visualized by the erythrocytic flow and a max. 800-fold magnification.

CONCLUSIONS

The confocal LSM is a nondestructive contact procedure and allows the in-vivo analysis of the tongue epithelium.

Die aktive Sprachentwicklung hochgradig h�rgesch�digter und geh�rloser Kinder in Abh�ngigkeit von der h�rtechnischen Versorgung

The extent of vocabulary depends on the success of rehabilitation in hearing, language and speech. In hearing impaired and deaf children, it is important to select the optimum technical device-hearing aid or cochlear implant. This study was performed on 30 children with hearing aids or cochlear implants using the Test of Expressive Vocabulary for Children Aged 3-6 years (Kiese-Himmel and Kozielski). The development of vocabulary was recorded over 12 months. The results were analysed dependent on the degree of hearing loss, age at primary diagnosis, duration of treatment and kind of hearing aid used. These were compared with the reference data from a normally hearing population. Cochlear implant users had better language development than hearing aid users despite a lower grade of hearing loss in the hearing aid group. In general, the extent of the expressive vocabulary was less in hearing impaired children than in the reference population. However, in terms of hearing age, the language development of some cochlear implant users was similar to that of normal children.

Thermographische Untersuchungen zur Durchblutungssituation der ein Cochlear Implant bedeckenden Haut

BACKGROUND

Sufficient blood supply of the flap is a significant factor for proper wound healing and lifelong integration of a cochlear implant. Superficial temperature as an indicator of cutaneous blood circulation can be visualized easily by thermography.

QUESTION

We examined the correlation between temperature distribution and the anatomic course of defined arteries, the significance of different types of incisions in this regard, and local irritations of skin temperature/blood circulation by the implant itself.

MATERIALS AND METHOD

The partially shaved heads of 15 patients were examined by thermography after cochlear implantation, using the Agema thermovision system.

RESULT

Temperature distribution of the skin can be closely related to the arterial blood supply. In our group of patients, no significant alterations could be found in the skin covering the implant. Hair growth in the area tested does not allow valid thermographies.

DISCUSSION

By the pattern of temperature-distribution/blood circulation some conclusions about typical incisions can be drawn. While most types of incisions respect the patterns of blood circulation, the retroauricular C-incision may cause problems. Postoperative scars can be regarded as places of minor resistance.

CONCLUSIONS

Thermography of the skin is an easy method for estimating the blood circulation of the skin above the implant. It is, however, limited to hair-free or shaved skin areas.

[Contact endoscopic quantification of fungiform papillae--correlation to taste ability?]

BACKGROUND

Besides anamnestic data and taste test, the clarification of epithelial taste disorders makes macroscopic evaluation of the surface of the tongue necessary.

METHODS

In this article the contact endoscopy is evaluated for examination of the tongue epithelium and for quantification of the fungiforme papillae. These results are related to the results of the spatial taste test (1. chemical taste test with sodium chloride in 2 different suprathreshold concentrations and sucrose in also 2 different suprathreshold concentrations; 2. electrogustometry with a bipolar electrode).

PATIENTS

In a prospective study we performed contact endoscopy in 16 healthy volunteers from ages 7 to 68 years. The subjects were divided into 2 age groups (< or = 45 years and > 45 years) and 2 papillae density groups. In 34 patients with either taste disorders of unknown cause or in patients with macroscopic changes at the tongue surface, the spatial and whole mouth taste tests and contact endoscopy were used to clarify the cause of the complaints.

RESULTS

Density and shape of the fungiform papillae as well as the shape of the subepithelial vessels of the papillae vary among the investigated human subjects in the different age groups. No correlation between intensity ratings, papillae density und age was found after stimulation with 40 % sucrose at the tongue tip in the younger age group. Stimulation of the tongue edge with 15 % sodium chloride, however, showed a relationship between the two different density groups and the different age groups.

CONCLUSIONS

The contact endoscopy allows the evaluation of the epithelium in the oral cavity. It is a nondestructive method and is additionally easy to handle, but the evaluation of the observed epithelia needs interdisciplinary co-operation with pathologists. No relevant informations are supplied in diagnostics of taste disorders.

[Taste disorders and recovery of the taste function after middle ear surgery]

BACKGROUND

The incidence and the scale of recovery of the taste function after middle ear surgery is usually determined by the use of anamnestic data and electrogustometry.

METHODS

Taste tests (regional chemical taste test, electrogustometry and subjective evaluation) were performed preoperatively, 2 to 3 weeks and 6 to 9 months after middle ear surgery. These results were evaluated by taking the scale of chorda tympani nerve (CTN) manipulation into consideration. Three groups were chosen: group 1: no or small CTN manipulation, n = 54; group 2: strong CTN manipulation, n = 14; group 3: severed CTN, n = 50.

PATIENTS

In a prospective study 118 patients were examined after middle ear surgery in the ENT-Department of the University of Rostock between 2001 and 2002. 61 females and 57 males, age from 7 - 81 years, were included.

RESULTS

Complaints were observed in all three groups, mainly in groups 2 and 3. These included taste disorders, taste phenomenon and numbness of the tongue. Using regional chemical taste tests, the taste loss of group 3 could be proven for those patients with complaints in 64 % and for those patients without complaints in 27 %. The electrogustometry is more sensitive than chemical taste test. All patients had pathological thresholds after chorda cutting (78 % no thresholds; 22 % elevated thresholds). 68 out of 118 patients (58 %) had a second follow-up after 6 to 9 months after middle ear surgery. The complaints are declining in all groups. In groups 2 and 3 a recovery of taste function could be observed. Even if the number of patients with severed chorda, who suffer from taste disorders, diminishes, a recovery of the taste function could only be observed in 30 %.

CONCLUSIONS

The scale of chorda manipulation is important for the recovery of the taste function after middle ear surgery. The CTN should be preserved intraoperatively, especially when an operation of the contralateral ear is planned as well.

Herpes zoster guideline of the German Dermatology Society (DDG)

Varicella zoster virus (VZV) causes varicella (chickenpox), remains dormant in dorsal root and cranial nerve ganglia and can be reactivated as a consequence of declining VZV-specific cellular immunity leading to herpes zoster (shingles). Patients older than 50 years of age affected by herpes zoster may suffer a significant decrease of quality of life. These patients and immunocompromised individuals are at increased risks for severe complications, involving the eye, the peripheral and the central nervous system (prolonged pain, postherpetic neuralgia). Such complications occur with and without cutaneous symptoms. The German Dermatology Society (DDG) has released guidelines in order to guarantee updated management to anyone affected by herpes zoster. Diagnosis is primarily clinical. The gold standard of laboratory diagnosis comprises PCR and direct identification of VZV in cell cultures. Detection of IgM- and IgA-anti VZV antibodies may be helpful in immunocompromised patients. Therapy has become very effective in the last years. Systemic antiviral therapy is able to shorten the healing process of acute herpes zoster, to prevent or to alleviate pain and other acute and chronic complications, particularly, when given within 48 h to a maximum of 72 h after onset of the rash. Systemic antiviral therapy is urgently indicated in patients beyond the age of 50 years and in patients at any age with herpes zoster in the head and neck area, especially in patients with zoster ophthalmicus. Further urgent indications are severe herpes zoster on the trunk and on the extremities, herpes zoster in immunosuppressed patients and in patients with severe atopic dermatitis and severe ekzema. Only relative indications for antiviral therapy exist in patients younger than 50 years with zoster on the trunk and on the extremities. In Germany acyclovir, valacyclovir, famciclovir and brivudin are approved for the systemic antiviral treatment of herpes zoster. These compounds are all well tolerated by the patients and do not differ with regard to efficacy and safety. Brivudin has a markedly higher anti-VZV potency than oral acyclovir, valacyclovir and famciclovir and thus offers a simpler dosing regimen. It must be given only once daily during 7 days in comparison to three and five times dosing per day of valacyclovir, famciclovir and acyclovir, respectively. Brivudin is an antiviral agent with no nephrotoxic properties, which is an advantage when compared to acyclovir. The most important aim of therapy of herpes zoster is to achieve painlessness. Appropriately dosed analgesics in combination with a neuroactive agent (i.e. amitriptylin) are very helpful when given together with antiviral therapy. The additive therapy with corticosteroids may shorten the degree and duration of acute zoster pain, but has no essential effect on the development of postherpetic neuralgia, which is a very difficult condition to treat. Thus early presentation to a pain therapist is recommended in specific cases.

[Early postoperative middle-ear ventilation -- risk for the transplant or guarantee for aeration of the tympanic cavity?]

BACKGROUND

Sufficient ventilation of the tympanic cavity is a decisive factor for the success of the therapy and the prognosis after tympanoplastic surgery. With the postoperative use of the Valsalva- and Politzer-maneuver the patient is able to influence the aeration of the tympanic cavity in a positive way by autoinsufflation. However this implicates the risk of a dislocation of the transplant, which is possibly caused by high middle-ear pressure-peaks during the maneuvers mentioned.

METHODS

The actual increase of pressure in the tympanic cavity respectively auditory canal during the Valsalva- and Politzer-maneuver is examined in 22 patients with chronic-mesotympanic Otitis media and additionally by using an experiment with a model of a reconstructed middle-ear. The risk of a transplant-dislocation after tympanoplasty type I is estimated.

RESULTS

The increase of pressure in the middle ear respectively auditory canal -- and with that the possibility of a dislocation of the transplant -- is lower after Politzer- compared with Valsalva-maneuver. If the transplant is secured through silicon sheets and packings in the auditory canal, the probability of "blowing away" the newly created cover of the tympanon will be very small.

CONCLUSIONS

Because of the benefits for the aeration of the tympanic cavity, an early post-operative insufflation of the middle-ear -- using the Politzer- and/or "cautious" Valsalva-maneuver -- is recommended.

[An intraosseous hemangioma in the perpendicular lamina of the ethmoid bone]

The incidence of intraosseous hemangiomas is very low. Most of them occur in adult females. The mandible,the zygoma,the maxilla, and the frontal and nasal bones are the areas of most frequent localization in the facial region. The intraosseous hemangioma is a benign, slowly growing,bony hard tumor causing facial deformity. It is diagnosed histologically. We report a case of an 18-year-old male with an intraosseous cavernous hemangioma located in the perpendicular lamina of the ethmoid bone. Intraosseous hemangioma often has characteristic signs on a CT scan, with either coarsened trabeculae lying adjacent to the vascular channels or multifocal lytic areas creating a honeycomb pattern. Because of the age of the patient we considered a midline granuloma and a chondrosarcoma. The therapy of choice is surgical excision; radiation is done in exceptional cases only.

Heat radiation during caloric vestibular test: thermographic demonstration in temporal bone experiments

Since Barany's descriptions in 1906, cold and warm irrigations of the external ear canal have been used for unilaterally testing vestibular excitability. The fluid kinetics within the endolymph have been studied thoroughly, whereas relatively few published articles deal with the mechanisms of heat transfer from the external to the internal ear. Even though heat conduction via the bone seemed to be well established in the textbooks, Feldmann and co-workers found heat radiation to be a very important factor. Using a rather uncommon method, we tried to make this heat radiation more apparent: in temporal bone experiments, temperature distribution was followed by thermography. Temporal bone specimens were prepared in such a way that heat distributions became visible after experimental caloric irrigations of the external ear canal. Temperature changes could well be verified by changes in coloration of the 2-dimensional thermograms. Conclusions were drawn from registrations performed in 2 projections, 90 degrees to each other, allowing cautious statements about 3-dimensional distribution. The velocity of heat transfer at the very onset of the reaction can only be explained by radiation, whereas later, other mechanisms, such as conduction via the bone or convection via the middle ear gas, may have some influence. Our results support Feldmann's findings and underline the significance of radiation in the heat transfer mechanism.

[Cholesteatoma recurrences caused by intraoperative cell seeding? Contact endoscopic and cytologic studies]

BACKGROUND

The high rate of recurrences of cholesteatomas after surgery is mostly caused by insufficient removal of matrix. Another factor may be intraoperative scattering of matrix cells e. g. with the running burr, which later may become the origin of new cholesteatoma growth. In this paper we tried to visualize these cells for gaining further informations.

PATIENTS AND METHODS

In 10 patients intraoperative contact endoscopy of the cholesteatoma was carried out during mastoidectomy. After intravital staining with methylene blue the very superficial tissue layers can directly be considered via a contacting endoscope. In addition, sucked-off rinsing fluid was cytologically examined for epithelial cells.

RESULTS

Both investigations show only very rare vital squamous cells - besides other cells like or ciliated cells and foreign body giant cells.

DISCUSSION AND CONCLUSIONS

Inspite of their small number, these squamous cells in principle could cause dispersed growth of cholesteatoma. However, this seems to be much less significant than the assumption of matrix left behind intraoperatively. The danger of dispersed cell growth can further be diminished by adequate operating techniques with sufficient rinsing, smoothing the bony cavity walls and avoiding blind corners.

[Vertigo in suction of open mastoid cavities ("radical surgery cavities")]

BACKGROUND

Vertigo during suction-cleaning of open mastoid cavities is caused by cold stimulation of the vestibular organ. In clinical and model-experimental measurements we tried to estimate the physical background and the dimension of this temperature drop.

METHODS

Using different techniques like thermo-probes, thermovision, or additional model experiments temperature changes during suction were measured in 5 volunteers with open mastoid cavities. These registrations were carried out with special regard to the moisture of the cavity-walls.

RESULTS

Distinct temperature changes during suction were observed. In moist cavities superficial temperature decrease was much higher than in dry ones. Using additional model experiments, temperature conduction towards e.g. the horizontal semicircular canal could be simulated.

DISCUSSION AND CONCLUSIONS

Among other mechanisms like replacement of sucked-off air by colder air, or taking away warm air close to the cavity walls, effects of evaporative cold seem to be very significant. This could be demonstrated by moistening cavity walls in patients as well as in model experiments. The conclusion to keep the cavity walls as dry as possible is already a clinical demand. In this paper, the physical background and the dimensions of thermal effects during suction-cleaning could be elucidated.

[Danger from exploding fireworks and blank firearms]

Explosive amusement and deterrent articles such as New Year's Eve cannons and rockets, toy pistols, and blank guns are not at all harmless items. Their potential dangerousness is often extremely underestimated. Two damaging mechanisms are important: during explosions, high pressures and temperatures develop and a considerable sound pressure level can be measured. If the explosion happens near the human body (intentionally or inadvertently), not only superficial lesions can occur, but also (mainly due to contact shots) serious, deep-seated tissue damage, especially in the head and neck region with its endangered sense organs such as eye and ear, the vessels and nerves supplying the brain, the speech- and voice-forming apparatus, and in particular the face, can be the consequence. Their mutilation can lead to serious and extensive interpersonalchanges. Accidents are published in the relevant otological and forensic medical papers, but nevertheless it seems important to us to point out the dangerousness of these readily available items.

[100 years of the Otto Körner ENT Clinic, Rostock. The merits of Christian Lemcke and Otto Körner in the development of ENT specialty]

BACKGROUND

The first special ENT hospital in Germany and northern Europe, the Department of Otorhinolaryngology, Head- and Neck-Surgery "Otto Körner" in Rostock is celebrating its 100th anniversary on October 25, 1999.

METHODS

There is a presentation on the efforts in the ENT-specialty from the beginning considering the special situation at the university of Rostock.

RESULTS

The efforts of Christian Lemcke (1850-1894), who associated the three sections Otology, Laryngology and Rhinology are appreciated, Otto Körner (1859-1935) continued this development. He achieved the building of a special ENT-hospital by his excellent knowledge and surgical skills. The opening date was October 25, 1899, Körner became the first full professor in Otology and Laryngology in Germany in 1901. His "Textbook Of Otology And It's Bordering Specialties" was published in 1906. As one of the first, he supported the independence of ENT-medicine as a separate field in the course of medicine.

CONCLUSION

Today, Otto Körner's claims are more relevant than ever before, because the today's students in their practical course of medicine and even young doctors at the hospitals obviously show a lack of knowledge in the ENT-field. The current "multiple choice" type of examinations could be one of the main reasons.

Inner ear damage in TORP-operated ears: experimental study on danger from environmental air pressure changes

In some cases of sudden inner ear hearing loss in ears with a total ossicular replacement prosthesis, the prosthesis has been found to be penetrating the footplate. Some authors have assumed an external pressure increase for this event. In this study I tried to estimate experimentally the pressure needed for perforating a normal footplate in a temporal bone model. From the data I concluded that "cracking" the footplate can hardly be due to 1 major event of increased pressure. On the other hand, different mechanisms making the footplate a "weak spot" must be discussed and further investigated. In those cases, secondary to thinned or even perforated footplates, environmental pressure changes may be dangerous.

[The "ear fever thermometer"--studies of ear thermography]

BACKGROUND

Though rarely mentioned in the ENT literature, the "ear thermometer" has become more and more popular in recent years, not only in hospitals but also in households. These instruments are easy to use, and their infrared technology is said to provide precise measurements. The purpose of this study was to verify these claims.

PATIENTS AND METHODS

Infrared thermometers were tested in various conditions, and the results were compared. We assessed the effects of "distending" the outer ear canal, different body positions, and irritation of the ear (slight external otitis, hearing aids, otitis media, etc.). We did not specifically test effects of ear wax, as it had sufficiently been studied in pediatric or anesthesiological papers before (almost no effect, except in cases of occlusion of the auditory canal).

RESULTS

Using the ear thermometer we found small but statistically significant differences in febrile patients in different body positions. Irritated ears always showed higher temperatures than the normal contralateral ears. The most significant differences were found in persons lying on one side. The "pillow ear" was found 0.7 degree C (average) warmer than the contralateral ear.

CONCLUSIONS

Ear thermometers for estimating the body temperature permit easy and fast measurements. However, they include possible sources of measurement error. This study describes possible errors that the therapists should be aware of to avoid misinterpreting the course of a disease.