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Lill C, Erovic BM, Seemann R, Faisal M, Stelter K, Gandler B, Frommlet F, Strobl A, Formanek M, Janik S. The role of elective neck dissection in T1 and T2 nasal cavity squamous cell carcinomas. Eur Arch Otorhinolaryngol 2023; 280:1875-1883. [PMID: 36342517 PMCID: PMC9988772 DOI: 10.1007/s00405-022-07718-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/23/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE To evaluate the role of elective neck dissection (END) on oncological outcome in early-stage nasal cavity squamous cell carcinomas (SCCs). METHODS In total, 87 patients with T1 (n = 59; 67.8%) and T2 (n = 28; 32.2%) SCCs were evaluated regarding performance of END, regional recurrences (RR) and its impact on cancer-specific survival (CSS). We further created a risk score based on T-classification, tumor subsite and grading to identify patients whom may benefit from END and calculated the corresponding numbers needed to treat (NNT) to prevent RR. RESULTS Nine (10.3%) patients experienced RR of whom 3 (5.1%) were T1 and 6 (21.4%) T2 tumors (p = 0.042). All RR originated from moderately or poorly differentiated (G2-G3) SCCs of the nasal septum or vestibule. END was done in 15 (17.2%) patients and none of those experienced RR (p = 0.121). Onset of RR represented the worst prognostic factor for CSS (HR 23.3; p = 0.007) with a 5y-CSS of 44.4% vs. 97.3% (p < 0.001). RR occurred in none of the patients with no or low risk scores compared to 31.6% (6/19) in patients with high-risk scores (p = 0.006). Accordingly, three high-risk patients would need to undergo END (NNT 2.63) to prevent RR compared to a NNT of 8 for the whole cohort. CONCLUSIONS Although rare, occurrence of RR significantly deteriorates outcome in early stage nasal cavity SCCs, which could be effectively reduced by performance of END. The importance of END is currently underestimated and our proposed risk score helps identifying those patients who will benefit from END.
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Affiliation(s)
- Claudia Lill
- Institute of Head and Neck Diseases, Evangelical Hospital, Vienna, Austria
| | - Boban M Erovic
- Institute of Head and Neck Diseases, Evangelical Hospital, Vienna, Austria
| | - Rudolf Seemann
- Institute of Head and Neck Diseases, Evangelical Hospital, Vienna, Austria
| | - Muhammad Faisal
- Institute of Head and Neck Diseases, Evangelical Hospital, Vienna, Austria
| | | | - Bernd Gandler
- Department of Otorhinolaryngology, Head and Neck Surgery, Clinic Klagenfurt, Klagenfurt, Austria
| | - Florian Frommlet
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Andreas Strobl
- Department of Otorhinolaryngology, Head and Neck Surgery, Ordensklinikum Linz, Linz, Austria
| | - Michael Formanek
- Department of Otorhinolaryngology and Phonetics, Hospital of St. John of God, Vienna, Austria
- Medical School, Sigmund Freud University, Vienna, Austria
| | - Stefan Janik
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria.
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Strassen U, Bas M, Wirth M, Wirth M, Gröger M, Stelter K, Volkenstein S, Kehl V, Kojda G, Hoffmann TK, Hahn J, Trainotti S, Greve J. Efficacy of human C1 esterase inhibitor concentrate for treatment of ACE-inhibitor induced angioedema. Am J Emerg Med 2023; 64:121-128. [PMID: 36516670 DOI: 10.1016/j.ajem.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/21/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND ACE inhibitor (ACEi) induced angioedema predominantly affects the upper aerodigestive tract. As ACEi induced angioedema is mediated by bradykinin, therapeutic response to antihistamines and glucocorticoids remains unsatisfactory. In bradykinin mediated hereditary angioedema, C1-esterase inhibitor (C1INH) is an effective and approved treatment since many years. Our aim was to evaluate the therapeutic effect of C1INH in ACEi induced angioedema. METHODS We performed a double-blind, parallel-group, multicentre randomised placebo-controlled trial between December 2013 and September 2018. Eligible were adults with ACEi induced angioedema with airway obstruction. Participants were randomised 1:1 to single doses of either C1INH (20 IU/kg) or placebo (0.9% NaCl) i.v in addition to standard care (i.v. 500 mg prednisolone and 2.68 mg clemastine) i.v. Composite symptom scores were assessed at baseline and up to 48 h, at discharge and 1 week after discharge. Physician assessed time to complete oedema resolution (TCER) and time to onset of relief (TOR). RESULTS 30 patients (16 C1INH, 14 placebo) were randomised and dosed. 25 (9 C1INH, 12 placebo) completed the study. TCER was 29.63 h ± 15.56 h in the C1INH and 17.29 h ± 10.40 h in the placebo arm (p = 0.0457). TORs were 4.13 h ± 3.38 h and 2.86 h ± 1.29 h for C1INH and placebo, respectively (p = 0.4443). There were no adverse events related to study medication. CONCLUSIONS In the context of baseline application of steroids and antihistamines C1INH was inferior in the treatment of ACEi induced angioedema when compared to placebo with respect to time to complete resolution of symptoms. Eudra-CT Number: 2012-001670-28.
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Affiliation(s)
- Ulrich Strassen
- Department of Otorhinolaryngology, Klinikum rechts der Isar, Technische Universität München, Germany.
| | - Murat Bas
- Department of Otorhinolaryngology, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Magdalena Wirth
- Department of Otorhinolaryngology, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Markus Wirth
- Department of Otorhinolaryngology, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Moritz Gröger
- Department of Otorhinolaryngology, Grosshadern Medical Center of the University of Munich, Germany
| | - Klaus Stelter
- Department of Otorhinolaryngology, Grosshadern Medical Center of the University of Munich, Germany
| | - Stefan Volkenstein
- Department of Otorhinolaryngology, Ruhr-University of Bochum, St. Elisabeth-Hospital Bochum, Germany
| | - Victoria Kehl
- Munich Study Center, Faculty of Medicine, Technical University Munich, Germany; Institute for AI and Informatics in Medicine, Faculty of Medicine, Technical University Munich, Germany
| | - Georg Kojda
- Institute of Pharmacology and Clinical Pharmacology, University Hospital Düsseldorf, Düsseldorf (G.K.), Germany
| | - Thomas K Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University, Medical Center, Ulm, Germany
| | - Janina Hahn
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University, Medical Center, Ulm, Germany
| | - Susanne Trainotti
- Department of Otorhinolaryngology, Klinikum rechts der Isar, Technische Universität München, Germany; Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University, Medical Center, Ulm, Germany
| | - Jens Greve
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University, Medical Center, Ulm, Germany
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Kisser U, Lill C, Adderson-Kisser C, Patscheider M, Stelter K. Total versus subtotal tonsillectomy for recurrent tonsillitis - a prospective randomized noninferiority clinical trial. Acta Otolaryngol 2020; 140:514-520. [PMID: 32049573 DOI: 10.1080/00016489.2020.1725112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: For many years experts have called for randomized controlled trials to resolve the question whether tonsillectomy, which is associated with significant comorbidity, can be replaced by partial tonsillectomy in patients with recurrent tonsillitis.Objective: To find out whether subtotal tonsillectomy is a suitable therapeutic alternative to total tonsillectomy in adult patients with recurrent episodes of acute tonsillitis.Material and methods: Study design - Single-blind prospective non-inferiority randomized clinical trial with intraindividual design. Setting - 80 patients were recruited at a tertiary referral center. Subjects - Adult patients with recurrent tonsillitis received total tonsillectomy on one side and subtotal tonsillectomy on the other side after randomization. Main outcome measure was frequency of postoperative tonsillitis on the side of subtotal tonsillectomy and postoperative pharyngitis in the former tonsil area on the side of total tonsillectomy. The study was registered in the German Clinical Trials Register (DRKS-ID: DRKS00015628).Results: Within 12 months none of the subjects suffered from recurrent tonsillitis after subtotal tonsillectomy. Subtotal tonsillectomy caused less pain than total tonsillectomy.Conclusion: Subtotal tonsillectomy might be an alternative treatment option associated with lower morbidity than total tonsillectomy in adults with recurrent tonsillitis.
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Affiliation(s)
- Ulrich Kisser
- Department of Otorhinolaryngology, Head and Neck Surgery, University Clinic Halle, Halle, Germany
| | - Claudia Lill
- Department of Otorhinolaryngology, Head and Neck Surgery, Evangelical Hospital, Vienna, Austria
| | | | - Martin Patscheider
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Munich, Munich, Germany
| | - Klaus Stelter
- ENT, Head and Neck Surgery, ENT Center Mangfall-Inn, Rosenheim, Germany
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San Nicoló M, Stelter K, Sadick H, Bas M, Berghaus A. A 2-Year Follow-up Study of an Absorbable Implant to Treat Nasal Valve Collapse. Facial Plast Surg 2018; 34:545-550. [PMID: 30227454 DOI: 10.1055/s-0038-1672213] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
The safety and effectiveness of an absorbable implant for lateral cartilage support have been recently demonstrated in subjects with nasal valve collapse (NVC) at 12 months postprocedure. This follow-up study aimed to assess whether the safety and effectiveness of the implant persist in these patients for 24 months after the procedure. Thirty subjects with Nasal Obstruction Symptom Evaluation (NOSE) score ≥ 55 and isolated NVC were treated; 14 cases were performed in an operating suite under general anesthesia and 16 cases were performed in a clinic-based setting under local anesthesia. The implant, a polylactic acid copolymer, was placed with a delivery tool within the nasal wall to provide lateral cartilage support. Subjects were followed up through 24 months postprocedure. Fifty-six implants were placed in 30 subjects. The mean preoperative NOSE score was 76.7 ± 14.8, with a range of 55 to 100. At 24 months, the mean score was 32.0 ± 29.3, reflecting an average within-patient reduction of -44.0 ± 31.1 points. There were no device-related adverse events in the 12 to 24 months period. There were five subjects who exited the study prior to the 24-month follow-up. Four of the five subjects who exited were elected for further intervention and one subject was lost to follow-up. This study demonstrates safety of an absorbable implant for lateral nasal wall support and symptom improvement in some subjects with NVC at 24 months postprocedure.
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Affiliation(s)
- Marion San Nicoló
- Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilian University of Munich, Munich, Germany
| | | | - Haneen Sadick
- Division of Facial Plastic Surgery, Department of Otorhinolaryngology, University of Mannheim, Mannheim, Germany
| | - Murat Bas
- Private Practice, Ottobrunn, Germany
| | - Alexander Berghaus
- Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilian University of Munich, Munich, Germany
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Abstract
SummaryBleeding after ear-nose-and throat surgery in children is a serious complication. With the help of the German Surveillance Unit for Rare Paediatric Disorders (Erhebungseinheit für seltene pädiatrische Erkrankungen in Deutschland; ESPED) a two year survey was performed to record the incidence, severity, reasons and treatment of haemorrhages. During the study period, 1069 bleeds were reported from 720 paediatric hospitals and departments of otorhinolaryngology after adenoidectomy and tonsillectomy. 713 reports could be analyzed. Two deaths occurred after adenoidectomy. Although laboratory screening was performed in more than 70% of all cases, bleeding complications were neither foreseeable nor preventable. Inherited coagulopathies were rare and in most cases not detected, neither by laboratory screening nor by taking a history. Since preoperative measures cannot help much to improve the situation, all efforts have to be taken to improve the postoperative period, especially since more than 20% of the hemorrhages occurred during weekends. Guidelines on postoperative care and behaviour should therefore be implemented and parents and patients must be informed on bleeding risks and on what to do in case of emergency. If bleeding occurs, extensive coagulation testing is mandatory.
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Abstract
OBJECTIVES The objective of this study is to determine whether partial tonsillectomy (tonsillotomy) impacts the occurrence of acute or recurrent tonsillitis in children. METHODS One hundred and eighty patients (1-14 years) were retrospectively surveyed by a questionnaire or by data analysis of a regional database. Subjects who suffered from severe systemic diseases or immunodeficiency syndromes were excluded. Episodes of acute tonsillitis before and after surgery, rate of antibiotic treatment, postoperative hemorrhage, and re-operation were obtained. RESULTS Fifty-one patients suffered from preoperative tonsillitis. The rate of reinfection was 9.8%. The frequency of tonsillitis was significantly reduced in children after tonsillotomy (p < .001). Further, tonsillotomy led to a significant reduction of antibiotic treatment (p < .001). The rate of definitive tonsillectomy was 1.1% and thus effectiveness was very high. About 1.7% of all children suffered from postoperative bleeding, of which one (0.6%) required surgical revision. None of the bleedings was life threatening. CONCLUSIONS Tonsillotomy is beneficial for patients with recurrent tonsillitis and carries less risk of postoperative complications than tonsillectomy.
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Affiliation(s)
- Elisabeth Foki
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Rudolf Seemann
- Department of Oral and Maxillofacial Surgery, Medical University of Vienna, Vienna, Austria
| | - Klaus Stelter
- Department of Head and Neck Surgery, ENT Centre Mangfall-Inn, RoMed Clinic Bad Aibling, Rosenheim, Germany
| | - Claudia Lill
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
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Kisser U, Stelter K, Gürkov R, Patscheider M, Schrötzlmair F, Bytyci R, Adderson-Kisser C, Berghaus A, Olzowy B. Diode laser versus radiofrequency treatment of the inferior turbinate - a randomized clinical trial. Rhinology 2017. [PMID: 25479227 DOI: 10.4193/rhin14.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Laser and radiofrequency induced volume reduction of the inferior turbinates are frequently used treatment modalities. Which of both is superior, however, is not clear to date due to a lack of controlled prospective studies. Here, we compare both methods regarding improvement of nasal breathing, complications, patient comfort and wound healing. METHODOLOGY Prospective, randomized, single-blinded clinical trial with intra-individual design. After randomization, one side of the nose was treated with a 940nm diode laser and the other side with bipolar radiofrequency therapy. Pre- and postoperative evaluation was performed using visual analogue scales, nasal endoscopy and objective measurements of nasal patency. RESULTS Of 27 enrolled patients, 26 completed the protocol. No severe complications were observed. Intraoperative discomfort was significantly more severe on the radiofrequency side. After three months, a significant reduction of nasal obstruction was observed for laser treatment and radiofrequency therapy with no significant difference between them. Objective parameters did not improve significantly. When asked which treatment modality they would chose again 50 % of the patients decided for radiofrequency treatment, 23 % for laser treatment, and 19 % for both. CONCLUSION DLVR and RFVR are well-tolerated treatment modalities and both significantly reduce the degree of nasal obstruction in patients with hypertrophic inferior turbinates. There was no significant difference between both treatment modalities regarding efficiency.
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San Nicoló M, Stelter K, Sadick H, Bas M, Berghaus A. Erratum: Absorbable Implant to Treat Nasal Valve Collapse. Facial Plast Surg 2017; 33:353-354. [PMID: 28571076 DOI: 10.1055/s-0037-1603201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Marion San Nicoló
- Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilian University of Munich, Munich, Germany
| | | | - Haneen Sadick
- Division of Facial Plastic Surgery, Department of Otorhinolaryngology, University of Mannheim, Mannheim, Germany
| | - Murat Bas
- Department of Otorhinolaryngology, Head and Neck Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Alexander Berghaus
- Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilian University of Munich, Munich, Germany
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Ledderose GJ, Stelter K, Betz CS, Englhard AS, Ledderose C, Leunig A. Cerebrospinal fluid leaks during endoscopic sinus surgery in thirty-two patients. Clin Otolaryngol 2017; 42:1105-1108. [PMID: 28317322 DOI: 10.1111/coa.12870] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 11/29/2022]
Affiliation(s)
- G J Ledderose
- Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilians University Munich, Germany
| | - K Stelter
- Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilians University Munich, Germany.,ENT-Center Mangfall-Inn, Rosenheim, Germany
| | - C S Betz
- Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilians University Munich, Germany
| | - A S Englhard
- Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilians University Munich, Germany
| | - C Ledderose
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - A Leunig
- Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilians University Munich, Germany.,Rhinology Center, ENT-Clinic Munich Bogenhausen, Dr. Gaertner GmbH, Munich, Germany
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Abstract
Objective To evaluate the safety and effectiveness of an absorbable implant for lateral cartilage support in subjects with nasal valve collapse (NVC) with 12 months follow-up. Methods Thirty subjects with Nasal Obstruction Symptom Evaluation (NOSE) score ≥ 55 and isolated NVC were treated; 14 cases were performed in an operating suite under general anesthesia and 16 cases were performed in a clinic-based setting under local anesthesia. The implant, a polylactic acid copolymer, was placed with a delivery tool within the nasal wall to provide lateral cartilage support. Subjects were followed up through 12 months postprocedure. Results Fifty-six implants were placed in 30 subjects. The mean preoperative NOSE score was 76.7 ± 14.8, with a range of 55 to 100. At 12 months, the mean score was 35.2 ± 29.2, reflecting an average within-patient reduction of -40.9 ± 31.2 points. The majority (76%) of the subjects were responders defined as having at least one NOSE class improvement or a NOSE score reduction of at least 20%. There were no adverse changes in cosmetic appearance at 12 months postprocedure. Three implants in three subjects required retrieval within 30 days postprocedure and resulted in no clinical sequelae. Conclusion This study demonstrates safety and effectiveness of an absorbable implant for lateral cartilage support in subjects with NVC at 12 months postprocedure.
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Affiliation(s)
- Marion San Nicoló
- Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilian University of Munich, Munich, Germany
| | | | - Haneen Sadick
- Division of Facial Plastic Surgery, Department of Otorhinolaryngology, University of Mannheim, Mannheim, Germany
| | - Murat Bas
- Department of Otorhinolaryngology, Head and Neck Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Alexander Berghaus
- Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilian University of Munich, Munich, Germany
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Braun C, Kisser U, Huber A, Stelter K. Bystander cricothyroidotomy with household devices – A fresh cadaveric feasibility study. Resuscitation 2017; 110:37-41. [DOI: 10.1016/j.resuscitation.2016.10.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/18/2016] [Accepted: 10/09/2016] [Indexed: 11/17/2022]
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Kisser U, Braun C, Huber A, Stelter K. Bystander cricothyrotomy with ballpoint pen: a fresh cadaveric feasibility study. Emerg Med J 2016; 33:553-6. [DOI: 10.1136/emermed-2015-205659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 03/19/2016] [Indexed: 11/04/2022]
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Strassen U, Greve J, Stelter K, Havel M, Rotter N, Veit J, Schossow B, Hapfelmeier A, Kehl V, Kojda G, Hoffmann TK, Bas M. A Randomized Trial of Icatibant in ACE-Inhibitor–Induced Angioedema. J Allergy Clin Immunol 2016. [DOI: 10.1016/j.jaci.2015.12.979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Holzer M, Thon N, Stelter K, Rachinger W, Betz CS. Intracranial and intradural nasal polyposis after iatrogenic skull base defect: A case report. Br J Neurosurg 2016; 31:379-381. [PMID: 26761416 DOI: 10.3109/02688697.2015.1122173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We report the first case of an intracranial and intradural nasal polyposis occurring in a close topographical relation to a previous, iatrogenic anterior skull base defect. The tumour was resected and the skull base defect was closed transnasally by an interdisciplinary team. The histopathological report confirmed recurrent polyposis.
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Affiliation(s)
- Martin Holzer
- a Department of Otorhinolaryngology , Head & Neck Surgery, University of Munich, Campus Grosshadern , Munich , Germany
| | - Niklas Thon
- b Department of Neurosurgery , University of Munich, Campus Grosshadern , Munich , Germany
| | - Klaus Stelter
- a Department of Otorhinolaryngology , Head & Neck Surgery, University of Munich, Campus Grosshadern , Munich , Germany
| | - Walter Rachinger
- b Department of Neurosurgery , University of Munich, Campus Grosshadern , Munich , Germany
| | - Christian Stephan Betz
- a Department of Otorhinolaryngology , Head & Neck Surgery, University of Munich, Campus Grosshadern , Munich , Germany
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Baş M, Greve J, Stelter K, Havel M, Strassen U, Rotter N, Veit J, Schossow B, Hapfelmeier A, Kehl V, Kojda G, Hoffmann TK. A randomized trial of icatibant in ACE-inhibitor-induced angioedema. N Engl J Med 2015; 372:418-25. [PMID: 25629740 DOI: 10.1056/nejmoa1312524] [Citation(s) in RCA: 145] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Angioedema induced by treatment with angiotensin-converting-enzyme (ACE) inhibitors accounts for one third of angioedema cases in the emergency room; it is usually manifested in the upper airway and the head and neck region. There is no approved treatment for this potentially life-threatening condition. METHODS In this multicenter, double-blind, double-dummy, randomized phase 2 study, we assigned patients who had ACE-inhibitor-induced angioedema of the upper aerodigestive tract to treatment with 30 mg of subcutaneous icatibant, a selective bradykinin B2 receptor antagonist, or to the current off-label standard therapy consisting of intravenous prednisolone (500 mg) plus clemastine (2 mg). The primary efficacy end point was the median time to complete resolution of edema. RESULTS All 27 patients in the per-protocol population had complete resolution of edema. The median time to complete resolution was 8.0 hours (interquartile range, 3.0 to 16.0) with icatibant as compared with 27.1 hours (interquartile range, 20.3 to 48.0) with standard therapy (P=0.002). Three patients receiving standard therapy required rescue intervention with icatibant and prednisolone; 1 patient required tracheotomy. Significantly more patients in the icatibant group than in the standard-therapy group had complete resolution of edema within 4 hours after treatment (5 of 13 vs. 0 of 14, P=0.02). The median time to the onset of symptom relief (according to a composite investigator-assessed symptom score) was significantly shorter with icatibant than with standard therapy (2.0 hours vs. 11.7 hours, P=0.03). The results were similar when patient-assessed symptom scores were used. CONCLUSIONS Among patients with ACE-inhibitor-induced angioedema, the time to complete resolution of edema was significantly shorter with icatibant than with combination therapy with a glucocorticoid and an antihistamine. (Funded by Shire and the Federal Ministry of Education and Research of Germany; ClinicalTrials.gov number, NCT01154361.).
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Affiliation(s)
- Murat Baş
- From the Department of Otorhinolaryngology (M.B., U.S.), Münchner Studienzentrum (B.S.), and Institut für Medizinische Statistik und Epidemiologie (A.H., V.K.), Klinikum rechts der Isar, Technische Universität München, and the Department of Otorhinolaryngology, Grosshadern Medical Center of the University of Munich (K.S., M.H.), Munich, the Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm ( J.G., N.R., J.V., T.K.H), and the Institute of Pharmacology and Clinical Pharmacology, University Hospital Düsseldorf, Düsseldorf (G.K.) - all in Germany
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Kisser U, Stelter K, Gürkov R, Patscheider M, Schrötzlmair F, Bytyci R, Adderson-Kisser C, Berghaus A, Olzowy B. Diode laser versus radiofrequency treatment of the inferior turbinate - a randomized clinical trial. Rhinology 2014; 52:424-30. [PMID: 25479227 DOI: 10.4193/rhino14.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Laser and radiofrequency induced volume reduction of the inferior turbinates are frequently used treatment modalities. Which of both is superior, however, is not clear to date due to a lack of controlled prospective studies. Here, we compare both methods regarding improvement of nasal breathing, complications, patient comfort and wound healing. METHODOLOGY Prospective, randomized, single-blinded clinical trial with intra-individual design. After randomization, one side of the nose was treated with a 940nm diode laser and the other side with bipolar radiofrequency therapy. Pre- and postoperative evaluation was performed using visual analogue scales, nasal endoscopy and objective measurements of nasal patency. RESULTS Of 27 enrolled patients, 26 completed the protocol. No severe complications were observed. Intraoperative discomfort was significantly more severe on the radiofrequency side. After three months, a significant reduction of nasal obstruction was observed for laser treatment and radiofrequency therapy with no significant difference between them. Objective parameters did not improve significantly. When asked which treatment modality they would chose again 50 % of the patients decided for radiofrequency treatment, 23 % for laser treatment, and 19 % for both. CONCLUSION DLVR and RFVR are well-tolerated treatment modalities and both significantly reduce the degree of nasal obstruction in patients with hypertrophic inferior turbinates. There was no significant difference between both treatment modalities regarding efficiency.
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Abstract
Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy. On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age. The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery. The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes. All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All "hot" techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage. Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.
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Affiliation(s)
- Klaus Stelter
- Dep. of Otorhinolaryngology, Head and Neck Surgery, Grosshadern Medical Centre, University of Munich, Munich, Germany
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19
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Kisser U, Ertl-Wagner B, Hempel JM, Müller J, D'Anastasi M, Schrötzlmair F, Adderson-Kisser C, Laubender RP, Stelter K, Braun C, Pomschar A. High-resolution computed tomography-based length assessments of the cochlea--an accuracy evaluation. Acta Otolaryngol 2014; 134:1011-5. [PMID: 25220722 DOI: 10.3109/00016489.2014.913313] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
CONCLUSION The length of the cochlea can be determined with good precision using a 3D-curved multiplanar reconstruction analysis technique and linear reconstruction of the cochlea. The method is not time-consuming and can be applied during clinical routine. OBJECTIVE A preoperative prediction of the best cochlear implant electrode length can help reduce the risk of intraoperative cochlear trauma in patients who need to retain residual acoustic hearing for electric-acoustic stimulation or in patients with anatomical anomalies or malformations. The goal of this study was to evaluate the accuracy and reliability of length measurement of the cochlea after linear reconstruction using 3D-curved multiplanar reconstrucion analysis of high resolution computed tomography (CT) scans. METHODS Human cadaveric temporal bone specimens underwent cochlear implantation using custom-made electrodes with two radiopaque markers of a defined length before CTscans were made. Length measurement was performed by four readers and the results were compared to the true value. Inter-reader reliability was calculated. The time needed for analysis was recorded. RESULTS The mean time needed for analysis of one specimen's radiologic data was 6.1 (± 3.4) min. The mean deviation of the length measurement from the true value was 0.8 (± 0.7) mm. Inter-reader reliability was excellent (0.76, p = 0.006).
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Affiliation(s)
- Ulrich Kisser
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Munich
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20
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Olzowy B, Abendroth S, von Gleichenstein G, Mees K, Stelter K. No Evidence of Intracranial Hypertension in Trekkers with Acute Mountain Sickness When Assessed Noninvasively with Distortion Product Otoacoustic Emissions. High Alt Med Biol 2014; 15:364-70. [DOI: 10.1089/ham.2013.1120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Bernhard Olzowy
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Rostock Medical Center, Rostock, Germany
| | | | | | - Klaus Mees
- Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilians University of Munich Medical Center, München, Germany
| | - Klaus Stelter
- Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilians University of Munich Medical Center, München, Germany
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21
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Zesewitz P, Stelter K. [Adeno-tonsillectomy in children: preoperative coagulation screening and bleeding complications]. Laryngorhinootologie 2014; 93:528-34. [PMID: 25073023 DOI: 10.1055/s-0034-1372601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND In 2006 German medical societies published recommendations: Before carrying out an adenoidectomy and/or a tonsillectomy in childhood a specific bleeding-anamnesis should be performed instead of a laboratory coagulation screening in order to determine a clinically relevant bleeding disorder. In the context of this survey it was investigated how many of the Bavarian ENT physicians in private practice had implemented these recommendations and what experiences they made with them. In addition, further data such as the number of performed operations and occurred bleeding complications were collected. METHOD Between 2009 and 2010 a prepared questionnaire was sent to all Bavarian ENT physicians, who were in private practice. If even after further sent covering letters no reply was received they were contacted by telephone. The analysis period was 2008. RESULTS In total 601 ENT physicians were contacted, whereas 495 valid replies could be obtained (rate of valid return>80%). 325 (66%) of these performed surgery in 2008, but only one of 3 of these operating ENT physicians had completely implemented the recommendations. The rate of postoperative bleeding complications following tonsillectomy was 1.80%, following adenoidectomy 0.30%. A significant difference in the postoperative bleeding rate between those, who had implemented the recommendations and those, who had not, could not be shown. But a highly significant difference favouring the surgeons, who quantitatively had performed more tonsillectomies could be revealed. CONCLUSION The results of this retrospective survey support the recommendations given by German medical societies.
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Affiliation(s)
- P Zesewitz
- Klinik und Poliklinik für Innere Medizin A, Universitätsmedizin Greifswald, Greifswald
| | - K Stelter
- Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Klinikum der Ludwig-Maximilians-Universität München, München
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Havel M, Ertl L, Bauer D, Schuster M, Stelter K, Sundberg J. Resonator properties of paranasal sinuses: preliminary results of an anatomical study. Rhinology 2014; 52:178-82. [PMID: 24932632 DOI: 10.4193/rhino13.097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The contribution of the nasal and paranasal cavities to vocal tract resonator properties is unclear as are voice effects of sinus surgery. Here we investigate resonance phenomena of paranasal sinuses with and without selective occlusion of the middle meatus and maxillary ostium in a cadaver. METHODOLOGY Nasal and paranasal cavities of a Thiel-embalmed cadaver were excited by sine-tone sweeps from an earphone in the epipharynx. The response was picked up by a microphone at the nostrils. Different conditions with blocked and unblocked middle meatus were tested. Additionally, infundibulotomy was performed allowing direct access to and selective occlusion of the maxillary ostium. RESULTS Responses showed high reproducibility. Minor effects appeared after removal of meatal occlusion. A marked low frequency dip was detected after removal of occlusion of maxillary ostium following infundibulotomy. CONCLUSION Reproducible frequency responses of nasal tract can be derived from cadaver measurements. Marked acoustic effects of the maxillary sinus appeared only after direct exposure of the maxillary ostium following infundibulotomy.
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Theodoraki MN, Ledderose GJ, Becker S, Leunig A, Arpe S, Luz M, Stelter K. Mental distress and effort to engage an image-guided navigation system in the surgical training of endoscopic sinus surgery: a prospective, randomised clinical trial. Eur Arch Otorhinolaryngol 2014; 272:905-913. [PMID: 25007736 DOI: 10.1007/s00405-014-3194-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 07/01/2014] [Indexed: 11/25/2022]
Abstract
The use of image-guided navigation systems in the training of FESS is discussed controversy. Many experienced sinus surgeons report a better spatial orientation and an improved situational awareness intraoperatively. But many fear that the navigation system could be a disadvantage in the surgical training because of a higher mental demand and a possible loss of surgical skills. This clinical field study investigates mental and physical demands during transnasal surgery with and without the aid of a navigation system at an early stage in FESS training. Thirty-two endonasal sinus surgeries done by eight different trainee surgeons were included. After randomization, one side of each patient was operated by use of a navigation system, the other side without. During the whole surgery, the surgeons were connected to a biofeedback device measuring the heart rate, the heart rate variability, the respiratory frequency and the masticator EMG. Stress situations could be identified by an increase of the heart rate frequency and a decrease of the heart rate variability. The mental workload during a FESS procedure is high compared to the baseline before and after surgery. The mental workload level when using the navigation did not significantly differ from the side without using the navigation. Residents with more than 30 FESS procedures already done, showed a slightly decreased mental workload when using the navigation. An additional workload shift toward the navigation system could not be observed in any surgeon. Remarkable other stressors could be identified during this study: the behavior of the supervisor or the use of the 45° endoscope, other colleagues or students entering the theatre, poor vision due to bleeding and the preoperative waiting when measuring the baseline. The mental load of young surgeons in FESS surgery is tremendous. The application of a navigation system did not cause a higher mental workload or distress. The device showed a positive effort to engage for the trainees with more than 30 FESS procedures done. In this subgroup it even leads to decreased mental workload.
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Affiliation(s)
- M N Theodoraki
- Department of Otorhinolaryngology Head and Neck Surgery, University of Ulm, University Clinic of Ulm, Ulm, Germany.
| | - G J Ledderose
- Department of Otorhinolaryngology Head and Neck Surgery, Ludwig Maximilians University, Munich, Germany
| | - S Becker
- Department of Otorhinolaryngology Head and Neck Surgery, Ludwig Maximilians University, Munich, Germany
| | - A Leunig
- Clinics and Private Practice Dr. Gärtner, Munich, Germany
| | - S Arpe
- Department of Otorhinolaryngology Head and Neck Surgery, Ludwig Maximilians University, Munich, Germany
| | - M Luz
- Industrial, Engineering and Organisational Psychology of the Technical University, Berlin, Germany
| | - K Stelter
- Department of Otorhinolaryngology Head and Neck Surgery, Ludwig Maximilians University, Munich, Germany
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Stelter K, Theodoraki MN, Becker S, Tsekmistrenko V, Olzowy B, Ledderose G. Specific stressors in endonasal skull base surgery with and without navigation. Eur Arch Otorhinolaryngol 2014; 272:631-8. [PMID: 24972542 DOI: 10.1007/s00405-014-3154-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 06/12/2014] [Indexed: 10/25/2022]
Abstract
The goal of modern organizational psychology is to recognize, anticipate and finally avoid stress situations. The aim of this study was to measure objectively the mental and physical demands during transnasal surgery with and without the aid of a navigation system. Forty endonasal surgeries (20 with and 20 without navigation, not blinded and not randomized) done by four different experienced rhinosurgeons (>250 FESS procedures done) were included. The heart rate, the heart rate variability, the respiratory frequency and the masseter tone were monitored as biometrical parameters by the surgeons during the whole surgery for the quantification of mental demand. Stress situations could be identified during the procedures by an increase in the heart rate and a decrease in the heart rate variability. Stress level in procedures with navigation did not significantly differ from procedures without navigation. Interestingly, in 10 % of the cases a navigation system would have been helpful, although the surgeon stated before the procedure that such a system would not be necessary. Other stressors could be identified like time pressure, students or colleagues speaking with the surgeon or chatting in the OR and system failure of medical devices, i.e. navigation, sinus drill, electrocautery or shaver. Surgical stressors blurred vision due to diffuse bleeding and drill out procedures in the sphenoid sinus. Calming situations were a quiet atmosphere in the OR (i.e. closed doors) and the participation of another experienced colleague, especially a neurosurgeon. Stress situations occur when complex medical devices like the navigation do not work. For their proper function it is important that the whole OR-team is trained with it. Unqualified or unmotivated OR personnel create stress for the surgeon and disharmony in the team, which then ends in inadequate behaviour.
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Affiliation(s)
- K Stelter
- Department of Otorhinolaryngology, Ludwig Maximilians University, Munich, Germany,
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25
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Abstract
Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcome after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy slowly change in Germany since that. However, there exist no national guidelines and the frequency of tonsil surgery varies in the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under 6 years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i. e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (= tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of the healthy children bear even streptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for 3 to 5 days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy to the standard 10 days therapy, as well. On the other hand, only the 10 days antibiotic therapy has prooven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100.000 children in school age. The main morbidity after tonsillectomy is pain and the late hemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after 3 weeks. Life-threatening hemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every hemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behavior in case of hemorrhage with a written consent before the surgery. The handout should contain important adresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of hemorrhage. Especially in small children hemorrhage can be life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive hemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate unflexible suction tubes. All different surgical techniques have the risk of hemorrhage and even the best surgeon will experience a postoperative hemorrhage. The lowest risk of hemorrhage is after cold dissection with ligature or suturing. All "hot" techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late hemorrhage. Children with a hereditary coagulopathy have a higher risk of hemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-points-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these test are inappropiate and incapable of detecting the von Willebrand disease, which is the most often coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.
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Affiliation(s)
- K Stelter
- Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Klinikum der Universität München
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26
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Havel M, Ertl L, Bauer D, Schuster M, Stelter K, Sundberg J. Resonator properties of paranasal sinuses: preliminary results of an anatomical study. Rhinology 2014. [DOI: 10.4193/rhin13.097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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27
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Stelter K. [Indications and methods of tonsil surgery]. MMW Fortschr Med 2013; 155:39-42. [PMID: 23930419 DOI: 10.1007/s15006-013-0885-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Klaus Stelter
- Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde am Klinikum der Universität München.
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Stelter K, Kramer MF. [Diagnosis and treatment of acute and chronic rhinosinusitis]. MMW Fortschr Med 2013; 155 Spec No 1:49-53; quiz 54. [PMID: 24260920 DOI: 10.1007/s15006-013-0321-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Klaus Stelter
- Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde am Klinikum der Universität München, Campus Grosshadern.
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Braun T, Betz CS, Ledderose GJ, Havel M, Stelter K, Kuhnel T, Strauss G, Waschke J, Kirchner T, Briner HR, Simmen D, Caversaccio M, Wormald PJ, Jones N, Leunig A. Endoscopic sinus surgery training courses: benefit and problems - a multicentre evaluation to systematically improve surgical training. Rhinology 2013; 50:246-54. [PMID: 22888480 DOI: 10.4193/rhino11.266] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this multicentre study was to systematically analyse the strengths and weaknesses in the surgical training for endoscopic sinus surgery (ESS) and identify measures that may improve training. METHODOLOGY Using a structured questionnaire, 133 participants of ESS courses in seven centres in Germany, Switzerland and Australia were asked about their experiences during their dissection courses and how they perceived their course could be improved. RESULTS Gaining confidence in handling of instruments and endoscopes was only a problem for participants with little experience in ESS. The majority of the participants, independent from their level of training, considered infundibulotomy and anterior ethmoidectomy as the easiest dissection steps, whilst surgery of the frontal sinus posed a considerable challenge for many surgeons even those with a higher level of training. Participants with and without ESS experience thought that emphasis on anatomy was the most important improvement that could be made during their surgical training. Virtually all participants stated that the course improved their anatomical knowledge, their surgical skills and their confidence when performing ESS. CONCLUSIONS ESS dissection courses are considered beneficial by surgical trainees. Participants felt that more emphasis on sinus anatomy in conjunction with private study is essential to maximize their skills in surgical dissection. For beginners with ESS, an infundibulotomy and anterior ethmoidectomy were thought to be the best initial procedures to help develop endoscopic surgical skills.
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Affiliation(s)
- T Braun
- Department of Otorhinolaryngology, Ludwig Maximilian University, Munich, Germany.
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Havel M, Sroka R, Englert E, Stelter K, Leunig A, Betz CS. Intraindividual comparison of 1,470 nm diode laser versus carbon dioxide laser for tonsillotomy: a prospective, randomized, double blind, controlled feasibility trial. Lasers Surg Med 2012; 44:558-63. [PMID: 22837058 DOI: 10.1002/lsm.22053] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2012] [Indexed: 11/12/2022]
Abstract
INTRODUCTION The need for reduction of post-tonsillectomy hemorrhage has led to promotion of tonsillotomy techniques for tonsil tissue reduction in obstructive tonsillar hypertrophy. This trial compares ablative tissue effects using 1,470 nm diode laser and carbon dioxide laser for tonsillotomy in an intraindividual design. METHODS 21 children aged 3-13 years (mean age 6.3 years) underwent laser tonsillotomy for obstructive tonsillar hypertrophy in this double blind, prospective, randomized, clinical feasibility trial. In each of the blinded patients, tonsillotomy was performed using fiber guided 1,470 nm diode laser (contact mode, 15 W power) on the one side and carbon dioxide laser (12 W power) on the other side. An independent, blinded physician documented clinical presentation and patients' symptoms preoperatively and on Days 1, 3, 7, 14, and 21 post-operatively using standardized questionnaire including VAS for each side separately. RESULTS The mean duration of operative treatment was 2.7 min using 1,470 nm laser and 4.9 min using carbon dioxide laser respectively. Intraoperative bleeding and the frequency of bipolar forceps use for intraoperative bleeding control was significantly less using 1,470 nm diode laser system. There was no difference in post-operative pain scores between the carbon dioxide laser treated and the 1,470 nm fiber guided diode laser treated side. No infections, hemorrhages or other complications occurred in the course of the 3 weeks post-operative period. CONCLUSIONS A fiber-guided 1,470 nm diode laser system offers an efficient and safe method for tonsillotomy as treatment of obstructive tonsillar hypertrophy. Compared to our standard practice (carbon dioxide laser), 1,470 nm laser application provides comparable tissue ablation effects with less intraoperative bleeding and shorter operation time.
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Affiliation(s)
- Miriam Havel
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Munich, Marchioninistr. 15, 81377 Munich, Germany.
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Stelter K, Ledderose G, Hempel JM, Morhard DF, Flatz W, krause E, Mueller J. Image guided navigation by intraoperative CT scan for cochlear implantation. ACTA ACUST UNITED AC 2012; 17:153-60. [DOI: 10.3109/10929088.2012.668937] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Stelter K, Ertl-Wagner B, Luz M, Muller S, Ledderose G, Siedek V, Berghaus A, Arpe S, Leunig A. Evaluation of an image-guided navigation system in the training of functional endoscopic sinus surgeons. A prospective, randomised clinical study. Rhinology 2012; 49:429-37. [PMID: 21991568 DOI: 10.4193/rhino11.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Many sinus surgeons report improved spatial orientation after using a navigation system. This study investigates the surgical, ergonomic and economic aspects of using a navigation system in training and teaching. MATERIALS AND METHODS Eight rhino-surgeons in training and 32 patients with bilateral diseases of the paranasal sinus system were included. After randomisation, one patient`s side was operated on with a navigation system while the other side was operated on without navigation. It was monitored how often the surgeon used the navigation pointer and then changed the procedures. A standardised and validated interview recorded the cognitive load when using the navigation system and the application efficiency. RESULTS The operations lasted on average 16 minutes longer with the navigation. Five paranasal sinuses could not be found in the control group without navigation. In only 10-13% of cases did the surgical procedure change after the use of the pointer. Most of the surgeons admitted that particular steps of the operation were more reliable and safer to carry out with the navigation system. The general trust in the system rose in proportion to intraoperative accuracy and repeated use. CONCLUSION Overall, there was an overwhelming level of trust in the navigation system. Trainee sinus surgeons seeing their more experienced colleagues using a navigation device tend to overestimate the possibilities of the system and to underestimate the risks. The assistance system was used particularly effectively in the group of slightly more experienced surgeons. In this group, the additional expenditure of time was less and the navigation substantially contributed to reinforcing the anatomical sense of direction.
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Affiliation(s)
- K Stelter
- Department of Otorhinolaryngology, Ludwig Maximilian University, Munich, Germany.
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Ledderose GJ, Braun T, Betz CS, Stelter K, Leunig A. Functional endoscopic surgery of paranasal fungus ball: clinical outcome, patient benefit and health-related quality of life. Eur Arch Otorhinolaryngol 2012; 269:2203-8. [PMID: 22249836 DOI: 10.1007/s00405-012-1925-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 01/03/2012] [Indexed: 01/08/2023]
Abstract
Paranasal fungus ball can cause chronic rhinosinusitis. Removal via functional endoscopic sinus surgery is usually performed; however objective data on the overall benefit and patient satisfaction are very scarce. The study focuses on the clinical outcome and the quality of life following endoscopic surgery due to fungus ball sinusitis. Forty patients diagnosed with fungus ball sinusitis who underwent functional endoscopic surgery were included. Epidemiologic data, pre-, intra- and postoperative findings were recorded. Surgical success, the detailed benefit and the health-related quality of life were objectively assessed 1 year after the surgery based on a standardized questionnaire (modified SNOT 20) and the Glasgow Benefit Inventory. Health-related quality of life improved significantly in >90% of patients (p < 0.05). There were no serious complications or recurrences. As the treatment of choice functional endoscopic sinus surgery of paranasal fungus ball sinusitis is associated with exceptionally high patient satisfaction.
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Affiliation(s)
- Georg J Ledderose
- Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilian University Munich, Marchioninistr. 15, 81377 Munich, Germany.
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Braun T, Betz C, Ledderose G, Havel M, Stelter K, Kohnel T, Straus G, Waschke J, Kirchner T, Briner H, Simmen D, Caversaccio M, Wormald P, Jones N, Leunig A. Endoscopic sinus surgery training courses: benefit and problems - a multicentre evaluation to systematically improve surgical training. Rhinology 2012. [DOI: 10.4193/rhin11.266] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ledderose GJ, Hagedorn H, Spiegl K, Leunig A, Stelter K. Image guided surgery of the lateral skull base: Testing a new dental splint registration device. ACTA ACUST UNITED AC 2011; 17:13-20. [DOI: 10.3109/10929088.2011.632783] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Stelter K, Ertl-Wagner B, Luz M, Muller S, Ledderose G, Siedek V, Berghaus A, Arpe S, Leunig A. Evaluation of an image-guided navigation system in the training of functional endoscopic sinus surgeons. A prospective, randomised clinical study. Rhinology 2011. [DOI: 10.4193/rhin11.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Stelter K, Ihrler S, Siedek V, Patscheider M, Braun T, Ledderose G. 1-year follow-up after radiofrequency tonsillotomy and laser tonsillotomy in children: a prospective, double-blind, clinical study. Eur Arch Otorhinolaryngol 2011; 269:679-84. [PMID: 21792687 DOI: 10.1007/s00405-011-1681-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 06/17/2011] [Indexed: 11/28/2022]
Abstract
In the last decade, tonsillotomy has come into vogue again, whereas the number of tonsillectomies is decreasing rapidly. In a previous study, the tonsillotomy with laser or radiofrequency therapy proved as a safe and effective procedure with minimal pain and hemorrhage. This follow-up study determines which method is more effective with respect to long-term outcome, recurrence of tonsillar hyperplasia and recurrence of tonsillitis. A prospective, randomised, double-blinded controlled clinical study was conducted at the Department of Otorhinolaryngology of the Ludwig-Maximilians-University, Munich, Germany. Twenty-six children with tonsillar hypertrophy were included. Tonsillotomy was performed on one side with monopolar radiofrequency and on the other side with a carbon dioxide laser. Exactly 1 year after the procedure, all 26 patients were documented by digital photography to define a possible recurrence of tonsillar hyperplasia. All parents were asked for occurring tonsillitis and fulfilled the Glasgow Children's Benefit Inventory (GCBI) for health-related quality of life after surgical procedures. In seven children, a slightly visible recurrence of the tonsillar hyperplasia occurred, without any symptoms or correlation to the different methods and sides. One child with recurrent tonsillitis and hyperplasia had to be tonsillectomized 8 months after the initial tonsillotomy procedure. The specimen showed open crypts with bacterial infection in the deep. The GCBI resulted in highly significant benefits of the surgery in all categories and subcategories. In conclusion, both methods, the laser tonsillotomy and the radiofrequency method, were equal concerning the effectiveness and safety after 1 year. Further investigations have to aim at the long-term outcome after tonsillotomy in patients with recurrent infections.
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Affiliation(s)
- Klaus Stelter
- Department of Otorhinolaryngology, Head and Neck Surgery, Grosshadern Medical Centre of Ludwig-Maximilians-University, Marchioninistr. 15, 81377, Munich, Germany.
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Abstract
BACKGROUND The literature lacks studies analyzing the specific problems of colleagues in the surgical training for FESS. The presented date can help to systematically improve the training. METHODS The participants of the 11 (th) Munich FESS Course were asked about problems occurring during dissection and about their opinion how the training could be improved. RESULTS Handling of instruments and endocopes was only a problem for participants without any experience in FESS. The majority of the participants, independently from their training level, considered infundibulotomy and anterior ethmoidectomy the easiest dissection steps. Participants with and without FESS experience regarded a more extensive study of anatomy in the forefront as the most important toehold in the improvement of the surgical training. Virtually all participants stated that the course improved their anatomical knowledge, their confidence on the patient, and their surgical skills. CONCLUSIONS FESS dissection courses are well accepted and considered as beneficial by surgical trainees. An exhaustive private study of anatomy is essential. For beginners with FESS, infundibulotomies and anterior ethmoidectomies should preferentially be chosen.
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Affiliation(s)
- T Braun
- Klinikum der Ludwig-Maximilians-Universität München, Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, München.
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Canis M, Olzowy B, Welz C, Suckfüll M, Stelter K. Simvastatin and Ginkgo biloba in the treatment of subacute tinnitus: a retrospective study of 94 patients. Am J Otolaryngol 2011; 32:19-23. [PMID: 20015810 DOI: 10.1016/j.amjoto.2009.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Revised: 08/31/2009] [Accepted: 09/06/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Studies suggest that hypercholesterolemia promotes the development of inner ear disorders such as tinnitus. However, the underlying pathomechanisms are still not clearly defined. METHODS A retrospective study was performed to assess whether a reduction of serum cholesterol by 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors may result in a relief of subacute tinnitus. Remission rates of 58 patients were investigated after 4 months of treatment with simvastatin (40 mg). Results were compared to treatment with Ginkgo biloba (120 mg; n = 36) as control group. Differences between tinnitus score at the day of first treatment and after 4 months were used as main outcome measure. RESULTS After treatment with simvastatin or G biloba, tinnitus score decreased from 41.3 ± 10.4 to 37.4 ± 17.3 and from 44.7 ± 11.2 to 41.2 ± 8.7, respectively. However, independently of the treatment regimen, differences of tinnitus scores were considered not significant. CONCLUSIONS After administration of simvastatin over 4 months, this retrospective study has shown no significant efficacy in treatment of subacute tinnitus. For a more conclusive answer, further prospective, double-blind, and placebo-controlled studies with a larger number of patients are needed.
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Affiliation(s)
- Martin Canis
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Munich, München, Germany.
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Strieth S, Weger T, Bartesch C, Bittmann P, Stelter K, Berghaus A. Biocompatibility of porous polyethylene implants tissue-engineered by extracellular matrix and VEGF. J Biomed Mater Res A 2010; 93:1566-73. [PMID: 20014297 DOI: 10.1002/jbm.a.32670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Rapid ingrowth of blood vessels and low inflammatory response are considered major prerequisites for successful implantation of biomaterials in reconstructive surgery. Aim of the present study was to evaluate whether tissue-engineered porous polyethylene (PPE) implants providing extracellular matrix components (ECM) and vascular endothelial growth factor (VEGF) in vivo improve microvascular ingrowth and mechanical integration with regard to initial inflammatory responses. PPE implants (3 x 3 x 0.1 mm(3), pore size approximately 100-200 microm) were tissue-engineered by incorporation of ECM components (GFR-Matrigel) adding recombinant murine VEGF (1 microg/mL) and grafted into dorsal skinfold chamber preparations of C57BL/6 mice. Control animals received uncoated implants or implants coated with ECM components alone (n = 6 per group). Using in vivo fluorescence microscopy angiogenic activity and inflammatory leukocyte-endothelial cell interactions were analyzed for 2weeks. Finally, mechanical integration was quantified by measurement of dynamic desintegration strengths at the host-implant border. Functional vessel density, red blood cell velocity, and vessel diameters increased continuously in all groups indicating that rapid microvascular integration of PPE occurred even without incorporation of ECM or VEGF. However, a transient initial inflammatory response with increased leukocyte-endothelial cell adherence on day 7 in uncoated control implants was efficiently reduced by incorporation of ECM and VEGF. Measurement of dynamic breaking strengths revealed no significant differences between the groups although there was a tendency to improved mechanical integration in tissue-engineered implants. Therefore, novel tissue- engineered constructs of PPE implants providing ECM and VEGF in high local concentrations can increase biocompatibility especially under unfavorable conditions for implantation.
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Affiliation(s)
- Sebastian Strieth
- Walter-Brendel-Center for Experimental Medicine (WBex), University of Munich (LMU), Marchioninistr. 27, Munich 81377, Germany.
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Bidlingmaier C, Olivieri M, Stelter K, Eberl W, von Kries R, Kurnik K. Postoperative bleeding in paediatric ENT surgery. First results of the German ESPED trial. Hamostaseologie 2010; 30 Suppl 1:S108-S111. [PMID: 21042683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
Bleeding after ear-nose-and throat surgery in children is a serious complication. With the help of the German Surveillance Unit for Rare Paediatric Disorders (Erhebungseinheit für seltene pädiatrische Erkrankungen in Deutschland; ESPED) a two year survey was performed to record the incidence, severity, reasons and treatment of haemorrhages. During the study period, 1069 bleeds were reported from 720 paediatric hospitals and departments of otorhinolaryngology after adenoidectomy and tonsillectomy. 713 reports could be analyzed. Two deaths occurred after adenoidectomy. Although laboratory screening was performed in more than 70% of all cases, bleeding complications were neither foreseeable nor preventable. Inherited coagulopathies were rare and in most cases not detected, neither by laboratory screening nor by taking a history. Since preoperative measures cannot help much to improve the situation, all efforts have to be taken to improve the postoperative period, especially since more than 20% of the hemorrhages occurred during weekends. Guidelines on postoperative care and behaviour should therefore be implemented and parents and patients must be informed on bleeding risks and on what to do in case of emergency. If bleeding occurs, extensive coagulation testing is mandatory.
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Affiliation(s)
- C Bidlingmaier
- Pädiatrische Hämostaseologie, Dr. von Haunersches Kinderspital, Lindwurmstr. 4, 80337 München.
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Bas M, Kojda G, Stelter K. [Angiotensin-converting enzyme inhibitor induced angioedema : new therapy options]. Anaesthesist 2010; 60:1141-5. [PMID: 20922352 DOI: 10.1007/s00101-010-1798-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Revised: 08/29/2010] [Accepted: 09/01/2010] [Indexed: 01/13/2023]
Abstract
Angiotensin-converting enzyme (ACE) inhibitors block the catalysis of angiotensin I to angiotensin II and also the breakdown of bradykinin. ACE inhibitor-induced angioedema is mediated by inhibited bradykinin degradation leading to enhanced bradykinin plasma levels. The efficacy of currently used standard treatments with antiallergic drugs is questionable. A patient with acute ACE inhibitor-induced angioedema was treated with icatibant, a specific bradykinin B2 receptor antagonist approved for the treatment of hereditary angioedema. A single subcutaneous injection of 30 mg icatibant resulted in a rapid onset of symptom relief and a remarkable shortening of duration of the attack.
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Affiliation(s)
- M Bas
- Hals-Nasen-Ohrenklinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Deutschland.
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Bas M, Greve J, Stelter K, Bier H, Stark T, Hoffmann TK, Kojda G. Therapeutic efficacy of icatibant in angioedema induced by angiotensin-converting enzyme inhibitors: a case series. Ann Emerg Med 2010; 56:278-82. [PMID: 20447725 DOI: 10.1016/j.annemergmed.2010.03.032] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2009] [Revised: 02/08/2010] [Accepted: 03/22/2010] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE The pathophysiology of angiotensin-converting enzyme inhibitor (ACEi)-induced angioedema most likely resembles that of hereditary angioedema, ie, it is mainly mediated by bradykinin-induced activation of vascular bradykinin B2 receptors. We hypothesize that the bradykinin B2 receptor antagonist icatibant might be an effective therapy for ACEi-induced angioedema. METHODS Eight patients with acute ACEi-induced angioedema were treated with a single subcutaneous injection of icatibant. The outcome was assessed by the time to first improvement of symptoms, complete symptom relief, and drug safety. In addition, we retrospectively assessed the clinical course of 47 consecutive patients of our clinic with ACEi-induced angioedema. RESULTS First symptom improvement after icatibant injection occurred at a mean time of 50.6 minutes (standard deviation [SD] 21 minutes) and complete relief of symptoms at 4.4 hours (SD 0.8 hours). No patient received tracheal intubation, other drug treatment, tracheotomy, or a second icatibant injection. There were no adverse effects except erythema occurring at the injection site. In the historical comparison group treated with methylprednisolone and clemastine, the mean time to complete relief of symptoms was 33 hours (SD 19.4 hours). Some of these patients received a tracheotomy (3/47), were intubated (2/47), or received a second dose of methylprednisolone (12/47). CONCLUSION Although sample size limits the external validity of our results, the substantial decrease of time to complete symptom relief suggests that this new treatment is likely effective as a pharmacotherapeutic approach to treat ACEi-induced angioedema.
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Affiliation(s)
- Murat Bas
- Hals-, Nasen- und Ohrenklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Strasse 22, Munich, Germany.
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Stelter K, Hiller J, Hempel JM, Berghaus A, Hagedorn H, Andratschke M, Canis M. Comparison of two different local anaesthetic infiltrations for postoperative pain relief in tonsillectomy: a prospective, randomised, double blind, clinical trial. Eur Arch Otorhinolaryngol 2010; 267:1129-34. [PMID: 20069307 DOI: 10.1007/s00405-009-1200-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2009] [Accepted: 12/29/2009] [Indexed: 10/20/2022]
Abstract
In previous studies, it was shown that the post-tonsillectomy wound infiltration of bupivacaine can reduce postoperative pain. The objective of this study is to determine whether the postoperative wound infiltration with a mixture of bupivacaine, mepivacaine and adrenaline is more effective than the sole application of bupivacaine. A prospective, double-blind, randomized, control study included 30 patients scheduled for "cold steel" tonsillectomy. All patients obtained post-tonsillectomy infiltration of 6.25 mg bupivacaine alone on one side and 3.75 mg bupivacaine, 25 mg mepivacaine and 0.0125 mg epinephrine on the other side (intra-individual study design). Intake of analgesics and postoperative pain was assessed 0-6 days after surgery by visual analogue scale in inactivity and during swallowing by the nurse staff. Bleeding, dysphagia, pain, aspiration or extraordinary pain sensation were registered by the patient. The pain scores did not differ between the groups. All patients received systemic painkillers; 6 (20%) patients needed intravenous analgesics. Postoperative haemorrhage occurred in two patients without correlation to a certain local anaesthetic. Two patients developed sinus tachycardia for 2.5 min after epinephrine infiltration. Because of cost-effectiveness and complication rates, we recommend only post-tonsillectomy wound infiltration of bupivacaine. The injection should be placed in superficial muscle and connective tissue. A stringent systemic analgesia regime is indispensable for pain relief after tonsillectomy.
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Affiliation(s)
- Klaus Stelter
- Department of Otorhinolaryngology, Head and Neck Surgery, Grosshadern Medical Centre, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany.
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Siedek V, Stelter K, Betz CS, Berghaus A, Leunig A. Functional endoscopic sinus surgery--a retrospective analysis of 115 children and adolescents with chronic rhinosinusitis. Int J Pediatr Otorhinolaryngol 2009; 73:741-5. [PMID: 19269044 DOI: 10.1016/j.ijporl.2009.01.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Revised: 01/20/2009] [Accepted: 01/26/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Functional endoscopic sinus surgery (FESS) is not frequently performed in children. The aim of our retrospective analysis was to determine symptoms, surgical extent, complications and outcome of operated children. METHODS For a period from 1994 to 2004 the clinical records of the Department of Otorhinolaryngology, LMU Munich, Germany, were screened for pediatric FESS procedures. Subsequently, a retrospective chart review was performed in all cases. For assessment of outcome, symptom- and quality of life-related questionnaires were sent out to all patients. RESULTS 115 children had a FESS procedure due to CRS, 77 were boys and 38 girls. The response rate of the questionnaires was 64% (73 of 115); the mean follow up of these was 5.4 (+/-1.8) years. 76% of the patients reported an improvement of their chief symptoms and 71% of their general quality of life. The overall quality of life had improved significantly (p<0.01) on VAS. In CRS patients nasal obstruction was completely relieved in 62.3%, facial pain in 65.5% and postnasal drip in 72.5%. Improvement of primary nasal symptoms (PNS) of CRS in patients with CF, asthma or allergies as well as in youngsters who had started or continued to smoke 35 out of 73 (48%) was significantly less. CONCLUSIONS Self-assessment after FESS showed in 76% improvement of chief symptoms in children with CRS. Besides known negative prognostic factors for long-term outcome as CF, asthma, nasal polyps, allergies and previous surgery, smoking was correlated with less favourable improvement.
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Affiliation(s)
- Vanessa Siedek
- Ludwig Maximilians-University, Department of Otorhinolaryngology, Head and Neck Surgery, Munich, Germany.
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Tschiesner U, Linseisen E, Baumann S, Siedek V, Stelter K, Berghaus A, Cieza A. Assessment of functioning in patients with head and neck cancer according to the International Classification of Functioning, Disability, and Health (ICF): A multicenter study. Laryngoscope 2009; 119:915-23. [DOI: 10.1002/lary.20211] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Stelter K, Hempel JM, Berghaus A, Andratschke M, Luebbers CW, Hagedorn H. Application methods of local anaesthetic infiltrations for postoperative pain relief in tonsillectomy: a prospective, randomised, double-blind, clinical trial. Eur Arch Otorhinolaryngol 2009; 266:1615-20. [DOI: 10.1007/s00405-008-0909-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2008] [Accepted: 12/24/2008] [Indexed: 11/24/2022]
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Winter H, Meimarakis G, Hoffmann G, Hummel M, Rüttinger D, Zilbauer A, Stelter K, Spelsberg F, Jauch KW, Hatz R, Löhe F. Does Surgical Resection of Pulmonary Metastases of Head and Neck Cancer Improve Survival? Ann Surg Oncol 2008; 15:2915-26. [DOI: 10.1245/s10434-008-0001-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Revised: 03/06/2008] [Accepted: 05/12/2008] [Indexed: 11/18/2022]
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Kopp R, Linn J, Stelter K, Weidenhagen R, Meimarakis G, Berndt J. Hybridoperation zur Behandlung eines distalen Aortenbogenaneurysmas mit linksseitiger Recurrensparese – Ortner-Syndrom. Laryngorhinootologie 2008; 87:723-7. [DOI: 10.1055/s-2007-995707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
PURPOSE OF REVIEW This review examines implant materials currently used in rhinoplasty. In revision cases, the most desirable autogenous grafts from the septum are often unavailable in adequate quantities. The 'ideal' implant has strict requirements concerning biocompatibility, plasticity, stability of form, resistance to infection, and removability. RECENT FINDINGS Silicone implants continue to be used in spite of frequent reports of rejection. In spite of its described absorption, conserved cartilage can help in preserving profiles. Increasingly, good results are being reported with porous polyethylene, although Proplast is sometimes used in its place. Despite the fact that AlloDerm is partially absorbed, it can still be useful. GoreTex is effective for smaller defects. Mersilene mesh is not absorbed and retains its stability of shape. 'Turkish Delight' (diced cartilage with a wrapping) seems to be absorbed when the wrapping is made of Surgicel, but a wrapping of autogenous fascia provides lasting results. SUMMARY Several alloplastic materials do have a place in nasal surgery. Provided that the correct techniques are employed, side effects from their use are no greater than the complications resulting from the use of autogenous costal cartilage, with the intervention necessary for its harvesting.
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Affiliation(s)
- Alexander Berghaus
- Department of Otorhinolaryngology, Head and Neck Surgery, Grosshadern Medical Centre, Ludwig-Maximilians-University, Munich, Germany.
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