Treatment of Peripheral Neuropathy in Leprosy: The Case for Nerve Decompression

Summary: Plastic surgery has a tradition of caring for patients with facial deformity and hand deformity related to leprosy. The approach, however, to the progressive deformity and disability related to chronic nerve compression is underappreciated in the world today. A cohort of patients with leprous neuropathy from an indigenous area of leprosy in Ecuador was evaluated for the presence of chronic peripheral nerve compression, and 12 patients were chosen for simultaneous upper and lower extremity, unilateral, nerve decompression at multiple levels along the course of each nerve. The results at 1 year of follow-up show that 6 patients improved into the excellent category and 4 patients improved into the good category for improved function. Based on the early results in this small cohort of patients with leprous neuropathy, an approach to peripheral nerve decompression, encompassing the concept of multiple crush at multiple levels of each nerve, seems to offer optimism to improve upper and lower extremity limb function. Long-term studies with quality-of-life outcomes would be welcome.

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The use of a single local analgesics infusion in operation cavity following mastectomy and its effect on postoperative pain—a retrospective cohort study

Abstract

Background

Pain following mastectomy often require use of opioids, drugs associated with a significant number of side effects. This study investigated the effect of a single perioperative infusion of bupivacaine in the mastectomy cavity on the postoperative outcomes: use of opioids, pain score, and nausea.

Methods

This retrospective cohort included 244 women undergoing mastectomies at the Odense University Hospital, Denmark. Thirty-five patients received bupivacaine in the mastectomy cavity and were compared to 209 controls who had no local analgesic.

Results

A reduction in the postoperative use of 6.1 "oral morphine equivalents" (OMEQs) was observed in the infusion group in the first 24 h after mastectomy compared to a control group not receiving infusion. This corresponds to a reduction of 6.1 mg of orally administered morphine, equivalent to a 52 % reduction. This was, however, not statistically significant (p = 0.1208). No statistically significant differences between the two groups were found in visual analogue scale (VAS) scores for pain and nausea or in the use of other nonopioid analgesics.

Conclusions

A single perioperative infusion of bupivacaine may have a morphine-sparing effect in the first 24 h after mastectomy. Our results were however not statistically significant when tested on these low-pain surgical procedures. Infusion of analgesics in surgical cavities is simple, fast, and low cost. It might prevent the often seen vicious cycle of nausea and impaired coping with postsurgical pain when patients are introduced to opioids.

Level of Evidence: Level III, therapeutic study.

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Right-sided aortic arch and aberrant left subclavian artery with or without a left nonrecurrent inferior laryngeal nerve

ABSTRACT

Background

In thyroid surgery, preserving the recurrent laryngeal nerve (RLN) is crucial for preventing postoperative phonatory dysfunction. Right nonrecurrent laryngeal nerves (NRLNs) are not particularly rare, and they are vulnerable to injury during surgery. This anomaly is associated with a right aberrant subclavian artery. Thus, a right-sided aortic arch with an aberrant left subclavian artery (LSA) suggests a possible left NRLN.

Methods

We report the cases of 4 patients with right-sided aortic arch and aberrant LSA. Preoperative imaging studies revealed those anomalies, but no signs of situs inversus. During the surgeries, only 1 of the 4 cases had a left NRLN. We retrospectively evaluated the patients' imaging studies.

Results

An aortic diverticulum was found at the point at which the aberrant LSA originated in the 3 patients with left-RLNs, but not in the patient with the left-NRLN.

Conclusion

In right-sided aortic arch + aberrant LSA cases, the absence of an aortic diverticulum suggests a left NRLN. © 2016 The Authors Head & Neck Published by Wiley Periodicals, Inc. Head Neck, 2016

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Functional outcomes of sensate versus insensate free flap reconstruction in oral and oropharyngeal reconstruction: A systematic review

ABSTRACT

The purposes of this article were to review the literature regarding subjective outcomes, objective functional outcomes, and objective sensation return after sensate and/or insensate free flap reconstruction of the oral cavity and oropharynx. Sensate radial forearm and anterolateral thigh free flaps tend to have better static 2-point discrimination and pressure threshold sensitivity than insensate flaps. There is insufficient evidence to draw conclusions on whether sensate flaps improve functional speech and swallowing outcomes measured by videofluoroscopic swallowing studies and percentage of word intelligibility by a listener blinded to the study. These data highlight the complexity and number of variables affecting functional outcomes in patients who have undergone reconstructive surgery after oral and oropharyngeal cancer ablative operations. A prospective randomized multicenter study that properly and rigidly stratifies patients by defect, flap and recipient nerve choice, adjuvant therapies, and uses widely agreed upon pretreatment and posttreatment evaluation tools could help to answer this important question. © 2016 Wiley Periodicals, Inc. Head Neck, 2016

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Complications after surgery for benign parotid gland neoplasms: A prospective cohort study

Abstract

Background

Prospective studies on procedure-specific incidences of complications after benign parotid surgery are lacking. Predictive factors for postoperative facial dysfunction remain controversial.

Methods

We conducted a prospective study on 132 patients undergoing parotid surgery for benign parotid neoplasms. We analyzed complication rates and assessed risk factors of postoperative transient facial palsy.

Results

Facial palsy rate was 40.2% on the first postoperative day, 28.3% at 2 weeks, 3.9% at 6 months, and 1.6% at 12 months. Immediate postoperative palsy rates in subgroups of partial superficial parotidectomy, superficial parotidectomy, extended parotidectomy, and ECD were 41.5%, 43.8%, 53.8%, and 6.3%, respectively. Age, duration of surgery, and use of ultrasound knife were identified as risk factors for transient facial palsy.

Conclusion

Depending on the operation type, up to half of the patients experience facial palsy after benign parotid surgery. Higher age and longer duration of operation increase the risk. The role of operative instrumentation requires further studies. © 2016 Wiley Periodicals, Inc. Head Neck, 2016

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Bilamina cortical tenting grafting technique for three-dimensional reconstruction of severely atrophic alveolar ridges in anterior maxillae: a 6-year prospective study

Publication date: Available online 29 April 2016
Source:Journal of Cranio-Maxillofacial Surgery
Author(s): Huajie Yu, Luo Chen, Yibo Zhu, Lixin Qiu
ObjectiveTo evaluate the efficacy and long-term outcome of the bilaminar cortical tenting grafting technique for reconstruction of vertical and horizontal alveolar ridge defects.Material and MethodsA bone block harvested from the lateral aspect of the mandibular ramus was bisected into two cortical laminae, which were then used to reconstruct the buccal and palatal walls of an alveolar ridge defect. The inter-laminar space was filled with particulate autogenous bone and the whole graft was covered with anorganic bone graft and collagen membrane. After 4 – 6 months, the width and height of the augmentation were recorded. The study sample consisted of 21 patients who were followed up for 6.09 ± 1.18 years.ResultsVertical and horizontal bone gain was 5.70 ± 1.09 and 8.45 ± 0.87 mm, respectively, and respective resorption rates were 10.20% and 6.15%. One patient showed soft-tissue dehiscence, while all others healed without complication. After an average follow-up of 6 years, the block grafts were well integrated into the recipient sites and there was only a small reduction in the peri-implant bone level (0.77 ± 0.50 mm).ConclusionThis technique was effective and reliable for three-dimensional reconstruction of severely atrophic alveolar ridges in anterior maxillae.



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Olfaction in Chronic Rhinosinusitis

Abstract

Olfactory dysfunction is a frequent complaint in chronic rhinosinusitis patients and has a significant impact on quality of life. Therefore, it is essential that clinicians are aware of the importance of olfactory dysfunction in chronic rhinosinusitis (CRS) patients and know how to deal with it. Notably, the evaluation of olfactory function (i.e., using psychophysical testing) and imagery of olfactory bulb play an important role in the evaluation of patients and give essential information about the "baseline" olfactory function. Because the high impact of olfactory function on quality of life and medical and/or surgical treatment should be proposed to patients. However, it remains difficult to predict the outcome of treatment as well as long-term efficacy. The first section of this review is dedicated to the assessment of olfactory function. Secondly, we will discuss the etiopathology of olfactory dysfunction in CRS with and without nasal polyps. Finally, we will review literature findings about the efficacy of different treatments on olfactory function.

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Subclinical atherosclerosis in patients with recurrent apthous stomatitis.

Related Articles

Subclinical atherosclerosis in patients with recurrent apthous stomatitis.

Oral Dis. 2016 Apr 29;

Authors: Sereflican M, Sereflican B, Dagistan E, Goksugur N, Kizildag B

Abstract
OBJECTIVE: Recurrent aphtous stomatitis (RAS) is an inflammatory oral mucosal disease. It has been known that inflammatory cascade plays important role in the atherosclerotic process. The aim of the study was to investigate the relationship between subclinical atherosclerotic findings and a systemic inflammatory disease, RAS.
METHODS: In total, 32 patients with RAS were matched with 30 control subjects on the basis of age, sex, and major cardiovascular risk factors. Laboratory parameters including lipid profiles were determined for patients and controls. B-mode ultrasonography was used to assess carotid extra-medial thickness (cEMT) and carotid intima-media thickness (cIMT).
RESULTS: Both cEMT and cIMT in the RAS group were significantly higher than in the control group (p = 0.002 and 0.013, respectively). There was a significant positive correlation between cIMT and cEMT (r = 0.381, p = 0.034). cIMT was positively correlated with age, triglyceride levels, and systolic blood pressure, while cEMT was positively correlated with age in patients with RAS.
CONCLUSIONS: To our knowledge, this is the first reported study to evaluate cEMT and cIMT in patients with RAS. This study presents morphological evidence of subclinical atherosclerosis in patients with RAS. Further studies investigating the relationship between atherosclerosis and RAS are needed. This article is protected by copyright. All rights reserved.

PMID: 27128209 [PubMed - as supplied by publisher]

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The prevalence of dysphagia among adults in the United States.

Related Articles

The prevalence of dysphagia among adults in the United States.

Otolaryngol Head Neck Surg. 2014 Nov;151(5):765-9

Authors: Bhattacharyya N

Abstract
OBJECTIVE: To determine the prevalence of dysphagia, reported etiologies, and impact among adults in the United States.
STUDY DESIGN: Cross-sectional analysis of a national health care survey.
SUBJECTS AND METHODS: The 2012 National Health Interview Survey was analyzed, identifying adult cases reporting a swallowing problem in the preceding 12 months. In addition to demographic data, specific data regarding visits to health care professionals for swallowing problems, diagnoses given, and severity of the swallowing problem were analyzed. The relationship between swallowing problems and lost workdays was assessed.
RESULTS: An estimated 9.44 ± 0.33 million adults (raw N = 1554; mean age, 52.1 years; 60.2% ± 1.6% female) reported a swallowing problem (4.0% ± 0.1%). Overall, 22.7% ± 1.7% saw a health care professional for their swallowing problem, and 36.9% ± 0.1.7% were given a diagnosis. Women were more likely than men to report a swallowing problem (4.7% ± 0.2% versus 3.3% ± 0.2%, P < .001). Of the patients, 31.7% and 24.8% reported their swallowing problem to be a moderate or a big/very big problem, respectively. Stroke was the most commonly reported etiology (422,000 ± 77,000; 11.2% ± 1.9%), followed by other neurologic cause (269,000 ± 57,000; 7.2% ± 1.5%) and head and neck cancer (185,000 ± 40,000; 4.9% ± 1.1%). The mean number of days affected by the swallowing problem was 139 ± 7. Respondents with a swallowing problem reported 11.6 ± 2.0 lost workdays in the past year versus 3.4 ± 0.1 lost workdays for those without a swallowing problem (contrast, +8.1 lost workdays, P < .001).
CONCLUSION: Swallowing problems affect 1 in 25 adults, annually. A relative minority seek health care for their swallowing problem, even though the subjective impact and associated workdays lost with the swallowing problem are significant.

PMID: 25193514 [PubMed - indexed for MEDLINE]

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Peri-implant bony overgrowth as a cause of revision surgery in auditory osseointegrated implantation

Publication date: July 2016
Source:International Journal of Pediatric Otorhinolaryngology, Volume 86
Author(s): Jared J. Tompkins, Dana K. Petersen, Daniel D. Sharbel, Brian J. McKinnon, C. Bruce MacDonald
Implantation of auditory osseointegrated implants, also known as bone-anchored hearing systems (BAHS), represents a surgical option for select pediatric patients aged 5 years or older with hearing loss. Functional indications in this patient population include conductive or mixed hearing loss. Common complications of implantation include skin infections, chronic skin irritation, hypertrophic skin overgrowth, and loose abutments. In a case series of 15 pediatric patients, we discovered an unexpectedly high skin-related complication rate requiring surgical revision of 53%. During revision surgery, we discovered 5 patients who exhibited significant bony overgrowth at the abutment site, a complication infrequently noted in past literature.



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Occlusal force characteristics of masseteric muscles after intramuscular injection of botulinum toxin A(BTX – A)for treatment of temporomandibular disorder

Publication date: Available online 29 April 2016
Source:British Journal of Oral and Maxillofacial Surgery
Author(s): Long-dan Zhang, Qi Liu, De-rong Zou, Lv-feng Yu
Our aim was to evaluate the occlusal force and therapeutic efficacy of the masseteric muscles after intramuscular injection of botulinum toxin A (BTX-A) for the treatment of patients with concurrent temporomandibular disorders (TMD) and bruxism. Thirty patients with TMD associated with bruxism were randomised into three groups (n=10 in each group), and treated by bilateral intramuscular injection of BTX-A into the masseter, placebo, or control. We used an occlusal force analysis system to collect several measures of occlusal force such as duration of biting and closing, the maximum occlusal force, and the distribution of occlusal force. The occlusal force in the intercuspid position was reduced in all three groups. There was a significant difference between the BTX-A and placebo groups (F(df=1)=8.08, p=0.01) but not between the control group and the other two(F(df=1)=4.34, p=0.047). The duration of occlusion was significantly increased in the BTX-A group after 3 months' treatment (t=4.07, p=0.003). The asymmetrical distribution of occlusal force was reduced in all three groups, but not significantly so (Levene's test F(df=2)=0.25, p=0.78,ANOVA F(df=2)=0.50, p=0.61). Treatment of TMD with BTX-A is effective in reducing the occlusal force, but psychological intervention plays an important part in treatment.



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Retropharyngeal Steroids and Dysphagia Following Multilevel Anterior Cervical Surgery.

Retropharyngeal Steroids and Dysphagia Following Multilevel Anterior Cervical Surgery.

Spine (Phila Pa 1976). 2016 May;41(9):E530-E534

Authors: Koreckij TD, Davidson AA, Baker KC, Park DK

Abstract
STUDY DESIGN: A retrospective case-control study.
OBJECTIVE: The aim of this study was to determine the effect of retropharyngeal steroids on postoperative dysphagia scores and clinical outcomes following multilevel anterior cervical discectomy and fusion (ACDF).
SUMMARY OF BACKGROUND DATA: Dysphagia is a well-known complication following ACDF surgery and increased rates of dysphagia are seen with increased levels of surgery. Retropharyngeal steroids have been shown to decrease painful swallowing and prevertebral soft tissue (PSTS) swelling in 1- and 2-level anterior cervical surgery.
METHODS: A retrospective review of 44 patients undergoing multilevel (2-, 3-, 4-level) ACDF. Twenty-two patients who received retropharyngeal steroids (methylprednisone) placed on a collagen sponge at the time of surgery were compared with a matched cohort of controls who did not receive local steroids. Postoperative day 1 and 6-week radiographs were analyzed for differences in PSTS. Clinical outcomes were measured pre-operatively, 6 weeks, and 3 months postoperatively utilizing the Neck Disability Index (NDI), the Bazaz-Yoo Dysphagia Scoring System, and Eat Assessment Tool (EAT-10).
RESULTS: Significant improvement in dysphagia scores were seen utilizing both outcome measures. Bazaz-Yoo scores were significantly better at both 6 weeks and 3 months in patients receiving local steroids compared with controls (P = 0.008 and P = 0.022, respectively). EAT-10 showed similar improvement of the steroid group versus control at 6 weeks and 3 months (P = 0.067 and P = 0.012, respectively). A trend toward decreased PSTS was found with locally delivered steroids on initial postoperative radiographs (P = 0.07), but was no longer evident at 6 weeks. NDI, although improved from pre-operative scores, failed to demonstrate significant differences between groups. No differences in length of stay or complications were observed between the groups.
CONCLUSION: The use of retropharyngeal steroids resulted in decreased rates of dysphagia following multilevel ACDF. Locally delivered methylprednisone did not result in increased rates of short-term postoperative complications.
LEVEL OF EVIDENCE: 4.

PMID: 27128258 [PubMed - as supplied by publisher]

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Dysphagia in Tongue Cancer Patients Before and After Surgery.

Dysphagia in Tongue Cancer Patients Before and After Surgery.

J Oral Maxillofac Surg. 2016 Apr 2;

Authors: Huang ZS, Chen WL, Huang ZQ, Yang ZH

Abstract
PURPOSE: To define factors influencing postoperative aspiration in tongue cancer patients and to analyze the characteristics of dysphagia before and after surgery.
MATERIALS AND METHODS: A total of 112 tongue cancer patients participated in this work. Videofluoroscopic swallowing studies were performed in all patients before and after surgery. A Penetration-Aspiration Scale score of 3 or greater was defined as an aspiration risk. Qualitative data were collected on a frame-by-frame basis from each videofluoroscopic swallowing study and analyzed.
RESULTS: Smoking (58.14%, P < .01), tongue resection greater than 50% (38.71%, P < .05), and advanced tumor stage (49.18%, P < .01) were strong risk factors for aspiration. High incidences of inadequate tongue movement, delayed oral transit time, reduced hyoid bone elevation, poor aspiration or penetration, vallecula epiglottica, and residual material in the pyriform sinuses were evident after surgery (all P < .001). The Penetration-Aspiration Scale score was significantly higher after surgery than before surgery. The incidence of silent aspiration increased to 6.25% postoperatively.
CONCLUSIONS: Smoking, larger tongue resection, and advanced tumor stage were strong risk factors for postoperative aspiration and dysphagia complications in tongue cancer patients. The aspiration rate was higher after surgery. Further studies should focus on the prevention and early treatment of dysphagia, especially postoperative aspiration, in tongue cancer patients.

PMID: 27126392 [PubMed - as supplied by publisher]

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Epidemiology of globus symptoms and its associated psychological factors in China.

Epidemiology of globus symptoms and its associated psychological factors in China.

J Dig Dis. 2016 Apr 29;

Authors: Tang B, Cai HD, Xie HL, Chen DY, Jiang SM, Jia L, Jiang SM, Xie HL

Abstract
AIM: To investigate epidemiological and psychological characteristics of globus symptoms in China.
METHODS: Three thousand three hundred and sixty individuals were randomly selected and invited to participate in the study. Subjects completed questionnaires about demographic characteristics, globus symptomatology questionnaire,Glasgow-Edinburgh Throat Scale, psychological characteristics, quality of sleep and life. Subjects who reported having experienced a globus sensation in their lifetime and there is no history of GERD, true dysphagia, odynophagia or alerting signal such as weight loss or hoarseness were judged as having globus.
RESULTS: A total of 3006 subjects completed the questionnaires, giving a response rate of 89.46%. The overall lifetime prevalence of globus was 21.46%, with a peak onset age in 35-54 years old. Lifetime prevalence of globus was higher in the urban area than in the rural area (26.48% vs. 16.41%, P = 0.001). No gender-related difference in prevalence was observed (female: 22.67%, male: 20.05%, P = 0.082). The incidence of anxiety, depression, and sleep disorders was significantly higher in respondents with globus than in respondents without globus (39.84% vs. 22.28%, P = 0.001; 31.16% vs. 17.96%, P = 0.001; and 23.72% vs. 13.55%, P = 0.001, respectively). Scores on all dimensions of the 36-item short-form health survey except physical function were lower in respondents with globus than in respondents without globus (all P < 0.05).
CONCLUSION: Globus symptoms is common, often accompanied by psychological and sleep disorders. The medical community should pay more attention to it.

PMID: 27125332 [PubMed - as supplied by publisher]

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The Effect of Optokinetic Stimulation on Perceptual and Postural Symptoms in Visual Vestibular Mismatch Patients.

The Effect of Optokinetic Stimulation on Perceptual and Postural Symptoms in Visual Vestibular Mismatch Patients.

PLoS One. 2016;11(4):e0154528

Authors: Van Ombergen A, Lubeck AJ, Van Rompaey V, Maes LK, Stins JF, Van de Heyning PH, Wuyts FL, Bos JE

Abstract
BACKGROUND: Vestibular patients occasionally report aggravation or triggering of their symptoms by visual stimuli, which is called visual vestibular mismatch (VVM). These patients therefore experience discomfort, disorientation, dizziness and postural unsteadiness.
OBJECTIVE: Firstly, we aimed to get a better insight in the underlying mechanism of VVM by examining perceptual and postural symptoms. Secondly, we wanted to investigate whether roll-motion is a necessary trait to evoke these symptoms or whether a complex but stationary visual pattern equally provokes them.
METHODS: Nine VVM patients and healthy matched control group were examined by exposing both groups to a stationary stimulus as well as an optokinetic stimulus rotating around the naso-occipital axis for a prolonged period of time. Subjective visual vertical (SVV) measurements, posturography and relevant questionnaires were assessed.
RESULTS: No significant differences between both groups were found for SVV measurements. Patients always swayed more and reported more symptoms than healthy controls. Prolonged exposure to roll-motion caused in patients and controls an increase in postural sway and symptoms. However, only VVM patients reported significantly more symptoms after prolonged exposure to the optokinetic stimulus compared to scores after exposure to a stationary stimulus.
CONCLUSIONS: VVM patients differ from healthy controls in postural and subjective symptoms and motion is a crucial factor in provoking these symptoms. A possible explanation could be a central visual-vestibular integration deficit, which has implications for diagnostics and clinical rehabilitation purposes. Future research should focus on the underlying central mechanism of VVM and the effectiveness of optokinetic stimulation in resolving it.

PMID: 27128970 [PubMed - as supplied by publisher]

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Dilemmatic group memberships of hard-of-hearing employees during the process of acquiring and adapting to the use of hearing aids.

Dilemmatic group memberships of hard-of-hearing employees during the process of acquiring and adapting to the use of hearing aids.

Int J Rehabil Res. 2016 Apr 28;

Authors: Koskela I, Ruusuvuori J, Juvonen-Posti P, Nevala N, Husman P, Aaltonen T, Lonka E, Laakso M

Abstract
We describe how hard-of-hearing (HOH) employees renegotiate both their existing and new group memberships when they acquire and begin to use hearing aids (HAs). Our research setting was longitudinal and we carried out a theory-informed qualitative analysis of multiple qualitative data. When an individual discovers that they have a hearing problem and acquire a HA, their group memberships undergo change. First, HOH employees need to start negotiating their relationship with the HOH group. Second, they need to consider whether they see themselves as members of the disabled or the nondisabled employee group. This negotiation tends to be context-bound, situational, and nonlinear as a process, involving a back-and-forth movement in the way in which HOH employees value different group memberships. The dilemmatic negotiation of new group memberships and the other social aspects involved in HA rehabilitation tend to remain invisible to rehabilitation professionals, occupational healthcare, and employers.

PMID: 27128825 [PubMed - as supplied by publisher]

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Orofacial reflex myocloni. Definition, relation to epilepsy syndromes, nosological and prognosis significance. A focused review.

Related Articles

Orofacial reflex myocloni. Definition, relation to epilepsy syndromes, nosological and prognosis significance. A focused review.

Seizure. 2015 Aug;30:1-5

Authors: Yacubian EM, Wolf P

Abstract
PURPOSE: There is increasing awareness that reflex epileptic mechanisms provide unique insight into ictogenesis in human epilepsies. Among the complex triggers of seizures, this review considers orofacial reflex myocloni (ORM) from the aspects of history and delineation, clinical and electroencephalographic presentation, syndromatic relations, prevalence, mechanisms of ictogenesis and nosological implications, treatment and prognosis.
METHODS: We reviewed all published articles and case reports on ORM in order to clarify clinical and electroencephalographic findings, treatment and outcome.
RESULTS: ORM, besides Reading Epilepsy (RE), is closely related to idiopathic generalized epilepsies especially Juvenile Myoclonic Epilepsy (JME) where hyperexcitability of the network supporting linguistic communication seems to provide the precondition for eliciting reflex myocloni in the perioral muscles active in the precipitating task.
CONCLUSION: The conclusions on ictogenesis derived from ORM support the concept of both, RE and JME, as system disorders of the brain.

PMID: 26216677 [PubMed - indexed for MEDLINE]

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Immunity in young adult survivors of childhood leukemia is more similar to elderly rather than age-matched controls: Role of cytomegalovirus (CMV)

Many treatment complications which occur late in childhood cancer survivors resemble age-related co-morbidities observed in the elderly. An immune phenotype characterized by increased immune activation, systemic inflammation and accumulation of late-differentiated memory CD57⁺CD28⁻ T cells has been associated with co-morbidities in the elderly. Here we explored if this phenotype was present in young adult leukemia survivors following an average of 19 years from chemotherapy and/or radiotherapy completion, and compared this with that in age-matched controls. We found that markers of systemic inflammation – IL-6 and human C-reactive protein (hCRP) and immune activation – CD38 and HLA-DR on T cells, sCD163 from monocytes and macrophages – were increased in survivors compared to controls. T-cell responses specific to cytomegalovirus (CMV) were also increased in survivors compared to controls while CMV IgG levels in survivors were comparable to levels measured in the elderly (>50years) and correlated with IL-6, hCRP, sCD163 and CD57⁺CD28⁻ memory T cells. Immune activation and inflammation markers correlated poorly with prior chemotherapy and radiotherapy exposure. These data suggest that CMV infection/reactivation is strongly correlated with the immunological phenotype seen in young childhood leukemia survivors and these changes may be associated with the early onset of age-related co-morbidities in this group.

This article is protected by copyright. All rights reserved

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Distinct IL-7 signaling in recent thymic emigrants versus mature naïve T cells controls T-cell homeostasis

Interleukin-7 (IL-7) is essential for T-cell survival but its availability is limited in vivo. Consequently, all peripheral T cells, including recent thymic emigrants (RTEs) are constantly competing for IL-7 to survive. RTEs are required to replenish TCR diversity and rejuvenate the peripheral T-cell pool. However, it remains unknown how RTEs successfully compete with resident mature T cells for IL-7. Moreover, RTEs express low levels of IL-7 receptors, presumably rendering them even less competitive. Here we show that, surprisingly, RTEs are more responsive to IL-7 than mature naïve T cells as demonstrated by markedly increased STAT5 phosphorylation upon IL-7 stimulation. Nonetheless, adoptive transfer of RTE cells into lymphopenic host mice resulted in slower IL-7-induced homeostatic proliferation and diminished expansion compared to naïve donor T cells. Mechanistically, we found that IL-7 signaling in RTEs preferentially upregulated expression of Bcl-2, which is anti-apoptotic but also anti-proliferative. In contrast, naïve T cells showed diminished Bcl-2 induction but greater proliferative response to IL-7. Collectively, these data indicate that IL-7 responsiveness in RTE is designed to maximize survival at the expense of reduced proliferation, consistent with RTE serving as a subpopulation of T cells rich in diversity but not in frequency.

This article is protected by copyright. All rights reserved

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IL-10 promotes homeostatic proliferation of human CD8+ memory T cells and, when produced by CD1c+ DCs, shapes naive CD8+ T-cell priming

IL-10 is an anti-inflammatory cytokine that inhibits maturation and cytokine production of dendritic cells (DCs). Although mature DCs have the unique capacity to prime CD8⁺ cytotoxic T -lymphocytes (CTL), IL-10 can promote CTL responses. To understand these paradoxic findings, we analyzed the role of IL-10 produced by human APC subsets in T-cell responses.IL-10 production was restricted to CD1c⁺ DCs and CD14⁺ monocytes. Interestingly, it was differentially regulated, since R848 induced IL-10 in DCs, but inhibited IL-10 in monocytes. Autocrine IL-10 had only a weak inhibitory effect on DC maturation, cytokine production and CTL priming with high-affinity peptides. Nevertheless, it completely blocked cross-priming and priming with low-affinity peptides of a self/tumor-antigen. IL-10 also inhibited CD1c⁺ DC-induced CD4⁺ T-cell priming and enhanced Foxp3 induction, but was insufficient to induce T-cell IL-10 production. CD1c⁺ DC-derived IL-10 had no effect on DC-induced secondary expansions of memory CTL. However, IL-15-driven, TCR-independent proliferation of memory CTL was enhanced by IL-10.We conclude that DC-derived IL-10 selects high-affinity CTL upon priming. Moreover, IL-10 preserves established CTL memory by enhancing IL-15-dependent homeostatic proliferation. These combined effects on CTL priming and memory maintenance provide a plausible mechanism how IL-10 promotes CTL responses in humans.

This article is protected by copyright. All rights reserved

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Monocyte/macrophage lineage commitment and distribution are affected by the lack of regulatory T cells in scurfy mice

Foxp3⁺ regulatory T (Treg) cells play a pivotal role in maintaining immunological tolerance. Loss-of-function mutations in the Foxp3 gene result in multi-organ inflammation known as IPEX syndrome in humans and scurfy (Sf) disease in mice. While the impact of missing Treg cells on adaptive immune cells is well documented, their role in regulation of myeloid cells remains unclear. Here we report that Sf mice exhibit an altered composition of stem and progenitor cells, characterized by increased numbers of myeloid precursors and higher efficiency of macrophage generation ex vivo. The proportion of monocytes/macrophages in the bone marrow, blood and spleen was significantly elevated in Sf mice, which was accompanied with tissue-specific monocyte expression of homing receptor and phagocytic activity. Sf mice displayed high levels of M-CSF and other inflammatory cytokines, including monocyte-recruiting chemokines. Adoptive transfer of wild type CD4⁺ cells and in vivo neutralization of M-CSF normalized frequencies of monocyte subsets and their progenitors and reduced high levels of monocyte-related cytokines in Sf mice, while Treg cell transfer to RAG2^−/− mice had no effect on myelopoiesis and monocyte/macrophage counts. Our findings illustrate that deregulated myelopoiesis in Sf mice is mainly caused by the inflammatory reaction resulting from the lack of Treg cells.

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NIH Funding in Plastic Surgery: A Crisis?.

Background: Decreasing funding rates and increasing competition for National Institutes of Health (NIH) research grants have prompted diverse interventions in various fields of biomedicine. Currently, the state of NIH funding for plastic surgery research is poorly understood. The purpose of this study was to describe the portfolio of NIH grants in academic plastic surgery. Methods: Plastic surgery faculty at integrated and independent programs were individually queried in the NIH RePORTER for grants awarded in 2014. Funding totals, mechanisms, and institutes were calculated. Abstracts were categorized by research type and field of interest. Characteristics of NIH-funded principal investigators were elucidated. Results: 861 academic plastic surgeons at 94 programs were queried and only 18 investigators (2.1%) were funded at 12 programs (12.8%). NIH-funded investigators were predominately male (72%), fellowship-trained (61%), and 49.3 +/- 7.8 years old. A total of 20 awards amounted to $6,916,886 with an average award of $345,844 +/- $222,909. Costs were primarily awarded through the R01 mechanism (77.2%). The top three NIH institutes awarded 72.9% of the entire portfolio. Funding supported clinical (41.1%), translational (36.9%), and basic science (22.0%) research. Craniofacial (20.5%), hand (18.7%), and breast (16.2%) had the greatest funding. Conclusions: Few programs and faculty drive the NIH portfolio of plastic surgery research. These data suggest a tenuous funding situation which may be susceptible to future spending cuts. Future research is needed to identify barriers to NIH funding procurement in academic plastic surgery. (C)2016American Society of Plastic Surgeons

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Allergan Style 410 Implants for Breast Reconstruction - A Prospective Study in Efficacy, Safety, and Symmetry.

Introduction: Implant based breast reconstruction is performed with both saline and silicone. In 2001 a study began using a novel implant made of highly cohesive silicone gel in anatomic shape. It differs from others because it holds its anatomic shape and forces tissue to conform to the implant. Methods: 212 consecutive patients who underwent reconstruction with Allergan 410 cohesive gel anatomic implants were prospectively enrolled over a 12-year period. Complications and satisfaction rates were recorded. Results: Average age was 48.5 and average BMI 24.1. Bilateral reconstruction was performed in 83% of patients. Long-term follow up was achieved in all patients and averaged 3.3 years (0.5-10.2 years). The overall complication rate was 19.8%, most were minor complications such as rippling (9.4%) and asymmetry (4.2%). Major complications included infection (2.4%), malposition (1.4%), capsular contracture (0.9%), seroma (0.5%), extrusion (0.5%), and implant rupture (0.5%). The rate of implant related reoperation, excluding cancer recurrence, was 9.0%, consisting of implant replacement (5.7%), implant removal (1.9) and implant repositioning (1.4%). Patient satisfaction averaged 4.83 (range 2-5) on a 5-point scale. Surgeon satisfaction averaged 4.9 (range 2-5). Conclusions: Allergan 410 cohesive gel anatomic implants have a favorable risk profile in reconstruction with excellent patient and surgeon satisfaction. This novel implant allows for a paradigm shift in implant-based breast reconstruction. Surgeons can now use an implant to help shape the final contour of the breast mound rather than rely on mastectomy flaps and suture techniques to create aesthetic contours needed to create an attractive breast reconstruction. (C)2016American Society of Plastic Surgeons

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Breast Implants' Capsular Rupture.

No abstract available

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Distraction osteogenesis for surgical treatment of craniosynostosis: a systematic review.

Background: Distraction osteogenesis (DO) has been proposed as an alternative to cranial remodeling surgery (CRS) for craniosynostosis, but technique descriptions and outcome analyses are limited to small case series. This review summarizes operative characteristics and outcomes of DO for craniosynostosis and presents data comparing DO to CRS. Methods: A systematic review of the literature was undertaken. Descriptive analysis, operative technical data, outcomes, or post-operative complications of DO for craniosynostosis were included. Results: A total of 1,325 citations were reviewed yielding 53 articles and 880 children who underwent DO for craniosynostosis. Conventional distraction plates (standard DO) were used in 754 (86%) patients, whereas spring-assisted DO was used with the remaining 126 (14%) patients. Conventional and Spring DO was reported to successfully treat the primary condition 98% of the time. However, suboptimal results were reported in 11 (1.3%) patients. There were no stated relapse or revision surgeries. Minor complications were reported in 19.5% (n= 172) of cases, while major complications were rare, occurring in 3.5% (n=31) of cases, and included 2 reported deaths. Absolute operative times and blood loss were marginally greater for CRS cases, but not statistically significant. Conclusion: As a technique for cranial vault remodeling, DO is effective in treating craniosynostosis. No statistical differences were found with respect to operative time, blood loss, need for transfusion, or intensive care resources compared to CRS. Outcome studies with longer follow up periods specifically investigating cost, relapse, and reoperation rates are necessary to effectively compare this treatment modality as an alternative to CRS. (C)2016American Society of Plastic Surgeons

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Reply to the Letter to the Editor regarding The Use of Autologous Fat Grafting for Treatment of Scar Tissue and Scar Related Conditions: A Systematic Review.

No abstract available

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The role of facial canal diameter in pathogenesis and grade of Bell's palsy: a study by high resolution computed tomography

Publication date: Available online 29 April 2016
Source:Brazilian Journal of Otorhinolaryngology
Author(s): Onur Celik, Gorkem Eskiizmir, Burak Ulkumen, Gokce Tanyeri Toker, Yuksel Pabuscu
IntroductionThe exact etiology of Bell's palsy still remains obscure. The only authenticated finding is the inflammation and edema of the facial nerve (FN) leading entrapment inside the facial canal.ObjectiveTo identify if there is any relationship between the grade of Bell's palsy and diameter of the facial canal and also to study any possible anatomic predisposition of facial canal for Bell's palsy including parts which have not been studied before.MethodsMedical records and temporal computed tomography scans of 34 patients with Bell's palsy were utilized in this retrospective clinical study. Diameters of both facial canals (affected and unaffected) of each patient were measured at labyrinthine segment, geniculate ganglion, tympanic segment, second genu, mastoid segment and stylomastoid foramen. House-Brackmann (HB) scale of each patient at presentation and 3 months after the treatment were evaluated from their medical records. The digital the paired samples t-test and Wilcoxon signed-rank test were used for comparison of width between the affected side and unaffected side. The Wilcoxon signed-rank test was also used for evaluation of relationship between the diameter of facial canal and the grade of the Bell's palsy. Significant differences were established at a level of p=0.05 (IBM SPSS Statistics for Windows, Version 21.0.; Armonk, NY, IBM Corp).ResultsThirty-four patients – 16 females, 18 males; mean age±Standard Deviation (SD), 40.3±21.3 with Bell's palsy were included in the study. According to the HB facial nerve grading system; 8 patients were grade V, 6 were grade IV, 11 were grade III, 8 were grade II and 1 patient was grade I. The mean width at the labyrinthine segment of the facial canal in the affected temporal bone was significantly smaller than the equivalent in the unaffected temporal bone (p=0.00). There was no significant difference between the affected and unaffected temporal bones at the geniculate ganglion (p=0.87), tympanic segment (p=0.66), second genu (p=0.62), mastoid segment (p=0.67) and stylomastoid foramen (p=0.16). We did not found any relationship between the HB grade and the facial canal diameter at the level of labyrinthine segment (p=0.41), tympanic segment (p=0.12), mastoid segment (p=0.14), geniculate ganglion (p=0.13) and stylomastoid foramen (p=0.44), while we found significant relationship at the level of second genu (p=0.02).ConclusionWe found the diameter of labyrinthine segment of facial canal as an anatomic risk factor for Bell's palsy. We also found significant relationship between the HB grade and FC diameter at the level of second genu. Future studies (MRI-CT combined or 3D modeling) are needed to promote this possible relevance especially at second genu. Thus, in the future it may be possible to decompress particular segments in high grade BP patients.



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Feasibility of ossicular chain reconstruction with resin cement

Publication date: Available online 29 April 2016
Source:Brazilian Journal of Otorhinolaryngology
Author(s): Fernando de Andrade Quintanilha Ribeiro, Yumi Tamaoki, Gabriel Wynne Cabral
IntroductionDisjunction of ossicular chain is a common finding in middle ear chronic disease. In addition to ossicular interposition, various materials have been used reconstruction, such as ceramic prostheses, polyethylene, and titanium.ObjectiveBecause of the high cost of the available options, the authors proposed to reconstruct the ossicular chain with resin cement, a material normally used in dental reconstruction and fixation.MethodsTwo anatomical parts of the temporal bones are be used, creating a disjunction of the ossicular chain between the anvil and stirrup and then rebuilding with resin cement. These reconstructions were repeated four times by three different surgeons to ensure the feasibility of the method.ResultsA total of 12 reconstructions were made, four per surgeon. After applying the cement, it could be verified by touch that the space was filled properly by the material used. Proper articulation with motion transfer to the entire ossicular chain was also observed.ConclusionResin cement is a suitable material in the reconstruction of ossicular chain injury, and it is inexpensive and technically simple.



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Assessment of hearing threshold in adults with hearing loss using an automated system of cortical auditory evoked potential detection

Publication date: Available online 29 April 2016
Source:Brazilian Journal of Otorhinolaryngology
Author(s): Alessandra Spada Durante, Margarita Bernal Wieselberg, Nayara Costa, Sheila Carvalho, Beatriz Pucci, Nicolly Gudayol, Kátia de Almeida
IntroductionThe use of hearing aids by individuals with hearing loss brings a better quality of life. Access to and benefit from these devices may be compromised in patients who present difficulties or limitations in traditional behavioral audiological evaluation, such as newborns and small children, individuals with auditory neuropathy spectrum, autism, and intellectual deficits, and in adults and the elderly with dementia. These populations (or individuals) are unable to undergo a behavioral assessment, and generate a growing demand for objective methods to assess hearing. Cortical auditory evoked potentials (CAEP) have been used for decades to estimate hearing thresholds. Current technological advances have lead to the development of equipment that allows their clinical use, with features that enable greater accuracy, sensitivity, and specificity, and the possibility of automated detection, analysis, and recording of cortical responses.ObjectiveTo determine and correlate behavioral auditory thresholds with cortical auditory thresholds obtained from an automated response analysis technique.MethodsThe study included 52 adults, divided into two groups: 21 adults with moderate to severe hearing loss (study group); and 31 adults with normal hearing (control group). An automated system of detection, analysis, and recording of cortical responses (HEARLab^®) was used to record the behavioral and cortical thresholds. The subjects remained awake in an acoustically treated environment. Altogether, 150 tone bursts at 500, 1000, 2000, and 4000Hz were presented through insert earphones in descending-ascending intensity. The lowest level at which the subject detected the sound stimulus was defined as the behavioral (hearing) threshold (BT). The lowest level at which a cortical response was observed was defined as the cortical electrophysiological threshold (CET). These two responses were correlated using linear regression.ResultsThe cortical electrophysiological threshold was, on average, 7.8dB higher than the behavioral for the group with hearing loss and, on average, 14.5dB higher for the group without hearing loss for all studied frequencies.ConclusionThe cortical electrophysiological thresholds obtained with the use of an automated response detection system were highly correlated with behavioral thresholds in the group of individuals with hearing loss.



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Difficult septal deviation cases: is it open or closed technique?

Publication date: Available online 29 April 2016
Source:Brazilian Journal of Otorhinolaryngology
Author(s): Sultan Şevik Eliçora, Duygu Erdem, Hüseyin Işık, Murat Damar, Aykut Erdem Dinç
IntroductionAim of this study is to compare the functional aspects of open technique (OTS) and endonasal septoplasty (ENS) in "difficult septal deviation cases".Methods60 patients who have nasal obstruction because of S-shaped deformities, multiple deformities, high deviations etc. were included in the study. The OTS was used in 30 patients and the ENS was performed in 30 patients. The Nasal Obstruction Symptom Evaluation (NOSE) scale was administered preoperatively and at first month following surgery. Patients were also evaluated with Visual Analog Scale (VAS) for pain postoperatively.ResultsThe mean NOSE score was decreased 62.5–11.0 in the OTS group and 61.3–21.33 in the ENS group. Improvement of the symptoms in two surgical techniques is accepted agreeable and no statistically significant difference was found between both techniques. Also there was no statistically significant difference in postoperative pain degrees which was evaluated by VAS between the OTS and the ENS group.ConclusionAccording to our data the ENS is as successful as the OTS in management of difficult septal deviation cases. In patients with severe septal deformities type of the surgical technique should be selected according to the surgeon's experience and the patient's preference.



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Descriptions of vestibular migraine and Menieres disease in Greek and Chinese antiquity

Background

Vestibular migraine and Menière's disease are two types of episodic vertigo syndromes that were already observed in Greek and Chinese antiquity. Descriptions first appeared in the work of the classical Greek physician Aretaeus of Cappadocia, who lived in the 2nd century AD, and in Huangdi Neijing, a seminal medical source in the Chinese Medical Classics, written between the 2nd century BC and the 2nd century AD.

Aim

The aim of this paper is to search in Aretaeus' book De causis et signis acutorum et chronicorum morborum and in Huangdi Neijing for descriptions of vertigo co-occurring with headache or ear symptoms that resemble current classifications of vestibular migraine or Menière's disease.

Results

Aretaeus describes a syndrome combining headache, vertigo, visual disturbance, oculomotor phenomena, and nausea that resembles the symptoms of vestibular migraine. In the Chinese book Huangdi Neijing the Yellow Thearch mentions the co-occurrence of episodic dizziness and a ringing noise of the ears that recalls an attack of Menière's disease.

Conclusions

The descriptions of these two conditions in Greek and Chinese antiquity are similar to the vertigo syndromes currently classified as vestibular migraine and Menière's disease. In clinical practice it may be difficult to clearly differentiate between them, and they may also co-occur.

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Regulation of allergic inflammation by the ectoenzyme E-NPP3 (CD203c) on basophils and mast cells

Abstract

Adenosine 5′-triphosphate (ATP) is released from dying or damaged cells, as well as from activated cells. Once secreted, extracellular ATP induces several immune responses via P2X and P2Y receptors. Basophils and mast cells release ATP upon FcεRI-crosslinking, and ATP activates basophils and mast cells in an autocrine manner. Nucleotide-converting ectoenzymes, such as E-NTPD1, E-NTPD7, and E-NPP3, inhibit ATP-dependent immune responses by hydrolyzing ATP, thereby contributing to immune response regulation. E-NPP3 is a well-known activation marker for human basophils. E-NPP3's physiologic function has recently been disclosed in mice. E-NPP3 is rapidly induced on basophils and mast cells after FcεRI-crosslinking and hydrolyzes extracellular ATP on cell surfaces to prevent ATP-dependent excess activation of basophils and mast cells. In the absence of E-NPP3, basophils and mast cells are overactivated and mice suffer from severe chronic allergic inflammation. Thus, the ATP-hydrolyzing ectoenzymes E-NPP3 has a nonnegligible role in the regulation of basophil- and mast cell-mediated allergic responses.

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Challenges of Active Surveillance Protocols for Low-Risk Papillary Thyroid Microcarcinoma in the United States

Thyroid , Vol. 0, No. 0.


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Triiodothyroacetic Acid Treatment in MCT8 Deficiency: A Word of Nuance

Thyroid May 2016, Vol. 26, No. 5: 615-617.


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Highly Concordant Key Genetic Alterations in Primary Tumors and Matched Distant Metastases in Differentiated Thyroid Cancer

Thyroid May 2016, Vol. 26, No. 5: 672-682.


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Inappropriate Suppression of Thyrotropin Concentrations in Young Patients with Thyroid Nodules Including Thyroid Cancer: The Fukushima Health Management Survey

Thyroid May 2016, Vol. 26, No. 5: 717-725.


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Characteristics of Antithyroid Drug–Induced Agranulocytosis in Patients with Hyperthyroidism: A Retrospective Analysis of 114 Cases in a Single Institution in China Involving 9690 Patients Referred for Radioiodine Treatment Over 15 Years

Thyroid May 2016, Vol. 26, No. 5: 627-633.


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Future Meetings

Thyroid May 2016, Vol. 26, No. 5: 756-757.


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Editorial Board

Publication date: May 2016
Source:Journal of Oral Biosciences, Volume 58, Issue 2





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Analytical Methods and Interpretation of Variation in Tooth Morphology

Publication date: Available online 29 April 2016
Source:Journal of Oral Biosciences
Author(s): Shintaro Kondo, Yoshitaka Manabe
BackgroundMorphological data of teeth have played an important role in the field of dental anthropology. For example, tooth form is useful in elucidating the evolutionary changes from fossil hominids to modern humans, reconstructing life history from archaeological human remains, and analyzing the population history of recent human groups.HighlightLinear measurements of the maximum diameter of the tooth crown are useful in understanding the overall features of a tooth. The crown structure is analyzed in greater detail by performing two and three-dimensional measurements on standard and moiré photographs, respectively. Computed tomography is used for the analysis of the internal tooth structure, and geometric morphometrics is a new method used for quantifying tooth shape. Certain tooth characteristics, for example, Carabelli's trait, are scored based on standardized plaques, and the data are analyzed as non-metric variants. Tooth structure has been expressed using various means, and the development of a new method for the same is advocated for future dental morphological studies.ConclusionOver the past few decades, the morphological data of teeth have been analyzed on the basis of tooth morphology itself as well as from an anthropological perspective. Morphologists should intensify their exchange with molecular biologists and evaluate tooth morphogenesis as well as the genetic basis of tooth structure.



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Neutrophil elastase enhances antigen presentation by upregulating human leukocyte antigen class I expression on tumor cells

Abstract

Neutrophil elastase (NE) is an innate immune cell-derived inflammatory mediator that we have shown increases the presentation of tumor-associated peptide antigens in breast cancer. In this study, we extend these observations to show that NE uptake has a broad effect on enhancing antigen presentation by breast cancer cells. We show that NE increases human leukocyte antigen (HLA) class I expression on the surface of breast cancer cells in a concentration and time-dependent manner. HLA class I upregulation requires internalization of enzymatically active NE. Western blots of NE-treated breast cancer cells confirm that the expression of total HLA class I as well as the antigen-processing machinery proteins TAP1, LMP2, and calnexin does not change following NE treatment. This suggests that NE does not increase the efficiency of antigen processing; rather, it mediates the upregulation of HLA class I by stabilizing and reducing membrane recycling of HLA class I molecules. Furthermore, the effects of NE extend beyond breast cancer since the uptake of NE by EBV–LCL increases the presentation of HLA class I-restricted viral peptides, as shown by their increased sensitivity to lysis by EBV-specific CD8+ T cells. Together, our results show that NE uptake increases the responsiveness of breast cancer cells to adaptive immunity by broad upregulation of membrane HLA class I and support the conclusion that the innate inflammatory mediator NE enhances tumor cell recognition and increases tumor sensitivity to the host adaptive immune response.

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Evidenz und Evidenzlücken zur Behandlung der gestörten Mittelohrbelüftung sowie der Otitis media

Laryngo-Rhino-Otol 2016; 95: S136-S154
DOI: 10.1055/s-0041-108952

Evidenzbasierte Medizin bedeutet, im Rahmen einer medizinischen Behandlung eine patientenorientierte Entscheidung auf der Grundlage von empirisch nachgewiesener Wirksamkeit zu treffen. Hierzu existieren Klassifizierungen, in welchen nach definierten Vorgaben Studien und damit Therapieoptionen hinsichtlich ihrer Evidenz eingeteilt werden können.Die Tuba eustachii verbindet den Nasopharynx mit dem Mittelohr. Ihre Hauptaufgabe ist die Gewährleistung der Belüftung des Mittelohres. Ist diese Belüftungsfunktion eingeschränkt, resultieren entzündliche Erkrankungen des Mittelohres.Für die Behandlung der gestörten Mittelohrbelüftung sowie der Otitis media sind bisher zahlreiche Therapieoptionen evidenzbasiert. Ein wesentlicher Therapieansatz ist die antibiotische Therapie. Aber auch neuere Verfahren wie die Tubenballondilatation zeigen erste Erfolge, müssen jedoch hoch hinsichtlich ihrer Evidenz weiter evaluiert werden. Weiter liegt z. T. für langjährig etablierte Verfahren keine Evidenz vor. Die Klassifikation einer Evidenz für die unterschiedlichen therapeutischen Ansätze ist aufgrund vielfältiger Variablen sehr diversifiziert zu betrachten.Daher sind für die Evidenz der Behandlung der gestörten Mittelohrbelüftung sowie der Otitis media zahlreiche evidenzbeitragende Studien notwendig, um bestehende und auch zukünftige Therapiekonzepte zu evaluieren. Wird dieses angegangen, sind im Laufe der kommenden Jahre zahlreiche Implikationen für therapeutische Ansätze zu erwarten.
[...]

© Georg Thieme Verlag KG Stuttgart · New York

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Implementierung von Studienergebnissen in Leitlinien und deren Umsetzung in die Klinik

Laryngo-Rhino-Otol 2016; 95: S233-S251
DOI: 10.1055/s-0041-108961

Leitlinien wurden in den neunziger Jahren des letzten Jahrhunderts in die klinische und praktische Hals-Nasen-Ohren-Heilkunde eingeführt und seither kontinuierlich weiterentwickelt. Aktuell liegen 20 Leitlinien der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie vor. An 34 weiteren Leitlinien fand eine Mitwirkung statt. Durch konkrete Vorgaben der Arbeitsgemeinschaft wissenschaftlicher medizinischer Fachgesellschaften (AWMF) wurde die Qualität der Leitlinien kontinuierlich verbessert. Die zunehmende Digitalisierung ermöglichte einen einfacheren und schnelleren Zugriff auf wissenschaftliche Publikationen, sodass relevante Studienergebnisse heute leichter Eingang in Leitlinien finden als in der früheren analogen Welt. Bei S2e- und S3-Leitlinien muss eine formale Literaturrecherche mit anschließender Evidenzbewertung erfolgen. Das Konsensusverfahren bei S2k-Leitlinien ist ebenfalls reglementiert. Die Implementierung von Leitlinieninhalten in den ärztlichen Alltag ist allerdings noch als unzureichend anzusehen, entsprechend gibt es bei Leitlinienadhärenz noch deutlichen Verbesserungsbedarf.
[...]

© Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Qualitative Umfrage zur Identifizierung von Evidenzlücken in der HNO-Heilkunde

Laryngo-Rhino-Otol 2016; 95: S13-S37
DOI: 10.1055/s-0041-108949

Einleitung: Der Zuwachs des Wissens in der HNO-Heilkunde übersteigt, wie in den anderen Disziplinen auch, seit langem die individuellen Möglichkeiten, dieses Wissen adäquat aufzunehmen und einen entsprechenden Überblick zu behalten. Somit können tatsächliche oder vermeintliche Wissenslücken entstehen, die der Weiterentwicklung des Faches und einer evidenzbasierten Behandlung von Patienten entgegenstehen. Zudem gibt es in Kliniken und Praxen traditionelle Lehrmeinungen, die den medizinischen Alltag prägen, ohne dass diese Schulen je hinsichtlich ihrer Evidenz hinterfragt wurden. Methode: Zwischen Februar und Juni 2015 wurde unter 160 HNO-Kliniken, davon 34 Lehrstuhlinhaber, und 2 670 HNO-Praxen eine 2-armige Online-Umfrage zu vorhandenen oder empfundenen Evidenzlücken im Fachgebiet der HNO-Heilkunde mittels eines zuvor entwickelten Fragebogens durchgeführt. Dabei erfolgte die Befragung zur einen Hälfte in offener Form, zur anderen Hälfte wurde eine Systematik des Fachgebietes den Befragten als Orientierung zur Verfügung gestellt. Ergänzt wurde die Befragung durch Zusatzangaben, wie der Anzahl von Publikationen und Forschungsschwerpunkten bei den Kliniken und dem Lebensalter und der Praxisform bei den niedergelassenen Kolleginnen und Kollegen. Ergebnisse: Bei den Kliniken gab es eine Rückläuferquote von 39,7%, bei der geschlossenen von 29,3%. Bei den Praxen antworteten 14,6% der geschlossen und 18,6% der offen befragten Ärztinnen und Ärzte. Große Unterschiede ergaben sich zwischen den beiden Befragungsformen nicht. Bei den Kliniken führten mit je etwa 30% otologische und onkologische Themen die Liste der Antworten an. Hierbei wurden zu aktuellen diagnostischen und therapeutischen Problemen, wie z. B. der stadiengerechten Tumortherapie oder bei implantierbaren Hörhilfen, entsprechende Fragen formuliert. Der Schwerpunkt der aus den Praxen stammenden Fragestellungen lag bei diagnostischen Verfahren, z. B. bei speziellen, neuen Verfahren der Audiologie und Vestibulogie. Sowohl Kliniken als auch Praxen benannten aber auch alltagsrelevante Randgebiete des Faches. Diskussion: Im folgenden müssten die benannten Wissenslücken verifiziert bzw. falsifiziert werden und durch eine entsprechende Literaturrecherche geklärt werden, ob die vorhandene Evidenz tatsächlich bei den Behandlern durch Leitlinien, Publikationen, Kongresse und Fortbildungen im Alltag ankommt. Weitere Schritte wären die Priorisierung der künftigen Forschung, ein Evidenz-Mapping, die Entscheidung für weitere systematische Reviews und gezielte Studien in Verbindung mit der Einwerbung von Drittmitteln und bei der Zusammenarbeit mit Patientenverbänden. Das so gewonnene Wissen sollte schließlich in einer verbesserten Form in den klinischen Alltag transferiert werden. Hierzu sollten für die Bereiche der Kliniken und Praxen jeweils die 10 wichtigsten Fragestellungen formuliert werden.
[...]

© Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
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Evidenz und Evidenzlücken zur Chirurgie des Larynxkarzinoms

Laryngo-Rhino-Otol 2016; 95: S192-S216
DOI: 10.1055/s-0041-108962

Die operative Therapie von Larynxkarzinomen ist seit Jahrzehnten etabliert. Neben der Laryngektomie, die erstmals 1873 durchgeführt wurde, haben sich eine Vielzahl larynxerhaltender Operationstechniken, wie verschiedene offene Teilresektionen, die transorale Laserchirurgie und zuletzt die transorale Roboterchirurgie, entwickelt. Die am häufigsten angewendeten Studienformen in Studien zur Chirurgie des Larynxkarzinoms sind retrospektive Analysen von Fallserien, hiernach folgen Vergleiche von prospektiv geführten Erhebungen mit historischen Kontrollgruppen. Die Weiterentwicklung der Radio(chemo)therapieprotokolle und deren Analyse in prospektiven randomisierten Studien haben zu einer steigenden Akzeptanz nicht-chirurgischer Therapieverfahren geführt, auch aus dem Grund, dass prospektive kontrollierte randomisierte Studien als das Rückgrat der evidenzbasierten Medizin gelten. In den letzten Jahren rückt neben einer Verbesserung der Prognose von Patienten mit Larynxkarzinomen jedoch auch der möglichst umfassende Erhalt der Larynxfunktionalität nach Primärtherapie zunehmend in den Mittelpunkt der Therapieplanung. Die nicht unerheblichen Spättoxizitäten nach Radiochemotherapie wurden verstärkt analysiert. Dies führt zu einer Neubewertung primär chirurgischer Konzepte und Initiierung von Studien zur chirurgischen Therapie des Larynxkarzinoms, die auch durch die Hinwendung zur transoralen Roboterchirurgie in den USA gefördert werden. Durch Priorisierung erforderlicher chirurgischer Forschung sollte in Zukunft die Evidenzlage zur chirurgischen Therapie des Larynxkarzinoms verbessert werden.
[...]

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Evidenz basierte Indikationen der Tonsillektomie

Laryngo-Rhino-Otol 2016; 95: S38-S87
DOI: 10.1055/s-0041-109590

Hintergrund: Die erste wissenschaftlich hochwertige Studie zur Indikationsstellung der Tonsillektomie wurde von Jack L. Paradise geleitet und 1984 (TE) publiziert. Ziel dieser systematischen Literaturrecherche war es, anhand einer standardisierten Suchstrategie Publikationen zusammenzustellen, die sich nach 1984 mit den Operationsindikationen der TE auseinandersetzten. Methoden: berücksichtigt wurden ausschließlich systematische Reviews, Metaanalysen, Leitlinien sowie Publikationen zu Evidenz-basierten Operationsindikationen der TE. Zunächst wurde in der Medline-Datenbank mit dem Suchwort „tonsillectomy" in Kombination mit den Filtern „Systematic Reviews" sowie „Meta-Analysis", „English", „German" und „from 1984/01/01 to 2015/05/31" recherchiert. In der „Cochrane Database of Systematic Reviews", im Register des „National Guideline Clearinghouse", bei dem „Guidelines International Network" und „BMJ Clinical Evidence" wurde ausschließlich das Suchwort „tonsillectomy" verwendet. Schließlich wurde bei „Trip Database" eine Recherche mit den Suchwörtern „tonsillectomy" und „indication" sowie den Filtern „from: 1984 to: 2015" entweder mit „systematic review" oder „metaanalysis" oder „meta-analysis" vorgenommen. Ergebnisse: Von 237 Treffern bei der Literaturrecherche entsprachen 57 Artikel den Suchkriterien und konnten den Themengebieten Peritonsillarabszess (3), Psoriasis (3), Leitlinien (5), Paukenerguss (5), Evidenz-basierte Indikationen (5), PFAPA-Syndrom (6), Nierenerkrankungen (7), Schlaf-bezogene Atmungsstörungen (11) und Tonsillitis/Pharyngitis (12) zugeordnet werden. Schlussfolgerungen: Die Übersichtsarbeiten der letzten 31 Jahre zu Indikationen der TE setzten sich mit 7 Krankheitsbildern auseinander: 1) Im Fall des Paukenergusses darf davon ausgegangen werden, dass die TE nicht gerechtfertigt ist und auch kein weiterer Forschungsbedarf dazu besteht. 2) beim PFAPA-Syndrom erscheinen die Operationsrisiken der TE angesichts der möglichen Alternativtherapie in Form von Steroidgaben sowie der wahrscheinlichen Spontanheilung kaum vertretbar. 3) Die Abszess-TE zur Behandlung eines Peritonsillarabszesses ist nur noch in therapierefraktären Fällen, eingetretenen Komplikationen, anamnestisch häufigen Tonsillitiden sowie ausgesuchten Einzelfällen vorbehalten, nicht aber als Routineverfahren. Für die Intervall-TE als Routineverfahren gibt es keine wissenschaftliche Grundlage. 4) Die TE in Form der Adenotonsillektomie zur Therapie von kindlichen Schlaf-bezogenen Atmungsstörungen wegen einer adenotonsillären Hyperplasie gilt als unstrittige Operationsindikation. Der Umgang mit Komorbiditäten wie Adipositas erfordert weitere klinische Forschung, da hierdurch der Operationserfolg erheblich reduziert wird. Der initial gleichwertige Effekt der weniger invasiven Tonsillotomie geht tendenziell im Langzeitverlauf verloren, hier muss an validen Selektionskriterien gearbeitet werden. 5) Die Hinweise auf einen positiven Effekt der TE auf die Psoriasis guttata bei Kindern sowie der therapierefraktären Psoriasis vulgaris bei Erwachsenen lassen sich nicht verneinen, hier besteht aber weiterhin klinisch-wissenschaftlicher Forschungsbedarf. 6) Inwieweit der TE eine Bedeutung im Behandlungskonzept der Ig-A Nephropathie zukommt, muss ebenfalls durch weitere Studien geklärt werden. 7) Sofern die TE auf eine Beseitigung der Gruppe A beta-hämolysierende Streptokokken abzielt, steht sie in Konkurrenz zur Antibiotikumtherapie, aber auch einer nicht zu vernachlässigenden Spontanheilungsrate. Ob die TE bei schweren Verlaufsformen von Tonsillitiden, gemessen an der Zahl von Halsschmerz-Episoden, der konservativen Therapie nachhaltig überlegen ist, muss die dringend angezeigte klinisch-wissenschaftliche Forschung noch nachweisen. Hierbei muss auch die Frage beantwortet werden, inwieweit Unterschiede zwischen Kindern, Jugendlichen und Erwachsenen bestehen.
[...]

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Evidenz und Evidenzlücken bei der Behandlung der behinderten Nasenatmung und der Rhinosinusitis

Laryngo-Rhino-Otol 2016; 95: S116-S135
DOI: 10.1055/s-0041-109059

Therapieverfahren in der Hals-Nasen-Ohrenheilkunde beruhen heute auf klinischer Erfahrung, chirurgischer Ausbildung und wissenschaftlicher Evidenz. Seit einigen Jahren gewinnt jedoch der Aspekt der evidenzbasierten Behandlung u. a. wegen des Potenzials zur Verbesserung von individuellen Behandlungen, aber auch aufgrund der wirtschaftlichen Rahmenbedingungen zunehmend an Bedeutung. Gleichzeitig ist es in der klinischen Praxis äußerst schwierig, fast unmöglich, einerseits einen Überblick über die wachsende Anzahl von Publikationen zu behalten, andererseits die publizierten Studien umfassend zu beurteilen, z. B. auch im Hinblick auf mögliche systematische Fehler, um die relevanten und neuesten Studienergebnisse in Therapieentscheidungen miteinzubeziehen. Metaanalysen, Übersichtsarbeiten und Leitlinien spielen deshalb heute eine wachsende Rolle für die evidenzbasierte Therapieplanung.In dieser Arbeit soll eine aktuelle und möglichst umfassende Übersicht über die Verfügbarkeit externer Evidenz bei der Behandlung der Nasenatmungsbehinderung und der Rhinosinusitis gegeben werden. Dabei wird schnell klar, dass sich beide Erkrankungsbereiche im Hinblick auf die externe Evidenz deutlich unterscheiden. Weiterhin wird klar, dass insbesondere die chirurgischen Verfahren deutlich schwieriger mit Studien höherer Evidenzlevel zu stützen sind, als dies bei medikamentösen Therapien der Fall ist.
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Tonsillektomie: offizielle Zahlen und Trends in Deutschland

Laryngo-Rhino-Otol 2016; 95: S88-S109
DOI: 10.1055/s-0041-109594

Hintergrund: Über eine unterschiedliche Tonsillektomierate pro Einwohnerzahl im regionalen und zeitlichen Vergleich wird in der internationalen Literatur immer wieder berichtet. Ziel der vorliegenden Studie war es, die Häufigkeit stationärer Behandlungen von chronischer Tonsillitis, Tonsillenhyperplasie und adenotonsillärer Hyperplasie für Deutschland mit über 80 Mio Einwohnern zu ermitteln. Außerdem sollte die Rate an Tonsillektomien, Abszesstonsillektomien, transoralen Inzisionsdrainagen von Peritonsillarabszessen sowie Tonsillotomien pro 100 000 Einwohner über mehrere Jahrgänge bestimmt werden. Eine abschließende Analyse widmete sich der Rate an Blutungskomplikationen nach Tonsillektomie in Abhängigkeit vom Geschlecht und Alter. Methoden: Grundlage für die diversen Kalkulationen mit Bezug auf die Gesamtbevölkerung in Deutschland waren die vom Statistischen Bundesamt veröffentlichten Daten sowie individuell angefragte Sonderauswertungen auf Basis des 6-stelligen OPS-Codes zu einzelnen Fragestellungen. Die aktuellsten Daten waren für den Jahrgang 2013 erhältlich. Ergebnisse: Innerhalb von 13 Jahren reduzierte sich die Zahl der Diagnosen „chronische Tonsillitis", „Hyperplasie der Gaumenmandeln" und „Hyperplasie der Gaumenmandeln und Hyperplasie der Rachenmandel" von 142 574 im Jahr 2000 auf 87 624 Fälle im Jahr 2013 (38,5%).Zwischen 2006 und 2013 wurden insgesamt 833 896 (Adeno)Tonsillektomien in Deutschland unter stationären Bedingungen vorgenommen. Die Zahl ging von 120 993 im Jahr 2006 auf 84 332 Operationen im Jahr 2013 zurück (30,3%). Die Detailanalyse ergab einen Rückgang vor allem bei den unter 20-jährigen, hier hatte sich die Tonsillektomierate von 70,92 pro 10 000 Einwohner im Jahr 2010 auf 58,68 im Jahr 2013 reduziert. Die altersunabhängige TE-Rate (alle Indikationen außer Abszesstonsillektomie) bezogen auf die Gesamtbevölkerung sank im gleichen Zeitraum von 13,34 auf 10,90 pro 10 000 Einwohner. Ein umgekehrter Trend ließ sich für die stationär vorgenommenen Tonsillotomien nachweisen: die Zahl stieg von 4659 Eingriffen im Jahr 2007 auf 11 493 im Jahr 2013 an, in der Summe waren es in diesem Zeitraum 59 049 Tonsillotomien.In Deutschland wurde pro Jahrgang etwa 15 000 Mal die Diagnose eines Peritonsillarabszesses gestellt (etwa 19 pro 100 000 Einwohner). Die Prävalenz steigt sprunghaft nach dem 15.Lebensjahr an, nur bis zu diesem Lebensalter waren überwiegend Patienten weiblichen Geschlechts betroffen. Bei der operativen Therapie betrug das Verhältnis von transoraler Inzisionsdrainage zu Abszesstonsillektomie 1:2,8.Für die Jahrgänge 2010 und 2013 wurden die Nachblutungsrate nach insgesamt 245 721 Tonsillektomien (alle Indikationen)kalkuliert, sie betrug 5,98%. Patientinnen waren seltener (5,06%) als Patienten (7,02%) von Blutungskomplikationen betroffen. In beiden Jahrgängen fand sich jeweils nur bei Patienten männlichen Geschlechts ein sprunghafter Anstieg der Nachblutungsrate nach dem 10.Lebensjahr. Schlussfolgerungen: Die Diagnosehäufigkeit von chronischen Erkrankungen der Gaumenmandeln sowie die absolute und relative Häufigkeit der Tonsillektomie erwies sich im Untersuchungszeitraum als deutlich rückläufig, bevorzugt bei Patienten weiblichen Geschlechts. Im Gegensatz dazu stieg die Zahl an ausgeführten Tonsillotomien kontinuierlich an, vor allem bei Patienten männlichen Geschlechts. Hinsichtlich der Zahl an diagnostizierten und operativ behandelten Peritonsillarabszessen fanden sich bei der Betrachtung über mehrere Jahrgänge keine nennenswerten Schwankungen. Überwiegend wurde die Abszesstonsillektomie, seltener die transorale Inzisionsdrainage ausgeführt. Unabhängig von der Operationsindikation entwickelten sich Blutungskomplikationen nach einer Tonsillektomie bevorzugt bei Patienten männlichen Geschlechts, vor allem nach dem 10.Lebensjahr. Die Analyse der Datenlage konnte zum Teil dramatische Änderungen nachweisen, die neben den bekannten demografischen Veränderungen in der Versorgungsmedizin national und regional berücksichtigt werden müssen.
[...]

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Evidenz- und Evidenzlücken der Tinnitustherapie

Laryngo-Rhino-Otol 2016; 95: S155-S191
DOI: 10.1055/s-0041-108946

Für die Behandlung von Ohrgeräuschen werden eine schier unübersichtliche Vielzahl von Verfahren erprobt und v. a. verkauft, leider nicht immer sachgerecht und evidenzbasiert untersucht. Eine kausale, den Tinnitus abschaltende Therapie gibt es nach wie vor nicht, ja eigentlich kann es sie nicht geben, hat man die verschiedenen Entstehungsmechanismen verstanden. Dennoch oder deshalb kehren im Verlauf der letzten Jahrzehnte wellen- und modeartig medizinische Interventionen wieder, die praktisch nie den Nachweis stabiler und belastbarer Behandlungserfolge erbringen können. In diesem Referat werden praktisch alle gängigen Therapieverfahren besprochen, gewürdigt und diskutiert und bezüglich vorliegender oder eben nicht bestehender Evidenz bewertet. Dabei sollte Evidenz neben der externen Evidenz durch Studien auch die interne Evidenz, d. h. die Erfahrung des Arztes und die Bedürfnisse des Patienten mit einbeziehen.Während für praktisch alle direkten Verfahren, die entweder die Kochlea oder bestimmte Hirnregionen wie insbesondere den auditorischen Kortex stimulieren oder modulieren wollen, keine Evidenz besteht oder erreicht wird, so gibt es Therapieverfahren, die sich in der klinischen Praxis bewährt haben und die zumindest einen gewissen Evidenzgrad und v. a. auch nachweisbare Effektstärken generieren. Dazu gehören besonders Habituationstherapien und psychotherapeutische Verfahren, besonders wenn sie mit konkreten Maßnahmen zur Verbesserung der Hörwahrnehmung (Hörgeräte, CI, Hörtherapien) verknüpft werden.
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Tonsillektomie bei PANDAS?

Laryngo-Rhino-Otol 2016; 95: S110-S115
DOI: 10.1055/s-0041-109592

Hintergrund: Beim PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Assocciated with Streptoccocal Infections) handelt es sich um ein Krankheitsbild, bei dem Zwangs- und Ticstörungen auf eine Streptokokken-Infektion zurückgeführt werden. Anhand einer Literaturrecherche sollte geklärt werden, inwieweit die Tonsillektomie (TE) als therapeutische Maßnahme zu empfehlen ist. Methoden: Bei PubMed wurde mit den Schlagworten tonsillectomy und PANDAS, OCD, compulsive, pediatric autoimmune, Chorea und Tic nach Studien gesucht, in denen die Tonsillektomie zur Behandlung einer PANDAS ausgeführt worden war. Herangezogen wurden ausschließlich Artikel ab 1995 bis zum 31.07.2015. Übersichtarbeiten zum Thema PANDAS ohne Patientendarstellung wurden ausgeschlossen. Ergebnisse: Insgesamt entsprachen 9 Artikel den Suchkriterien. In 6 Publikationen wird über 8 Einzelfälle berichtet, in denen die TE einen mehr oder weniger positiven Effekt auf die neurologischen Auffälligkeiten ausübte. Daneben fanden sich 3 Fallserien mit insgesamt 173 Patienten, von denen 91 der TE zugeführt worden waren. Die Nachbeobachtungszeit schwankte bei den Fallberichten zwischen 2 und 36 Monaten. Nur in zwei der drei Fallserien war eine Nachbeobachtung vorgesehen, die zwischen zwei und drei Jahren betrug. Über einen vollständigen Therapieerfolg wurde bei vier der acht Einzelfälle sowie in einer Fallserie bei weiteren drei Patienten berichtet. Dieser Effekt ließ sich bei den tonsillektomierten Patienten der beiden anderen Fallserien nicht beobachten, nicht einmal tendenziell. Schlussfolgerung: Die Diagnosestellung einer PANDAS ist wegen der möglichen Überlagerungen durch neurologisch-psychiatrische Komorbiditäten und Fehlen eines zuverlässigen Biomarkers und erschwert. Der positive Einfluss der TE in den Einzelfallberichten kann nicht zweifelsfrei von dem Effekt der postoperativen Medikation abgegrenzt werden. Größere Fallserien konnten den vereinzelt beobachteten positiven Effekt des Eingriffs nicht bestätigen. Angesichts der nicht zu vernachlässigenden operationsbedingten Morbidität und Mortalitätsrate erscheint eine Indikationsstellung nur im Rahmen von kontrollierten Studien mit standardisierter Vorgehensweise empfehlenswert.
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Evidenz und Evidenzlücken für medikamentös zu behandelnde, nicht-tumoröse Erkrankungen im Gebiet der HNO-Heilkunde

Laryngo-Rhino-Otol 2016; 95: S217-S232
DOI: 10.1055/s-0041-108940

In unserem Fach der HNO-Heilkunde behandeln wir zahlreiche Krankheiten, die leider aufgrund mangelnder Studienlage nicht immer evidenzbasiert sind.Während für die spezifische Immuntherapie der allergischen Rhinitis und bedingt auch für das durch Angiotensin-Converting-Enzyme-Hemmer induzierte Angioödem ausreichend hochwertige Studien zur Verfügung stehen, ist für den Morbus Menière oder für die medikamentöse Behandlung des postoperativen Larynxödems die Evidenzlage sehr dünn. In diesem Beitrag werden die Studienlage und Evidenz der jeweiligen Krankheiten diskutiert.
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Zufriedenheit nach Stimmerhöhung bei Transsexualität – Entwicklung eines Therapiealgorithmus

Laryngo-Rhino-Otol
DOI: 10.1055/s-0042-103590

Hintergrund: Im Rahmen der Transition von Mann zu Frau ist die Stimmtherapie ein wichtiger Bestandteil einer ganzheitlichen Therapie. Die Therapie besteht aus konservativ logopädischen und operativen Ansätzen, es existieren allerdings keine einheitlichen Standards. Neben der Sprechstimmlage wird die Geschlechtswahrnehmung von vielen Faktoren wie Formantfrequenzen, Intonation, Prosodie und Verhaltensmerkmalen beeinflusst. Material und Methoden: Bei 21 transsexuellen Patientinnen nach operativer Stimmerhöhung wird ein eigenes Addendum zu etablierten Fragebögen wie dem Voice Handicap Index (VHI) und dem Fragebogen zur Lebenszufriedenheit (FLZ) eingeführt. Es wird ein neuer Therapiealgorithmus hergeleitet. Dieser ist unabhängig von der gewählten Operationsmethode einsetzbar. Ergebnisse: Durch die Stimmerhöhungsoperation ist das Selbstbewusstsein der Patientinnen stark gestiegen. Identifikationsprobleme aufgrund der veränderten Stimme traten nicht auf. Trotz der erhöhten Stimme sind einige Patientinnen mit ihrer Stimme subjektiv nicht zufrieden. Schlussfolgerungen: Durch die stimmerhöhende Operation wird die Sprechstimmlage als einziger Parameter verändert. Für einen weiblicheren Stimmklang sollte logopädische Therapie als nötige Voraussetzung vor der Indikationsstellung operativer Maßnahmen stehen. Hierbei kann neben der Stimmlage auch an den anderen Parametern der Geschlechtszuordnung gearbeitet werden. Kann durch logopädische Therapie ein zufriedenstellend weiblicher Stimmklang erreicht werden, ist eine Operation nicht indiziert.
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Comparison of Single and Double Venous Anastomoses in Head and Neck Oncologic Reconstruction Using Free Flaps: A Meta-Analysis

Background: Venous insufficiency is the main cause of failure and surgical revision in free flap surgery. Achieving a double venous anastomosis is frequently proposed to improve flap drainage. However, this procedure remains controversial. The authors evaluated, through a meta-analysis, the benefit of double venous anastomoses in the venous thrombosis, surgical revision, and failure rates of free flaps in head and neck oncologic reconstruction. Methods: A systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria in the MEDLINE, PubMed Central, Cochrane Library, and EMBASE databases. Statistical heterogeneity evaluation and then fixed effects and random effects models were used. Results: Sixteen articles were included involving 3684 flaps. The overall success rate was 96.15 percent. The authors reported a failure rate of 1.51 percent in the group with two anastomoses versus 5.03 percent in the group with single anastomoses (OR, 0.64; 95 percent CI, 0.277 to 1.522; p = 0.320). The authors found a venous thrombosis rate of 2.74 percent in the group with two anastomoses versus 4.54 percent in the group with single anastomoses (OR, 0.535; 95 percent CI, 0.334 to 0.858; p = 0.009). There were also more surgical revisions in the single venous anastomoses group, 11.87 percent versus 6.04 percent (OR, 0.474; 95 percent CI, 0.349 to 0.643; p

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Discussion: Volumetric Planning Using Computed Tomographic Angiography Improves Clinical Outcomes in DIEP Flap Breast Reconstruction

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Current Applications of Facial Volumization with Fillers

Learning Objectives: After reading this article and watching the accompanying videos, the participant should be able to: 1. Assess patients seeking facial volumization and correlate volume deficiencies anatomically. 2. Identify appropriate fillers based on rheologic properties and anatomical needs. 3. Recognize poor candidates for facial volumization. 4. Recognize and treat filler-related side effects and complications. Summary: Facial volumization is widely applied for minimally invasive facial rejuvenation both as a solitary means and in conjunction with surgical correction. Appropriate facial volumization is dependent on patient characteristics, consistent longitudinal anatomical changes, and qualities of fillers available. In this article, anatomical changes seen with aging are illustrated, appropriate techniques for facial volumization are described in the setting of correct filler selection, and potential complications are addressed.

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The Transverse Musculocutaneous Gracilis Free Flap: Virtual Animation–Assisted Dissection and Application in Breast Reconstruction

Summary: The transverse musculocutaneous gracilis free flap is a valuable choice for autologous tissue, unilateral or bilateral breast reconstruction. This procedure is an excellent and customized option for immediate or delayed breast reconstruction in patients with small to moderate size breasts. Few descriptions of flap dissection and breast mound shaping are available. In this first educational video, the authors report the original dissection of the transverse musculocutaneous gracilis free flap used for breast reconstruction. Virtual animations insist on surgical key points and relevant details of the harvesting of the flap.

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A Closer Look at the 2013 to 2014 Integrated Plastic Surgery Match: Correction

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The Blood Supply of the Breast Revisited

Background: Many surgeons are under the impression that the blood supply is clearly defined in textbooks. Unfortunately, the majority of textbooks supply inadequate information and illustrations can be misleading in many instances. None of the textbooks describe a segmental pattern of blood supply when in actual fact a basic segmental pattern does exist. The reason for inadequate information is the perpetuation of facts since the work of the pioneers Cooper and Manchot from one textbook to another. A paucity of research studies thereafter and the fact that the results of some of these studies did not find their way into textbooks is another contributing factor. Methods: The findings of research studies since the descriptions by Cooper and Manchot are analyzed and compared in an effort to find common ground and its clinical implication. Results: Researchers concurred on the main sources of blood supply; these are internal thoracic, lateral thoracic, anterior intercostal, and acromiothoracic (thoracoacromial) arteries. However, the different research studies showed considerable variation in the branches from the main sources to supply the nipple-areola complex. Conclusions: Even though the locations of the main sources of blood supply are constant, partial or complete absence of branches from the main sources does occur and therefore the blood supply to the nipple-areola complex is unpredictable. Cognizance of the basic segmental pattern and the variations resulting from embryologic development will be helpful for the surgeon to use or adapt a technique to minimize the risk of nipple necrosis.

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Presurgical Nasoalveolar Molding for Cleft Lip and Palate: The Application of Digitally Designed Molds

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Discussion: The Blood Supply of the Breast Revisited

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ASPS/PSF Sponsored Symposia and Workshops

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Three-Dimensional Topographic Surface Changes in Response to Compartmental Volumization of the Medial Cheek: Defining a Malar Augmentation Zone

Background: Given the widespread use of facial fillers and recent identification of distinct facial fat compartments, a better understanding of three-dimensional surface changes in response to volume augmentation is needed. Advances in three-dimensional imaging technology now afford an opportunity to elucidate these morphologic changes for the first time. Methods: A cadaver study was undertaken in which volumization of the deep medial cheek compartment was performed at intervals up to 4 cc (n = 4). Three-dimensional photographs were taken after each injection to analyze the topographic surface changes, which the authors define as the "augmentation zone." Perimeter, diameter, and projection were studied. The arcus marginalis of the inferior orbit consistently represented a fixed boundary of the augmentation zone, and additional cadavers underwent similar volumization following surgical release of this portion of the arcus marginalis (n = 4). Repeated three-dimensional computer analysis was performed comparing the augmentation zone with and without arcus marginalis release. Results: Volumization of the deep medial cheek led to unique topographic changes of the malar region defined by distinct boundaries. Interestingly, the cephalic border of the augmentation zone was consistently noted to be at the level of the arcus marginalis in all specimens. When surgical release of the arcus marginalis was performed, the cephalic border of the augmentation zone was no longer restricted. Conclusions: Using advances in three-dimensional photography and computer analysis, the authors demonstrate characteristic surface anatomy changes in response to volume augmentation of facial compartments. This novel concept of the augmentation zone can be applied to volumization of other distinct facial regions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

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A Novel Surgical Approach to Chronic Temporal Headaches

Summary: The targets for the surgical treatment of temporal headaches are the zygomaticotemporal branch of the trigeminal nerve and the auriculotemporal nerve. The former is often accessed by means of an endoscopic brow approach or potentially by laterally extending a transpalpebral incision. An established surgical approach, the Gillies incision, was modified to access the zygomaticotemporal nerve, as it was felt to combine the advantages of the traditional techniques. Nineteen patients underwent zygomaticotemporal nerve decompression and neuroplasty or neurectomy and muscle implantation using this surgical approach. A 3.5-cm incision was made behind the anterior, temporal hairline and the zygomaticotemporal branch of the trigeminal nerve was approached directly, remaining superficial to the deep temporal fascia. Each patient was assessed preoperatively and postoperatively with regard to the frequency, duration, and severity of their symptoms to calculate a Migraine Headache Index score. All evaluations were performed at least 1 year postoperatively. The mean preoperative Migraine Headache Index score was 131.7 and the mean postoperative score was 52 (p

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Safety of Monopolar Electrocautery in Patients With Cochlear Implants

Objective:

The outcomes of 2 patients with cochlear implants (CIs) who underwent adenotonsillectomy (AT) with inadvertent use of monopolar cautery are presented. The safety data regarding monopolar cautery use in CI recipients is also reviewed.

Study Design:

This is a retrospective case series of 2 CI recipients that underwent AT with monopolar cautery and literature review of electrocautery safety in the setting of CI.

Results:

Two patients with CIs underwent AT with use of monopolar cautery inadvertently by surgeons that do not routinely perform cochlear implants as part of his or her clinical practice. Patient 1 was a 9-year-old female who had AT for obstructive sleep apnea (OSA) after undergoing unilateral CI for profound congenital sensorineural hearing loss (SNHL) 8 years ago. Patient 2 was a 7-year-old female who underwent AT for OSA 4 months after undergoing unilateral CI for congenital SNHL. Both patients had no immediate signs of complications with their CI use postoperatively. Both patients demonstrated unchanged postoperative neural response telemetry and behavioral audiometric testing. Patient 1 continues to have no CI-related complications 3.5 years after the procedure. Patient 2 has been followed for at least 3 months by audiometric testing and 10 months by otolaryngologist with no CI-related complications.

Conclusion:

Although animal and cadaveric studies suggest that monopolar cautery may be safely used in patients with cochlear implants, there have been no in vivo human studies that have evaluated the risk to the patient or implant. This is a report of a small, unintended experience with 2 patients, both of whom exhibit no complications or changes to CI function thus far.

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