[Skull base surgery in the German DRG system-New categorization of important procedures]

Surgery of the skull base includes interventions between the nose or paranasal sinuses (anterior skull base) or ear/temporal bone (lateral skull base) and the intracranial space. As interventions at the anterior skull base almost exclusively involve complex pathologies in a demanding anatomical region, in many cases two experienced surgeons from different disciplines are required who should be experienced in operating together. The technical and time requirements are also considerable in many cases; however, for many procedures there are no specific skull base operational and procedural keys (OPS) codes that take the considerable personnel and structural effort into account. A change in the diagnosis-related groups (DRG) system, implemented since the beginning of 2023, now adjusts the remuneration of the abovementioned effort for malignant pathologies of the anterior and lateral skull base. The reallocation of procedures 5‑015.0/1/3/4 and 5‑016.0/2/4/6 results in a significant upgrade of anterior and lateral skull base surgery. Since the beginning of 2023 skull base surgery will no longer be charged under DRG D25C with a (former) relative weight of 1.893, but with DRG D25B with a current relative weight of 3.753 when a code of the aforementioned groups is used. Nevertheless, further adjustments are necessary, for example, in the available reconstructive steps in order to provide the Institute for the Remuneration System in Hospitals (InEK) with the most differentiated data possible on the procedural effort of the intervention and to achieve a more balanced distribution of the reimbursements of skull base surgery in the long term.

[Accreditation and certification of skull base centres in Germany by the German Society for Skull Base Surgery (Gesellschaft für Schädelbasischirurgie, GSB). German version]

The German Society for Skull Base Surgery (Gesellschaft für Schädelbasischirurgie, GSB) has developed a protocol for the certification of GSB skull base centres. The development of such a protocol has led to numerous open and sometimes controversial discussions among the GSB members. The various critical discussion points will be reviewed and the ensuing results, which will then be included in the accreditation protocol, presented. The current GSB accreditation protocol will be presented and explained in an international comparison.

[Social reimbursement-the Spanish-German ENT Society's (SDGHNO) Latin America project]

Nowadays, social projects are usually oriented in such a way that after a given period of time, they can either support themselves independently or even allow a pecuniary reimbursement. In the latter case, experts speak of a profit-oriented reimbursement. On the other hand, there is so-called social reimbursement, which in contrast to the abovementioned form is not profit oriented, but, for example, considers its task fulfilled by the fact of successful knowledge transfer. The Spanish-German Society for ENT Medicine and Head and Neck Surgery (SDGHNO) launched the Latin America project in 2001 under the patronage of the then President Prof. Dr. Wolfgang Draf (Fulda). The goal of the SDGHNO was and is to create a professional as well as cultural platform for Spanish- and German-speaking ENT doctors. This platform can and should be used for professional purposes, e.g., for knowledge transfer. Since the beginning of its existence, the Latin America project has thus brought numerous scientific events into being and created specific contacts which have lasted until today or have even been continued and further developed. Particularly successful examples are Chile, Colombia, and Peru. This is a vivid example of social reimbursement, because the participating German-speaking members/speakers carried out their tasks on an entirely voluntary basis. Thus, the SDGHNO did not bear any travel, catering, or accommodation costs. The activities of the SDGHNO within the framework of the Latin America project are explained.

[Traumatic optic neuropathy: a review of the literature in the light of personal experiences]

BACKGROUND

Therapy of traumatic optic neuropathy (TON) is still discussed controversially. Studies of medical treatment and surgical decompression of the nerve could not find any correlation between therapy and result. Today's knowledge of the treatment in TON is to be analyzed by the latest results in the literature, supplemented by personal experiences with our own patients, who underwent a combination of corticosteroids and surgical decompression.

METHODS

The study group consisted of 9 patients at the age of 13-58 years. 8 patients suffered from a cranial trauma, 1 patient had sinus surgery, which resulted in an indirect damage of the optic nerve. Pretherapeutically, 5 patients had residual vision, 4 patients were blind. A fracture line through the optic canal in the CT-scan was seen in 6 cases. Decompression was performed within 24 hours in 3 cases; in the worst 3 cases it took up to 8 days. In 8 patients the intervention was performed via an endonasal, microscopic-endoscopic approach, once it was done transfacially. Simultaneously, high-dose corticosteroids were administered.

RESULTS

All patients with a residual vision before therapy showed an improvement of their visual acuity: In the best case visual acuity changed from perception of light to 0.8. All patients with posttraumatic blindness remained blind after therapy.

CONCLUSION

A surgical decompression may be considered in patients with residual vision. Referring to the latest data in the literature endonasal, microscopic-endoscopic decompression is then to be combined with simultaneous application of high-dose corticosteroids. In our opinion, a mere wait-and-see strategy completely without any treatment can hardly be recommended.

[Results in otosurgically treated patients with acoustic neuroma. Part 1: Facial nerve function after translabyrinthine and middle fossa resection]

BACKGROUND

Regardless of all efforts to preserve a residual hearing, facial nerve function is still the primary issue for patients with acoustic neuromas. Since alternative methods like the gamma-knife treatment are of increasing importance, results after surgery have to be compared and discussed critically.

PATIENTS

The results of 538 patients operated at the Dept. of Otolaryngology, Head and Neck Surgery, University of Wuerzburg between 1989 and 2004 are presented. 392 had surgery via a middle fossa, 146 via a translabyrinthine approach.

RESULTS

Shortly after surgery 82.2 % of patients showed no facial palsy. 74 patients had an incomplete, 7 a complete paresis. After 12 months 144 of the patients operated on via middle fossa approach showed no palsy, 13 had an incomplete and one a complete paresis. Out of 76 patients operated on translabyrinthine approach 75 had no paresis, one had an incomplete, and no patient had a complete paresis. There was no difference between intrameatal tumors and tumors extending beyond the porus. Regular facial nerve function was seen in 93 %, postoperatively. Permanent paresis was seen in 0.4 % of cases.

CONCLUSION

Acoustic neuroma confined to the internal meatus or with minor extension into the cerebello-pontine angle (i. e. no contact to structures of the brain stem or vessels of the posterior fossa) are feasible for resection via a middle fossa or translabyrinthine approach. The possibility of hearing preservation combined with low morbidity and good results of facial nerve function makes these approaches the treatment of choice for this group of tumors.

Akute Komplikationen in der Mittelohrchirurgie

Stapes surgery is remarkably different from regular middle ear surgery. The inner ear space has to be opened and the risk of postoperative deterioration of hearing and deafness is much higher. Peculiarities involve submerged parts of the foot plate into the vestibulum, the overhanging facial nerve with or without bony covering, bleeding from the mucosa, and problems involving the chorda tympani. Labyrinthine reactions during or post surgery are common. Important is the question of whether or when the piston should be removed. Rare cases such as a gusher with a wide connection between perilymph and CSF space are a major challenge in stapes surgery.

[Acute complications during middle ear surgery: part 1: Problems during tympanoplasty--what to do?]

Due to the unusual anatomical situation in the middle ear, there are a variety of possible complications that may occur during tympanoplasty. Dislocation of the ossicular chain with and without opening of the labyrinth, injuries to the facial nerve and hemorrhage from large arteries and veins may occur. Adequate management of these complications is necessary in order to avoid further damage for the patient. The first question in case of an acute complication is always whether it is possible to stop the operation. It is also important to determine the time to react, e.g. if an injury of the facial nerve is assumed, when a revision needs to be performed. It also should be considered to refer the patient to a colleague who is not as emotionally involved in the case as the primary surgeon.

[Doubling of the pinna, a rare branchial arch developmental disorder]

BACKGROUND

Auricular appendices are not unusual, but doubling of the pinna is rare. There is still a controversy if these are derivates from the first or the second branchial arch.

PATIENT

The case of a 3 year old girl is described with doubling of the pinna and hemi facial atrophia. The second pinna was on third of the orthotop regular auricle. It seemed to come from the tragus anlage i. e. originating from the first otic hillock.

RESULTS

The accessory pinna was resected, an aesthetic result could be achieved.

CONCLUSION

Morphology and position of accessory pinnas arise again the question of the origin of the auricular hillocks. This case supports the opinion of Otto that the first hillock only belongs to the first branchial arch and the major part of the auricle is originating from the hillock 2-6 i. e. to the second branchial arch.

[Malignant paranasal sinus tumors. Diagnosis, therapy and results]

BACKGROUND

Malignant neoplasmas of the paranasal sinuses are rare and present usually in advanced tumor stage due to the lack of early clinical symptoms.

PATIENTS AND METHODS

In the last 10 years, 63 patients with paranasal malignancies were treated at the Department of Otolaryngology, Head and Neck Surgery of the University of Würzburg. 33% of the patients showed an occupational exposition (wood-processing or metal industry). At the time of the first visit to our institution 95% of the patients presented with an extensive disease, staged T3 and T4. Adenocarcinoma (24%), squamous cell carcinoma (22%) and malignant melanoma (19%) were the most common histologies. Surgery combined with radiotherapy was the treatment strategy in 55 patients (87%).

RESULTS

Patients with a complete surgical resection showed a higher 5-year-survival rate (77%) than patients with an incomplete resection (56%). In 38% (n=21) of the patients treated with surgery and radiotherapy, a local recurrence of the tumor was observed. This recurrence localised in the skull base and/or the orbita/periorbita occurred most frequently in the first (46%) or the second year (31%).

CONCLUSION

The prognosis of malignant paranasal tumors depends mainly on the control of the local tumor growth. Modern strategies of surgical treatment in combination with radiotherapy need to be implemented in an effort to achieve a continuous remission.

Infizierte Parotiszyste als Ursache einer Fazialisparese

BACKGROUND

Inflammatory processes are a rare cause of peripheral facial palsy. In most cases even massive infection does not lead to a loss of facial nerve function. In the literature, only 8 cases of facial paralysis associated with parotid cyst have been described.

PATIENT AND RESULTS

We present a case of facial palsy caused by an inflamed cyst of the parotid gland. The patient was operated on with the diagnosis malignant parotid tumor. The pathological report showed a squamous epithelial cyst, massive lymphocytic infiltration.

CONCLUSIONS

As a rule the combination parotid gland lesion and facial palsy is a sign of malignancy, clinicians should be aware that, on rare occasions, facial nerve dysfunction may result from benign parotid gland disease.

Tonsillektomienachblutungen im Zeitraum von 1985 bis 2001 und Erfahrungen bei der Anwendung der Lasertonsillotomie bei Kleinkindern

BACKGROUND

Tonsillectomy is one of the most often performed surgery in our specialty. But postoperative bleeding is not only a statistic risk, it can lead to a tragic end individually. In the future and according to the DRGs, a postoperative stay in hospital for more than 6 days will be difficult to realise.

METHODS

10 052 patients after tonsillectomy were measured, 7663 were performed in the ORL-Department of Würzburg, 2389 in the ORL-Department of Augsburg. Further data was measured by questioning the parents of 65 young children after lasertonsillotomy.

PATIENTS

The patient group of the tonsillectomies included all ages, the group of the lasertonsillotomies included young children aged 1- 6 years.

RESULTS

The first spike of bleedings of the ORL-Department in Würzburg was found within the first 24 hours after surgery. A second spike showed between the 5 (th) and 7 (th) postoperative day, an other after the 8 (th) and 15 (th) postoperative day. In the ORL-Department Augsburg the main spike was found from the 7 (th) until the 9 (th) postoperative day. No postoperative bleedings were found in the lasertonsillotomies.

CONCLUSIONS

A postoperative stay in hospital is sufficient for 3 days, but should vary individually. On young children with symptomatic hyperplasia of the tonsils a lasertonsillotomy should be performed.

[Ceramic model for temporal bone exercises--an alternative for human temporal bones?]

BACKGROUND

The complexity of the temporal bone anatomy makes it necessary to train in a model before starting middle ear surgery. The classical object are human cadaver temporal bones, but these are not always available for different reasons. Alternatively in cooperation between the department of otolaryngology, head and neck surgery of the University of Jena and the 3di company Jena, Germany, a calcium sulfate based model was developed.

METHODS

During a temporal bone course at the Bugando Medical Centre, Mwanza, Tanzania, these ceramic temporal bone specimens were used for training. Because of the lack of drills, the specimens were worked on in chisel and carving technique. All participants were beginners in ear surgery. Classical procedures in mastoid surgery were performed: Exposing of sigmoid sinus, facial nerve, labyrinth, dura, jugular bulb and internal carotid artery.

RESULTS

The temporal bone models were very useful for these exercises. Good exposure was possible for the dura, the facial nerve and the major blood vessels. The possibility of exposing tinier structures like the labyrinth was still insufficient. Nevertheless the understanding of the 3-dimensional anatomy of the temporal bone using the ceramic model was excellent. The relationship of all important anatomical structures could be taught intensively.

CONCLUSIONS

Particularly for beginners or in cases where human temporal bones are not available the calcium sulfate based temporal bone is an alternative training model for mastoid and middle ear surgery.

[Titanium as a material for ossicular replacement - basic aspects and clinical application]

BACKGROUND

The use of titanium as a biomaterial in ossicular chain reconstruction is increasing. The situation for integration of biomaterials is more difficult in the semiopen implantation site middle ear than in other parts of the body. Important for integration is the contact of the biomaterial's surface toward proteins. Studies of the integration in living tissue still have to be performed in animal experiments. Morphological examinations of explanted prostheses after clinical use complete the picture of an ossicular replacement material.

METHODS

Preclinical studies where performed to compare the adsorption behaviour of titanium, stainless steel and aluminum oxide toward radioactive marked albumin and native collagen type I. An animal model in the rabbit was performed to study the integration of titanium in the middle ear morphologically. Middle ear prostheses removed during revision surgery were studied as well.

RESULTS

Titanium showed an adsorption amount of 360 microgram/cm(2), stainless steel of 230 microgram/cm(2) and aluminum oxide of 500 microgram/cm(2) out of an albumin solution of 400 mg/ml. Comparing desorption the mean loss was 16 % for titanium, 21 % for stainless steel and 23 % for aluminium oxide. Reassembled collagen fibrils could be detected after adsorption in collagen type I solution by means of scanning electron microscopy. Morphological studies in animal experiments showed regular healing after implantation. Explanted prostheses from humans did not show any cellular signs of repulsion.

CONCLUSION

The results of preclinical studies and clinical use demonstrate titanium as a useful material for ossicular reconstruction in middle ear surgery.

[Cylindrocarcinoma in a patient with Brooke-Spiegler syndrome]

BACKGROUND

Cutaneous cylindromas are benign adnexal tumors that may occur as a solitary lesion or in a multiple familiar pattern. Malignant change is rare. The association of multiple trichoepitheliomas and cylindromas, the so called Brooke-Spiegler Syndrome, is supposed to be inherited in an autosomal dominant manner.

PATIENTS

A 55 year old woman presented with multiple skin tumors on the scalp, as well as the nasolabial and periauricular area since the age of 20 years. Her daughter and her nephew were also affected. Tumors were surgically removed for cosmetic reasons and showed histological signs of benign cylindromas and trichoepitheliomas. 35 years after diagnosis patient presented with a large exulceration on the right occipital area with intracranial invasion. Staging revealed multiple metastases in both lungs. Patient died 1 month later.

RESULTS

Histological examination showed beside zones of massive necrosis multiple mitosis. The jigsaw puzzle pattern and the thick PAS positive basal layer, the striking characteristics of benign cylindromas, were lost. These histological findings and the clinical presentation led to the diagnosis of cylindrocarcinoma.

CONCLUSIONS

Cylindrocarcinoma is an aggressive tumor with tendency to a local destructive growth and metastases. As malignant transformation of a benign cylindroma occurs more often in the multiple form a close follow-up of patients with multiple cylindromas is necessary. A family study is indicated.

[Diagnosis, treatment and results of malignant skull base tumours]

BACKGROUND

Malignant tumours of the cranial base are rare and present usually in advanced tumour stage due to the lack of early clinical symptoms.

PATIENTS AND METHODS

Sixty patients with malignant tumours infiltrating the skull base were treated at the Department of Otorhinolaryngology Head and Neck Surgery, University of Würzburg between 1987 and 1999. Most of the tumours (n = 51) originated from the nose or paranasal sinuses, the epipharynx, the outer ear canal or the middle ear. Seven tumours were malignant brain tumours infiltrating the bony structures of the skull base or originated from the cranial base itself. Two patients suffered from metastases of an adenocarcinoma of the prostata. The histological diagnosis was confirmed in 53 patients preoperatively and in seven patients during tumour resection. Squamous cell carcinoma (n = 24), adenocarcinoma (n = 10) and sarcoma (n = 7) were the most common histologies found.

RESULTS

A radical en bloc resection of the tumour was only possible in 26 out of 60 cases. A surgical tumour reduction with postoperative radiation therapy was performed in seven patients as a palliative approach. Eight patients underwent a combined radio- and chemotherapy according to the histological diagnosis. Primary radiotherapy was the treatment of choice in eleven patients, where the tumours were located in the central area of the cranial base. Palliative radiotherapy or solely medical pain control were applied to eight patients who presented either with distant metastases or an advanced tumour growth. The mean postoperative survival following radical surgery was 48 months and after primary radiotherapy 27 months.

DISCUSSION

A statistical analysis of the results is not applicable due to the great variety of the disease concerning the histological diagnosis, the tumour size and the location as well as the small number of patients.

[Carcinoma of the external ear canal and middle ear as interdisciplinary challenge for ear surgery and radiotherapy]

BACKGROUND

Carcinoma of the external auditory canal are tumours considered to have a poor prognosis. Improvement of the survival rate by surgical means alone is not possible. Individual therapy modalities as a result of an interdisciplinary approach between otosurgeon and radiotherapist are necessary.

PATIENTS AND METHODS

A series of 30 patients (3 patients pretreated at other institutions) with carcinoma of the external auditory canal and middle ear treated between 1978 and 1997 in our institutions was analysed with particular reference to tumour size and its relation to surrounding tissues, patterns of neck node involvement, surgical procedures, and radiation techniques. Clinical endpoints were freedom from local failure, overall survival, disease-free survival. The mean follow-up was 4.7 years (range: 0.1 to 18.8 years), median 3 years.

RESULTS

Treatment by surgery and radiotherapy resulted in an overall 5-year survival rate of 51%. According to Pittsburgh classification the 5-year survival rate for early disease (T1- and T2-tumours) was 89%, for stage III 67% and for stage IV 39%. Most important prognostic factors were dural infiltration (all patients with dural invasion died within 2.2 years) and the infiltration of surgical margins (the 5-year survival rate of patients with complete tumour resection was 100%, but 54% in patients with tumour beyond surgical margins). 192-iridium HDR afterloading brachytherapy based on 3D CT-treatment planning is an effective tool in the management of local recurrences following surgery and a full course of external beam radiotherapy.

CONCLUSIONS

Surgical resection followed by radiotherapy adapted to the stage of disease and grade of resection is the preferred treatment of cancer of the external auditory canal and middle ear.

[Scanning electron microscopy findings in titanium middle ear prostheses]

BACKGROUND

Titanium as a biomaterial in ossicular replacement has widely spread within the last couple of years.

METHODS

23 prostheses (12 PORPs, partial ossicular replacement prostheses and 11 TORPs total ossicular replacement prostheses) removed during revision surgery were studied using scanning electron microscopy. The average implantation time was 8 (range 3-15) months. The specimens were investigated regarding tissue growth, epithelialization, inflammation and cellular signs of rejection.

RESULTS

Only few prostheses were totally covered by connective tissue or epithelium due to technical problems in removing the implant and the covering tissue as one specimen. But this offered the possibility to study the interface at the edges where the tissue was torn off. The connective tissue looked unremarkable. Polygonal squamous epithelium was detected on several implants. Respiratory epithelium with ciliated cells and mucus producing goblet cells was seen in two specimens. In cases of cholesteatoma or protrusion the explanted prostheses showed typical rosette-like formation of hornifying squamous epithelium. According to underlying disease a lymphocytic infiltration could be seen. There were no cellular signs of incompatibility noticed neither macrophages nor foreign body giant cells.

CONCLUSIONS

From these investigations titanium seems to be a favorable biomaterial for ossicular replacement with good acceptance also in an implantation site showing chronic inflammation.

[Second primary carcinomas in the upper aerodigestive tract in different locations and age groups]

BACKGROUND

Second primary tumors are of great importance for diagnostics, therapy and prognosis in patients suffering from squamous cell carcinomas of the upper aerodigestive tract. The clinical observation of an increase of second primaries was the reason for analyzing all patients with head and neck cancer treated for a certain period of time at our institution.

METHODS

The hospital charts of 576 patients treated for squamous cell carcinoma of the oral cavity, the oropharynx, the hypopharynx and larynx treated from 1993 till 1996 at the Department of Otolaryngology, Head and Neck Surgery of the University of Würzburg were reviewed retrospectively.

RESULTS

10.1% of all patients developed a second primary tumor. The rate was highest for patients with carcinoma of the oral cavity (17.5%), followed by tumors of the hypo- and oropharynx (11.7% and 11.5%) and the larynx (6.4%). Besides the location, younger age was detected as a risk factor for the formation of second malignancies. The latency between first and second primary tumor was 2.9 years in average. 31% of the second primaries were detected synchronous, 39% metachronous.

CONCLUSION

The results demonstrate that younger patients and patients with carcinomas of the upper digestive tract need a consequent follow-up. The development of second primaries even years after the first malignoma demonstrates the necessity of lifelong follow-up and oncological care.

Free-flap reconstruction for laryngeal preservation after partial laryngectomy in patients with extended tumors of the oropharynx and hypopharynx

Partial laryngeal resection often results in major aspiration problems, making larynx preservation during surgical removal of tumors of the oropharynx and hypopharynx impossible. However, free flaps can be used to reconstruct perilaryngeal tissue, thus preserving the larynx and ensuring a better quality of life for patients. We present the results of forearm free-flap reconstruction of the supraglottis in 22 patients who underwent resections of extended squamous cell carcinomas of the oropharynx and hypopharynx. A total of 9 patients had T3 lesions and 13 had T4 lesions. All patients were additionally treated with radiation therapy alone (to 70 Gy) or in combination with chemotherapy (Cisplatin; 5-fluorouracil). The mean follow-up was 2.4 years. In four patients, tracheostomy could be closed. Five patients suffered from severe aspiration, one of whom had to undergo a laryngectomy. Six patients had mild aspiration and 7 patients had no aspiration, but extensive edema made decanulation impossible. A total of 13 patients were free of disease, 4 patients died of disease, 1 patient died as the result of a second primary cancer and 1 patient died of other causes. Three patients are alive with persistent tumor. Although the majority of patients experienced a better quality of life as a result of larynx preservation, aspiration has remained a problem following treatment.

Carcinoma of the external auditory canal and middle ear

PURPOSE

To evaluate therapeutic modalities used at our institutions regarding local control, disease-free survival and actuarial survival in carcinoma of the external auditory canal and middle ear, in an attempt to provide guidelines for therapy.

METHODS AND MATERIALS

A series of 27 patients with carcinoma of the external auditory canal and middle ear treated between 1978 and 1997 in our institutions were analyzed with particular reference to tumor size and its relation to surrounding tissues, patterns of neck node involvement, surgical procedures, and radiation techniques employed. Clinical endpoints were freedom from local failure, overall survival, and disease-free survival. The median follow-up was 2.7 years (range 0.1-17.9 years).

RESULTS

Treatment by surgery and radiotherapy resulted in an overall 5-year survival rate of 61%. According to the Pittsburgh classification, the actuarial 5-year survival rate for early disease (T1 and T2 tumors) was 86%, for T3 tumors 50%, and T4 stages 41%. Patients with tumors limited to the external auditory canal had a 5-year survival rate of 100%, patients with tumor invasion of the temporal bone 63%, and patients with tumor infiltration beyond the temporal bone 38%. The rate of freedom from local recurrence was 50% at 5 years. Unresectability by dural and cerebral infiltration, and treatment factors such as complete resection or resection with tumor beyond surgical margins are of prognostic relevance. All patients with dural invasion died within 2.2 years. The actuarial 5-year survival rate of patients with complete tumor resection was 100%, but 66% in patients with tumor beyond surgical margins. 192Iridium high-dose-rate (HDR) afterloading brachytherapy based on three-dimensional computed tomography (3D CT)-treatment planning was an effective tool in management of local recurrences following surgery and a full course of external beam radiotherapy.

CONCLUSION

Surgical resection followed by radiotherapy adapted to stage of disease and grade of resection is the preferred treatment of cancer of the external auditory canal and middle ear.

[Outcome after resection of extensive oropharyngeal carcinomas and defect coverage by microvascular anastomosis of a radialis flap]

BACKGROUND

Extensive tumors of the oropharynx require an open approach and plastic reconstruction for good oncologic and functional results.

PATIENTS AND METHODS

From January 1988 through December 1996 at the Department of Otolaryngology, Head and Neck Surgery, of the University of Würzburg, 62 patients with extensive tumors of the oropharynx underwent surgical treatment (T2 = 6, T3 = 24, T4 = 32). In 40 patients, the resection was performed via a median mandibulotomy approach, in 22 patients using a lateral pharyngotomy. All patients underwent postoperative radiotherapy up to 70 Gy.

RESULTS

Using the Kaplan-Meier method, the five-year survival was 80% for T2, 52% for T3, and 22% for T4. Four patients (7%) presented with a second primary carcinoma, and one also had a third carcinoma. Seven patients who died of T3- and T4-tumors had distant metastases, among them 5 patients who were free of local disease. A regular oral diet was possible on average 14 days postoperatively. All patients underwent tracheostomy. Ninety percent of them were decanulated one year postoperatively.

CONCLUSIONS

Resection of extensive carcinomas of the oropharynx and microvascular reconstruction produces good oncological and functional results. The best access to extensive tumors is provided by a mandibulotomy. The advantage of this excellent approach outweighs an increasing morbidity in occasional cases.

Ionomeric cement implants in the middle ear of the baboon (Papio ursinus) as a primate model

Faced with an inadequate supply of autogenous materials, the otologic surgeon may have to utilize various alloplastic materials to reconstruct bony middle ear structures. Allogenic materials have fallen into disfavor clinically because of the possible spread of infections. Implantation of the hybrid bone substitute ionomeric cement in viscous or hardened physical states into the middle ears of a primate animal model was undertaken in order to be able to approximate as closely as possible conditions found clinically. The posterior meatal wall was replaced by freshly mixed ionomeric cement in nine baboons (Papio ursinus). After repositioning the meatal flap, the residual skin defect was left to secondary epithelialization. After removal of the stapes superstructure, incus and malleus head, a columella of hardened ionomeric cement was trimmed to the appropriate size and inserted between the footplate and the malleus handle. In three cases the prosthesis shaft was fixed in position with freshly mixed cement near the footplate. The time of follow-up ranged from 47 to 277 days. Gross sections were obtained without decalcification (using a Zeiss saw microtome) and stained with Giemsa solution. In no instance was there any spontaneous epithelialization of the external meatus, although occasional granulation was seen to develop at the free edge of the flap and subepithelially. Epithelialization of the alloplastic columellae occurred as early as 42 days post-implantation. Over the middle ears reconstructed with the viscous cement, there was growth of a thickened epithelium that partially tended to granulate. On light microscopy, the bony footplate area was found to be unaffected by the cement that had been applied when still fluid. Our findings indicate that reconstruction of the posterior meatal wall with the viscous ionomeric cement can be useful clinically. The material does not become dislocated but, as with all other alloplastic materials, spontaneous overgrowth of the adjacent meatal skin is unlikely to occur. The early epithelialization of the columellae and their middle ear compatibility and biostability give support to the excellent tolerability of the ionomeric cement. At present, complications occurring during otoneurological application of the material necessitated its commercial withdrawal from the market in May 1995.

Titanium as a biomaterial for ossicular replacement: results after implantation in the middle ear of the rabbit

The middle ear poses unique challenges when finding suitable materials for ossicular reconstruction, primarily because of its link to the external environment via the eustachian tube and, hence, its greater exposure to infectious agents. In this study, the biocompatability of titanium was examined in the middle ear of rabbits by using light and scanning electron microscopy. Implants were placed as middle ear prostheses or as free implants. These were inspected at 28 days, 84 days, 168 days, 336 days and 504 days following implantation for mucosal coverage, percent epithelization and any sign of foreign-body reaction. After 28 days, the prostheses were covered by regular mucosa. Although a majority of the free implants took up to 336 days for complete epithelialization, some of the free implants were not epithelialized even at day 504. There were no inflammatory cells observed on the surface of the material, nor were unusual amounts of fibrous tissue seen. In addition, the titanium material exhibited an affinity toward bone. The results of this animal experiment indicate that titanium is a favorable material for ossicular replacement prostheses.

Titanium and glass-ionomer cement as ossicular replacement materials: biocompatibility results after implantation in the rabbit

The middle ear poses unique challenges when finding suitable materials for ossicular reconstruction, primarily because of its link to the external environment via the eustachian tube, which leads to a greater potential for exposure to infectious agents. In this animal study, the biocompatibilities of titanium and glass-ionomer cement were assessed in the middle ear of the rabbit after being implanted as total ossicular replacement prostheses (TORPs) or as free pins. Animals were sacrificed after 28, 84, 168, 336, or 504 days or 2 years, and a cutting saw technique was used to prepare slides for light microscopy. Slides were examined for mucosal coverage and any sign of foreign body reaction. Both materials showed good acceptance in the middle ear. After 28 days, the TORPs were covered by middle ear mucosa. As expected, it took a longer time (up to 504 days) to cover the free implants. An interesting finding was the growth of new bone on both the surface of the titanium implants and the glass-ionomer prostheses. The results of this animal study indicate that both titanium and glass-ionomer cement are favorable materials for ossicular replacement prostheses.

Titanium as an ossicular replacement material: results after 336 days of implantation in the rabbit

OBJECTIVE

Titanium in other parts of the body, well known for its biocompatibility, was examined in an animal model for its use as an ossicular replacement material.

STUDY DESIGN

The biocompatibility of titanium was studied in the middle ear of rabbits using light and scanning electron microscopy. Titanium pins were placed as middle ear prostheses or as free implants and were examined after 28, 84, 168, and 336 days.

RESULTS

After 28 days, the prostheses were covered by regular mucosa. The free implants took up to 336 days to be totally epithelialized. There were no inflammatory cells observed on the surface of the material nor were unusual amounts of fibrous tissue seen. In addition, the titanium material exhibited an affinity toward bone.

CONCLUSIONS

The results of this animal experiment indicate that titanium is a useful material for ossicular replacement prostheses.