[Bone substitutes used for sinus lift]

In dental surgery today a variety of bone substitutes are used for sinus lift. After the increased application of synthetics during the last decade there has now been a move back to autologous bone transplants, combined with allogenic and xenogenic augmentation materials. The effects of transforming growth factors and recombinant equivalents of bone morphogenetic proteins remain to be seen. Covering the augmented area with a collagen membrane is the basic standard in many cases. Concomitant illnesses of dental origin or of the maxillary sinus have to be assessed prior to any sinus lift. Once complications such as laceration of the Schneiderian membrane, infection or adverse reaction have occurred, early and consistent therapy is required.

[Techniques for correction of the nasal dorsum]

Correction of the nasal dorsum ranks among the most common surgical procedures in rhinoplasty. Due to the involvement of nasal support structures such as septolateral cartilage and the K and scroll areas, these procedures have both aesthetic and functional impacts. In addition to spreader grafts and spreader flaps, the most important surgical methods currently include the split hump reduction technique, cartilage-fascia transplants and cartilage grafts from rib and ear. In addition to serving to correct deformities, the techniques described here help prevent complications such as inverted V, hourglass and saddle nose deformities, as well as nasal valve stenosis. The basic operative principle calls for reinforcement and reconstruction of the anatomical support structures, while avoiding overresection and mucosal lacerations.

[Septal surgery in septorhinoplasty]

In general septoplasty precedes all other procedures in rhinoplasty as a straight, stable septum dictates the aesthetic and functional outcome. The patient's history and expectations, correct preoperative analysis and the surgeon's skills determine the approach in septum correction. As a rule of thumb, slight deviations, e.g. single vomer spurs, maxillary crests, the septal tilt and simple C and S-shaped deformities can be managed endonasally using a hemitransfixion incision and procedures such as the swinging door technique, scoring, batten grafts or caudal septal replacement grafts. In contrast, for severe S-shaped and wave-like deviations, cleft nose deformities, the multiple fractured septum as well as for most revision cases, the open approach with complete septal reconstruction has been found to be the method of choice. After initial general remarks on the basic procedures, the present article focuses on current concepts of septum correction which have to be adapted to the individual pathology.

[Principles of nasal defect repair]

The repair of nasal defects is a frequent challenge to facial plastic surgeons, mainly due to the high frequency of basal cell carcinomas. In general, small defects of up to 1 cm in diameter may be closed directly, whereas larger defects of up to 2.5 cm require the use of local flaps. For more extended defects, regional flaps such as the paramedian forehead flap are the method of choice. These rules have to be modified for the nasal tip, the alar region, the columella and the vestibulum where free skin grafts and auricular composite grafts have to be considered. In order to achieve pleasing aesthetic results, the aesthetic subunits of the nose have to be respected in each situation.

Gene and protein expression of protease-activated receptor 2 in structural and inflammatory cells in the nasal mucosa in seasonal allergic rhinitis

BACKGROUND

Protease-activated receptor 2 (PAR 2) has been shown to be responsible for trypsin and mast cell tryptase-induced airway inflammation. Here, the present study aimed to explore the expression of PAR 2 in the nasal mucosa of seasonal allergic rhinitis (SAR).

METHODS

Study subjects were recruited for the study by medical history, physical examination and laboratory screening tests. Using immunohistochemistry, laser-assisted cell picking and subsequently real-time PCR, nasal mucosa biopsies of SAR patients were investigated for PAR 2 gene and protein expression in complex tissues of the nasal mucosa.

RESULTS

Gene and protein expression of PAR 2 was firstly detected in nasal mucosa of SAR patients. The relative gene expression level of PAR 2 was significantly increased in complex tissues of the nasal mucosa of SAR (6.21+/-4.02 vs. controls: 1.38+/-0.86, P=0.004). Moreover, PAR 2 mRNA expression in epithelial cells (SAR: 4.78+/-4.64 vs. controls: 0.84+/-0.61, P=0.003) but not in mucus (SAR: 1.51+/-1.15 vs. controls: 1.35+/-1.02, P=0.78) and endothelial cells (SAR: 1.20+/-0.57 vs. controls: 1.73+/-1.30, P=0.5) was found to be significantly changed in the nasal mucosa in SAR. Using double immunohistochemistry the present study demonstrated that the total numbers of mast cells (P=0.0003) and eosinophils (P=0.03) and the numbers of eosinophils expressing PAR 2 (P=0.006) were significantly elevated in the nasal mucosa of SAR compared with the controls.

CONCLUSION

The abundant presence and distribution of gene and protein expression of PAR 2 in different cell types in the nasal mucosa under normal situation, the increased expression of PAR 2 in epithelial cells and the increased number of eosinophils with PAR 2 suggest that PAR 2 may contribute to the pathogenesis of allergic diseases such as SAR.

Transcriptional up-regulation of histamine receptor-1 in epithelial, mucus and inflammatory cells in perennial allergic rhinitis

BACKGROUND

Histamine receptors play an important role in the pathogenesis of nasal allergy. Activation of histamine receptor 1 (H1R) and 2 (H2R) can cause allergic symptoms which can be blocked effectively by antihistamines. H1R and H2R transcript levels have been found to be up-regulated in perennial - but not in seasonal - allergic rhinitis (AR). The present study aimed to explore H1R and H2R expression in complex tissues of the nasal mucosa of perennial allergic rhinitis (PAR).

METHODS

Ten patients with PAR and 13 non-AR subjects were recruited for the study by medical history, physical examination and laboratory screening tests. In this study, we have analysed single cells dissected from the nasal mucosa biopsies by laser-assisted microdissection. H1R mRNA expression was analysed in different cell types such as epithelial, endothelial, mucus and inflammatory cells isolated from the nasal mucosa of PAR in comparison with non-AR subjects.

RESULTS

H1R mRNA gene expression level was significantly increased in the nasal mucosa of PAR in comparison with non-AR (P<0.0001). H1R mRNA was significantly elevated in epithelial (P<0.001) and mucus cells (P<0.05) of PAR in comparison with non-AR whereas H1R gene expression levels in endothelial cells between both groups were not changed (P=0.23). Interestingly, inflammatory cells in the nasal mucosa of PAR patients were also strongly expressed H1R mRNA (P<0.001).

CONCLUSION

The present study indicates that PAR alters the expression of H1R mRNA in epithelial, mucus and inflammatory cells of the nasal mucosa and but not in endothelial cells. Therefore, epithelial, mucus and inflammatory cells may play an important role in histamine-mediated allergic airway inflammation in PAR.

Phenotypic alteration of neuropeptide-containing nerve fibres in seasonal intermittent allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is the most common allergic disease affecting the respiratory tract. Next to inflammatory changes, the airway innervation plays an important modulatory role in the pathogenesis of the disease.

OBJECTIVE

To examine the participation of different neuropeptides in the human nasal mucosa of intermittent (seasonal) AR tissues in the allergic season.

METHODS

Immunohistochemistry for substance P (SP), calcitonin gene-related peptide (CGRP), vasoactive intestinal polypeptide (VIP) and neuropeptide tyrosine (NPY) was related to the characterization of inflammatory cells in tissues of patients with seasonal AR (n=18).

RESULTS

While there was a significant increase in the number of eosinophils present if compared with a control group, no changes occurred in mast cell numbers. Immunostaining was abundantly found in different nerve fibre populations of both groups. SP expression was significantly increased in mucosal nerve fibres of patients with intermittent (seasonal) AR. Also, significantly increased numbers of VIP- and NPY-immunoreactive nerve fibres were found in biopsies of rhinitis patients in comparison with sections of normal human nasal mucosa. In contrast, CGRP expression did not change significantly.

CONCLUSION

The increase of neuropeptide expression in mucosal nerve fibres indicates a major role of the autonomous mucosal innervation in the pathophysiology of intermittent (seasonal) AR.

Aspirin-sensitive rhinitis-associated changes in upper airway innervation

Aspirin-sensitive rhinitis is the manifestation of aspirin intolerance in the upper respiratory tract. The disease represents a pseudoallergy against aspirin or related nonsteroidal anti-inflammatory drugs. As a major immunomodulatory role for airway innervation has been proposed in airway inflammatory diseases, the present study assessed changes in human nasal mucosa innervation in patients with aspirin-sensitive rhinitis in comparison to a control group. Immunohistochemistry for protein gene product 9.5, tachykinins, calcitonin gene-related peptide, vasoactive intestinal peptide (VIP) and neuropeptide tyrosine was performed on cryostats sections of nasal mucosa and neuropeptide containing nerves were examined independently using a score grading. In comparison to the control, the aspirin-sensitive rhinitis group had a significant increase of VIP-like immunoreactivity in mucosal nerve fibres. In contrast to constant numbers of mast cells, highly significant increases in the numbers of eosinophils were found in the group of aspirin-sensitive rhinitis patients. In summary, the present quantification of neuropeptide-immunoreactivity of mucosal nerves demonstrated differences in the human nasal mucosa innervation between nonrhinitic and aspirin-sensitive rhinitic individuals. These differences may reflect a pathophysiological role of upper airway innervation in pseudoallergic reactions.

[Statistics on allergology and environmental medicine in the ENT specialty in Germany]

Environmental medicine and allergy were found to be important in the daily ENT practice after statistical analysis and an inquiry among all ENT doctors in Germany. 64% of ENT colleagues do practice allergy, 20% environmental medicine. With reference to all registered ENT doctors 24% are titled allergists, 4% specialists in environmental medicine. Focussing on the teaching there is a big difference between both groups. Whereas training facilities for allergists are reasonable, there are only a few chief instructors for environmental medicine in the ENT society. This fact has to be considered on educational plannings in future.

[The skin prick test and nasal provocation test with individually prepared flour extracts in patients with bakers' rhinitis and asthma]

The reliability of skin prick tests (SPT) may be insufficient for the screening of occupational inhalant allergies. The influence of different flour extracts on the SPT in flour allergic subjects has not been compared previously. In this study, SPT reactions against two commercially available rye and wheat flour extracts and individually prepared extracts from flour samples were compared in 35 patients with known bakers' rhinitis. Flour sensitization was confirmed by a positive nasal provocation test (NPT) and/or serum-specific IgE. The sensitivity of NPT with a combination of rye and wheat flour extracts of individual flour samples was 94%. Wheat and/or rye flour specific IgE (RAST>/=2) was true positive in 86%. The sensitivity of the SPT was 94% for individual rye flour extracts compared to 38% and 59% for two commercially available rye flour extracts and 88% for individual wheat flour extract compared to 53% and 48% for commercially available wheat flour extracts. SPT and sIgE did not reveal a significant difference in prevalence between rye and wheat flour sensitization. Thirty healthy volunteers served as the control group. Three control subjects with histamine equivalent SPT reactions to grass pollen had a positive SPT reaction against individual flour extracts, whereas NPT with undiluted individual flour extracts was negative in all controls. SPT with individually prepared flour extracts appears to be sensitive for the demonstration of inhalant flour allergy. Our findings show that extracts of individual flour samples rather than commercially available extracts should be used for both SPT and NPT if flour allergy is suspected.

[Otoplastic techniques for the correction of protruding ears]

Protruding ears are the most common auricular deformities for which patients seek consultation. These deformities belong to the first degree dysplasias and result from an overdeveloped concha, an underdeveloped anthelix or a prominent lobule. Otoplastic techniques to correct these malformations are based on such surgical principles as suturing, incision, excision, scoring and burring of the auricular cartilage. By emphasizing these basic procedures the most useful techniques are described. Special importance is placed on the indications for surgery, basic principles and techniques used.

Tree-pollen allergy is efficiently treated by short-term immunotherapy (STI) with seven preseasonal injections of molecular standardized allergens

The efficacy and tolerance of short-term immunotherapy (STI) by seven preseasonal injections of tree-pollen allergens (ALK7 Frühblühermischung) was investigated in a double-blind, placebo-controlled, multicenter study with 111 rhinoconjunctivitis patients. Nasal and bronchial symptoms simultaneously analyzed, and nasal symptoms as a single end point, but not the overall score of nasal, bronchial, and conjunctival symptoms, showed a significantly lower increase with STI during birch-pollen exposure (both P=0.033, n=105, Mann-Whitney U-test). However, a selective analysis with patients from centers with high recruitment figures (n> or =10 patients, n=29 STI, n=32 placebo) showed a significantly lower increase of nasal, bronchial, and overall symptom score (STI 11.0 vs placebo 18.0, P=0.001, U-test). STI had equidirected effects on conjunctival, nasal, and bronchial symptoms analyzed as multiple end points, although conjunctival symptoms were not significantly different as a single end point. The seasonal increase in drug use was reduced by 62% in the STI group compared with placebo (P=0.032, t-test). Specific IgG4 increased only after STI (P<0.001); IgE was not significantly different. Eosinophil cationic protein remained unchanged with STI, but significantly increased with placebo in the pollen season (P=0.003). STI was well tolerated. In conclusion, STI was shown to be efficacious and safe for the treatment of patients with tree-pollen rhinoconjunctivitis.

Nitric oxide synthase in the innervation of the human nasal mucosa: correlation with neuropeptides and tyrosine hydroxylase

Nitric oxide (NO) is a powerful mediator in the central and peripheral nervous system. In the present study the authors have examined the human nasal mucosa innervation for the presence of the neuronal isoform of the NO-generating enzyme, NO-synthase (NOS), and its correlation with other neuronal mediators and markers by means of double-labeling immunohistochemistry. NOS-immunoreactive nerve fibers were observed to be numerously present around glands and venous sinusoids and, less frequently, around small arteries and veins. Few fibers were seen in the lamina propria. NOS appeared to be frequently colocalized in nerve fibers with vasoactive intestinal peptide and, occasionally, with substance P and tyrosine hydroxylase, a marker for catecholamine biosynthesis. These findings suggest that neurally released NO is an important regulatory mediator of glandular secretion and blood flow in the nasal mucosa.

Development of an in vitro human nasal epithelial (HNE) cell model

The upper respiratory tract is mainly involved in reactions to airborne substances. So the primary culture of human nasal tissue may provide an application model for assessment of toxic or inflammatory processes caused by environmental pollutants. HNE cells were isolated from nasal tissue biopsies by protease digestion and cultured in serum-free hormone-supplemented medium. When grown on porous membranes at the air-liquid interface, a higher portion of ciliated cells developed within 2 weeks compared with cells maintained submerged. Submerged grown cultures on collagen gel matrix maintained a cuboidal epithelial-like morphology and stained positive for cytokeratin. The primary cultures of nasal cells exhibited a marked activity for acid phosphatase. Second passage HNE cells exhibited marked enzymatic reactivity upon treatment with particulate matter. Induction of the lysosomal marker enzyme acid phosphatase was stronger in cells treated with toluene-extracted diesel exhaust particles compared with cells treated with native diesel exhaust particles. Non-specific esterase activity was increased more than 7-fold by native diesel particles, whereas the induction of esterase activity by extracted particles was relatively low compared with the control group.

[Reconstructive surgery in the head-neck area with regional and free tissue transfer]

BACKGROUND

Operative treatment of head and neck cancer requires radical resection of the tumor with not only severe impairment of important functions like swallowing speech, and respiration but also aesthetic mutilation because of the exposed character of the head and neck region. Therefore the rehabilitation from a functional and cosmetic standpoint is an essential goal of treatment in addition to control of the malignant disease. Fortunately regional plastic surgery offers a variety of options for reconstruction of the defects to receive a solution tailored to each individual patient.

PATIENTS

Between the years 1986 and 1996, 107 patients with advanced head and neck cancer were treated surgically by radical resection of the tumor and plastic reconstruction. In this study we made a retrospective analysis of the functional and aesthetic outcome of the techniques of reconstructive surgery we used for rehabilitation. The sex ratio was 79 males to 28 females. Average age was 59.4 years (ranging from 39 to 78 years). Most of the patients suffered from squamous cell carcinoma of the upper digestive tract (97 cases). The others included an adenocarcinoma of the paranasal sinuses (three cases), adenoid cystic cancer of the palate (two cases), squamous cell carcinoma of the temporal bone (two cases), two deep infiltrating basaliomas in the area of the nose and forehead and one chondrosarcoma of the neck. Our oncological concept includes a radical resection of the tumor and a onestep reconstruction of the defect, if the patient's general condition enables this approach. The surgical techniques we used include the approved pedicled myocutaneous flaps like the pectoralis major flap, latissimus dorsi flap (which can be also applied as a free microvascular tissue graft), temporalis muscle flap, and the free radial forearm flap.

RESULTS

In previous years, the pedicled myocutaneous pectoralis-major- and latissimus-dorsi-flaps were used for reconstruction (n = 67), but the arc of rotation and the huge bulk of the graft are limiting factors for the indication of these techniques. The free forearm flap has increasingly been used to provide an excellent closure of large pharyngeal defects (n = 16), whereas the temporalis flap is useful for restoration after limited resection of the palate (n = 18). Beside these rather invasive procedures, aesthetic rehabilitation may be achieved with bone-anchored epithesis especially after exenteration of the orbit and ablation of the external ear in case of elderly patients with multiple morbidities (n = 5). In most cases, sufficient rehabilitation from the anatomical and functional point of view was possible even after large tumor resections. A main problem can be longstanding aspiration after resection of large areas of the pharyngeal mucosa (n = 8). Complications included eight cases of necrosis of the flaps and seven patients who developed significant seromas at the donor site.

CONCLUSIONS

The potential of modern regional reconstructive surgery enables the surgeon to achieve anatomically and functionally rehabilitation in a one-step procedure in most cases, even after extended resection for head and neck cancer. One should be aware of the fact that these techniques do not offer a significant improvement of prognosis. As such, the aggressiveness of surgical therapy should remain in reasonable relation to the prognosis of the malignant disease.

[Rhinosinusitis in AIDS patients]

We examined microbic infections and topical immunity in 36 AIDS patients with rhinosinusitis (AIDS CDC stage IV b-d) who had an average serum CD4 count of 90/microliters. We also examined the presence of the HIV genome in nasal mucous. Microbiological examination revealed an increased number of fungal infections in addition to bacterial infections with multiresistant strains. There was no evidence of CD4-T cells or HIV reverse transcriptase. The size of study was too small to permit generalised conclusions about the infectious risk of nasal mucous.

[The nasometer. An instrument for the objective study of hyperrhinophonia in cheilognathopalatoschisis patients]

The aim of this study was to evaluate the reliability and validity of the nasometer in diagnosing hypernasality in cleft palate patients. For this purpose the results of the nasometric examination of 30 patients with hypernasality were compared with the results obtained by using the currently taught methods. Sensitivity and specificity of nasometry were high with coefficients, respectively, of 0.80 and 1.00. Overall accuracy reached 0.90. Our results, which correspond almost exactly to those obtained in similar Anglo-American studies, demonstrate that also in German-speaking countries the nasometer can be a reliable instrument for diagnosing hypernasality. Moreover, the nasometer presents the possibility of calculating the extent of hypernasality during routine examination and diagnosis.

Clinical experiences with ofloxacin sequential therapy in chronic ear infections

Quinolones are the drugs of first choice in therapy of chronic ear infections with multiresistant bacteria, especially because of their efficacy against various Pseudomonas species and their lack of ototoxicity. According to clinical experience, best results can be obtained after application of the sequential treatment schedule. To verify this, 61 patients with acute exacerbations of chronic ear infections were treated sequentially with ofloxacin. After a single dose of 400 mg ofloxacin intravenously, the treatment was continued orally with 400 mg once a day over 7 days. Microbiological and serological examination was performed just prior to and 1 week after treatment. Predominant bacteria isolated from the patients' ears were Pseudomonas aeruginosa, Staphylococcus aureus, Proteus spp. and Enterobacteriaceae spp. Following treatment, infections were cured in 23% of cases and 59% showed improvement. Eighteen percent of the cases were persistent, mainly due to epitympanic chronic otitis media, which was an indication for surgical intervention. In general, sequential therapy with ofloxacin revealed encouraging clinical results based on improved patient compliance with the treatment schedule recommended.

[Acute tonsillitis--peritonsillitis--paratonsillar abscess: Differential diagnosis by flexible endosonography]

The role of flexible endosonography in diagnosis of acute tonsillitis and their complications was investigated in 59 patients. Our results show that flexible endosonography enables the examiner to differentiate acute tonsillitis from peritonsillitis and paratonsillar abscess. In particular, abscesses of retrotonsillar spread possibly leading to life-threatening complications can be detected in an early stage.

[Oncogenes and their significance for head and neck cancers]

During the past few decades medical science has accepted the concept that cancer is a fundamental disorder of cellular growth control. A disorder can originate in some cells through changes in genes (DNA level: gene amplification, mutation and rearrangement) or their expression (RNA and protein levels), and stimulates growth in contrast to surrounding cells. Over the last decade genes affected in the cancer cell have been identified as well as the nature of changes undergone. Only a few of the known oncogenes play a role in head and neck cancer. These are epidermal growth factor receptor, c-myc, the ras gene family, int-2, hst-1 and bcl-1. In some clinical disorders, such as childhood neuroblastoma and breast cancer, oncogenes have been shown to play an important role in tumor staging or as a prognostic parameter. The aim for future therapy is the effective application of oncogenes (or "gene therapy") in clinical practice.

[Leiomyosarcoma of the mouth floor and oropharynx]

Leiomyosarcomas arise rarely in the head and neck. We report a 41-year-old woman with an extremely rare leiomyosarcoma of the floor of the mouth extending to the oropharynx. This article stresses the value of imaging methods such as CT, MRI and ultrasound for preoperative diagnosis, and emphasises histopathological findings. The therapeutic principles and prognostic factors of leiomyosarcomas are illustrated on the basis of this case.

[Osteoma of the mid-face area--a rare site]

Osteomas are benign, symptomless, slowly growing tumors that are usually found incidentally. The most frequent site of origin is a paranasal sinus. We report a 17 year old man with an osteoma of the middle face. The history, clinical findings and surgical procedure are described. Aetiological factors and possible complications of paranasal osteomas are discussed.

The role of flexible endosonography in diagnostic imaging of carcinomas of the oral cavity and oropharynx

Currently-used imaging methods often fail to depict carcinomas of the oral cavity and oropharynx properly. Scanning these tumours with recently developed digitally-guided transducers of 5 and 7.5 MHz, we found that diagnosis and assessment are significantly facilitated by flexible endosonography. The demonstration of T1- and T2-tumours was shown to be facilitated by this technique as compared to other imaging methods. The assessment of large tumours is improved in special areas. Nonetheless, we recommend that in such cases flexible endosonography be supported by CT or MRI for a complete demonstration of the extent of the tumour.

[Retrotonsillar abscess. Diagnosis by flexible endosonography]

A retrotonsillar abscess is a dangerous complication of acute tonsillitis that can be fatal if treatment is delayed. We report the pre-operative findings of flexible endosonography and transcutaneous sonography of a patient with retrotonsillar abscess. The results show, that the new digitally guided, flexible probes of endosonography improve the diagnosis of paratonsillar abscess and are superior to transcutaneous sonography especially for delineating retrotonsillar spread.

[Endoscopic B-mode ultrasonography in the diagnosis of head-and-neck tumors]

Examination of 40 patients with malignant laryngeal and/or pharyngeal tumours shows the possibility of utilising endoscopic B-mode-sonography in ENT. The currently available devices enhance diagnostic certainty of the established radiographic methods only in cases involving oropharyngeal or certain recurrent tumours and blood vessel infiltration. The pros and cons of endoscopic ultrasonography as well as case studies are discussed.

[Diagnostic value of sialochemistry. Results of an albumin study]

In 196 patients suffering from disease of the cephalic salivary glands and in 57 healthy controls the concentration of albumin in parotid and submandibular saliva was measured by the immunodiffusion technique. To summarize the results, albumin seems to be a reliable marker of inflammations of the salivary glands even in the early stages and is therefore recommended for the primary diagnostic and the follow-up of acute and chronic inflammatory conditions of the major cephalic salivary glands. In combination with the evaluation of the flow rate, other sialochemic parameters like phosphohexose isomerase and kallikrein activity, B-mode sonography and fine needle aspiration biopsy the frequency of x-ray examination of the radiosensitive salivary glands may be reduced.

[Nasalance: a new concept for objective analysis of nasality]

None of the methods described in the literature on the objective analysis of nasality has so far been introduced in routine diagnosis. The present study describes initial experiences with the nasometer in german language and presents nasalanz as a new term for objective analysis of nasality in german-speaking countries. Typical cases are demonstrated via a rhinophonia test designed for the use of the nasometer. Results obtained in 75 subjects show that nasalanz provides a valid parameter of objective measurement of closed and open rhinophonia and emphasize the value of the nasometer in follow-up studies of surgery as well as in biofeedback therapy of patients suffering from rhinophonia. Fundamental aspects of nasality with reference to the obtained results are discussed.

[Laryngeal obstruction due to familial Recklinghausen's disease]

A case of familial multiple neurofibromatosis with laryngeal involvement is described. The patient required surgical treatment because of rapid tumour growth associated with dyspnoea, dysphonia and dysphagia. Whereas the extensive growth prevented entire removal of all tumour lumps, endolaryngeal microsurgery resulted in an important improvement of laryngeal symptoms and of the quality of life.

[Use of B-mode sonography in the diagnosis of laryngocele]

A case of a combined laryngocele is presented, including clinical features, the histopathological findings, and the treatment of the disease. The article stresses the value of imaging methods such as CT-scan and high-resolution real-time sonography for preoperative diagnosis. Especially note-worthy is the fact that the internal and external parts of laryngoceles, filled with fluid and with air, can be shown by sonography.

[Tonsillolith: clinical picture and mineralogic analysis]

We report the clinical appearance and mechanism of origin of a tonsillolith 7 g in weight, found in a 77-year-old patient and simulating a tumour of the oropharynx. Mineral analysis showed the main ingredients to be CaO and P2O5. Only trace amounts of SiO2, MgO, Na2O and K2O were found.

[Detection of muscle, vein and artery infiltrations of cervical lymphatic metastases]

In a prospective study, 15 patients with squamous cell carcinomas of head and neck and clinical fixed cervical lymph node metastases were examined to determine the value of computed tomography, magnetic resonance imaging and high resolution real time ultrasonography in preoperative recognition of muscle and vessel infiltration. The preoperative findings were compared with the microscopic results of neck specimens and the operative reports. For each diagnostic method sensitivity, specificity, and effectivity were calculated. Ultrasonography, magnetic resonance imaging and computed tomography can assess muscle infiltrations as well. Metastatic infiltrations of carotid arteries are best recognised by ultrasonography and magnetic resonance imaging. Both methods are more valuable than computed tomography. All methods are unsuccessful in detecting infiltrations of the jugular vein. In conclusion, metastatic infiltrations of surrounding tissue, as described by imaging methods, are rarely confirmed by histological results.

[Detection and assessment of cervical lymph node metastases in head-neck tumors. A comparison of methods]

From 1984 to 1987, seventy-two patients with squamous cell carcinomas involving oropharynx, hypopharynx, larynx and cervical lymph nodes, who underwent surgery, were examined to determine the value of computed tomography (CT), magnetic resonance (MR), high-resolution real-time sonography (US) and palpation in preoperative staging of cervical nodal metastases. The clinical staging was compared with the microscopic findings in the neck specimens and with operative reports. For the identification and description of cervical lymph node metastases, US and CT are more valuable than MR and palpation. In comparison to CT, however, US has advantages in most cervical areas as a dynamic method with variable representation of interesting regions. False positive errors are related to confusion with inflammatory nodes in all examinations. Metastatic infiltration of surrounding tissue especially of neck vessels, are best recognised by means of US and MR. However, the high rates of sensitivity and low rates of specificity of all methods point to the possibility of a great number of false positive errors in demonstrating tissue infiltration.