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Aufgrund des submukosen Wachstums und der Ausbildung von feinen Tumorauslaufern ist bei Zungenkarzinomen die genaue Einschatzung der Tumorgrose und Bestimmung adaquater Resektionsgrenzen haufig sehr schwierig. Wir entwickelten ein Verfahren zur intraoperativen Darstellung und Markierung von Tumorgrenzen bei Zungenkarzinomen: Bei 9 Patienten wurde die intraoperative Sonographie mit Hilfe eines 8–12-MHz-Schallkopfs nach Fluten der Mundhohle mit physiologischer Kochsalzlosung im Nicht-Kontakt-Verfahren durchgefuhrt. Die Tumorgrenzen wurden unter sonographischer Kontrolle mit Hilfe von Nahtmaterial markiert. In allen Fallen entsprachen die Tumorgrenzen im pathologischen Praparat den sonographisch ermittelten Tumorgrenzen. Die ultraschallgesteuerte Markierung erwies sich somit als sehr hilfreich bei der Tumorresektion. Stets erfolgte die Resektion im Gesunden mit entsprechendem Sicherheitsabstand. Diese nichtinvasive Methode erlaubt eine schnelle und zuverlassige Orientierung wahrend der Resektion von Zungenkarzinomen. Somit ist eine prazise und individuelle Festlegung von Resektionsgrenzen moglich. Diese Methode sollte durch Folgestudien weiterentwickelt werden.

Hintergrund In den letzten Jahren nahm die Zahl der Sporttaucher und in der Folge die Anzahl von Tauchunfallen stetig zu. Die meisten tauchmedizinischen Erkrankungen betreffen das Hals-Nasen-Ohren-arztliche Gebiet. Insbesondere kochleovestibulare Storungen nach dem Tauchen konnen zu persistierenden Schadigungen des Innenohrs fuhren.

Einleitung Mithilfe der dynamischen Magnetresonanztomographie (dMRT) konnen mikrozirkulationsabhangige Gewebeparameter erfasst werden.

In order to identify squamous cell carcinomas of the head and neck (HNSCC) with common biological and clinical features, we investigated the incidence and properties of carcinomas lacking retinoblastoma protein (pR6) cell cycle control. Of 208 HNSCC investigated, 23 (11%) showed a lack of pRb expression. The majority of these tumors (65%) were tonsillar carcinomas. The pRb-negative tonsillar tumors were all stage IV, had metastasized to lymph nodes at the time of diagnosis and were in general poorly differentiated or undifferentiated. Very significantly, the pRb-negative phenotype was strongly associated with the presence of oncogenic human papilloma viruses, implying a viral etiology and functional inactivation of pRb by the viral E7 oncoprotein. Despite the very adverse histopathological factors, patients with pRb-negative tonsillar carcinomas had a better clinical outcome, which was consistent with a uniform favorable responsiveness of these tumors to postoperative radiation therapy.

The diagnosis of cystic echinococcosis (echinococcus granulosus) in an atypical location can be difficult to make and frequently can only be established by histological examination of affected tissues. Surgical excision and fine-needle aspiration biopsy usually lead to the diagnosis. Since puncture of these cysts may cause an anaphylactic reaction due to spillage of hydatid fluid and/or dissemination of infection, the use of fine-needle aspiration biopsy is controversial at present. We report on a patient with a cystic neck mass who developed an allergic reaction after diagnostic fine-needle aspiration biopsy. Cytological examination of the specimen was inconclusive. The allergic reaction led to the diagnosis of echinococcosis, which was confirmed by serological examination. We describe a possible diagnostic procedure for a cystic mass of unknown etiology. If imaging and serological tests are not conclusive, we believe that fine-needle aspiration biopsy is justified. However, this should only be performed in a setting that provides sufficient management for anaphylactic reactions.

In addition to mucositis and myelotoxicity as well known early reactions after radiotherapy or radiochemotherapy in advanced head and neck tumors, late toxicity following treatment is an often underestimated problem. Between 1992 and 1995, 68 patients with advanced oro- and hypopharyngeal tumors were treated primarily with accelerated concomitant boost radiochemotherapy (total dose irradiations of 66 Gy and carboplatin as chemotherapy). Ninety-three per cent of the patients had stage IV disease according to the UICC-TNM classification. Monitoring of follow-up included late toxicity with special attention given to laryngeal edema. In 37 patients (54%) edema of the larynx as a late complication of radiochemotherapy was observed by clinical investigation and CT scan. The median onset of laryngeal edema was found 121 days after completion of therapy, with a median time of observation of 250 days. Observations in these patients demonstrated the chronic character of this edema. An increase in the laryngeal edema in 5 cases resulted in tracheostomy. Laryngeal edema in 10 patients was associated with recurrence of tumor. These results show that after xerostomia laryngeal edema is the main late toxicity in the head and neck after radiochemotherapy and should lead to further investigations to exclude possible recurrent tumor.

Eine neue Methode wird vorgestellt, mit der die Perfusion und der Schwellungszustand der Nasenschleimhaut sonographisch dargestellt werden. Durch die seitlichen Nasenweichteile hindurch kann das vordere Septum, der Nasenboden und der Kopf der unteren Nasenmuschel der Gegenseite im B-mode-Verfahren sowie die Perfusion der entsprechenden Schleimhaut im farbkodierten Power-Doppler-Mode dargestellt werden. Die Ankopplung des Ultraschalls erfolgt durch ein neutrales Gel bzw. Flussigkeit im Vestibulum nasi. Die Fixierung des Schallkopfes mit Hilfe einer Bisschiene verhindert Bewegungsartefakte und gewahrleistet eine gleichbleibende Bildebene. Fur die Quantifizierung der Perfusion wurde eine automatisierte Farbpixelanalyse entwickelt. Bei 23 von 30 untersuchten Probanden und Patienten war mit dieser Methode die Schleimhautperfusion darstellbar. Eine auswertbare Abbildung der Sonoanatomie gelang in 16 Fallen. Es wurden Perfusionsanderungen unter Einwirkung von physiologischer Kochsalzlosung (bei 10 gesunden Probanden), Naphazolin (bei 10 Patienten mit chronisch behinderter Nasenatmung) und Allergenlosungen (bei 10 Patienten mit allergischer Rhinitis) untersucht. Physiologische Kochsalzlosung fuhrte innerhalb von 10 min zu einer maximalen Perfusionsabnahme um 10% bzw. einer Zunahme um 27% ohne Schwellungsanderung. Wahrend der Provokation mit Naphazolin trat erwartungsgemas eine Abnahme der Perfusion zwischen 10% und 57% und ein Abschwellen der Muschel- bzw. Septumschleimhaut um 17%–43% bzw. 4%–27% auf. Allergenextrakt induzierte eine Zunahme der Perfusion um 24%–181% und ein Anschwellen der Schleimhaut um 4%–31%. Diese Ergebnisse werden als Grundlage fur weitere Untersuchungen von Perfusionsanderungen der Nasenschleimhaut durch Medikamenten- und Allergenprovokationen dienen.

In soft tissue surgery of the head and neck region tissue shifts limit the usefulness of conventional CT/MRI-based navigation procedures. Furthermore, changes caused by invasive measures cannot be visualized.A novel navigation device for sonography of soft tissues was developed. This consists of a navigated ultrasound scanner, a navigated surgical instrument, and a personal computer with custom-made software. Its use makes an additional visualization by means of CT or MRI dispensable.The system deviation (three-dimensional error) of this newly developed prototype was less than 1 mm. The practical application in a model setup showed good handling properties of the system. Orientation and approach of the surgical instrument to the sonographically visualized target structure were rapid and accurate.This new navigation system does not require additional CT or MRI images. The navigated ultrasound probe shows tissue changes in real time. This navigation system is especially suitable for invasive procedures in soft tissues.

In 2003, our department inaugurated a quality management system. The certification according to DIN EN ISO 9001:2000 as required by the hospital management was achieved in August 2005. The aims were optimization of internal operating schedules and standardization of procedures according to logistic interfaces with external structures.Since 2000, the implementation of an internal quality management system is required by German law and threatened by penalty in case of non-implementation. Beside a basic audit and optimization of all organizational procedures, all core processes were determined and the approvals checked. These aims involve both the quality of operational procedures, in and outpatient treatment, research, study and teaching and aspects of service such as quickness of scheduling and forwarding of reports as well as economic aspects and efficiency. The department of "quality management", whose main tasks are the professional guidance and the training of the quality management representatives, plays an important role.Realization of the new regulations and restructuring resulted in an increase in effectiveness and an improvement in operational procedures. In particular, patients and staff have benefited from the reorganized and modified sequence of operations.Implementation of a quality management system in different hospital departments is recommended.

The introduction of Diagnosis-Related Groups, which standardize payment for each clinical service, entails keeping the inpatient treatment as short as possible. Thus outpatient treatment is gaining in importance. To cope with this change, organizational and structural modifications of clinic routine are necessary.In the ear, nose, and throat outpatient clinic of Johann Wolfgang Goethe University in Frankfurt, Germany, a hotline was established that allows patients to make appointments and get advice based on quality management guidelines according to DIN EN ISO 9001:2000. The development of this project is described here step by step, from planning to inclusion in the daily clinic routine.Patient visits became more effective despite increasing demand. This resulted in high satisfaction of patients and clinic personnel alike.This model may contribute considerably to coping with the increasing demand for clinic appointments and to optimal use of a clinic's human resources.

Exact estimation of a tumor's size and the definition of adequate resection margins in carcinomas of the tongue are often difficult because of the tumor's extension and deep infiltration.We have developed a method that allows intraoperative visualisation and marking of tumor margins. Intra-operative endosonography was performed on nine patients with carcinomas of the tongue using a 8-12 MHz linear array transducer. The oral cavity was flooded with normal saline solution and the transducer was immersed therein. This allowed scanning in a non-contact mode. The tumor margins were marked with a surgical suture under endosonographic monitoring.In the nine patients studied, the histological margins corresponded to the sonographic margins. The sonographic marking proved to be useful during the resection of the tumor and histological safety margins were respected in each case.This non-invasive procedure provides a quick and reliable orientation during the resection of tongue carcinoma, and a more precise and individual definition of resection margins is possible. Intraoperative non-contact use of endosonography is a promising method.

With the help of dynamic magnetic resonance tomography (dMRT) the status of tissue microcirculation can be visualized.Dynamic MRI was performed in 13 patients with advanced, nonresectable oro- or hypopharynx carcinoma at the beginning and the end of therapy. Maximal signal intensity and exchange rate constant in the tissue of the tumor and the lymph node metastases were analyzed using a pharmacokinetic two-compartment model.In all six patients with clinical complete response (CR), the maximal signal intensity increased after therapy in the tissue of the primary tumor and the lymph node metastases. Furthermore, a high decrease in the parameter k(21) was associated with a better prognosis and could be observed especially after combined radiochemotherapy.Our first results indicate that contrast-enhanced dynamic MRI studies before and after radio- or combined radiochemotherapy offer important information about the changes of microcirculation in the tissue of the tumor and lymph node metastases. Furthermore, this information seems to be a promising predictor for clinical outcome of therapy.

In order to identify squamous cell carcinomas of the head and neck (HNSCC) with common biological and clinical features, we investigated the incidence and properties of carcinomas lacking retinoblastoma protein (pR6) cell cycle control. Of 208 HNSCC investigated, 23 (11%) showed a lack of pRb expression. The majority of these tumors (65%) were tonsillar carcinomas. The pRb-negative tonsillar tumors were all stage IV, had metastasized to lymph nodes at the time of diagnosis and were in general poorly differentiated or undifferentiated. Very significantly, the pRb-negative phenotype was strongly associated with the presence of oncogenic human papilloma viruses, implying a viral etiology and functional inactivation of pRb by the viral E7 oncoprotein. Despite the very adverse histopathological factors, patients with pRb-negative tonsillar carcinomas had a better clinical outcome, which was consistent with a uniform favorable responsiveness of these tumors to postoperative radiation therapy.

The diagnosis of cystic echinococcosis (echinococcus granulosus) in an atypical location can be difficult to make and frequently can only be established by histological examination of affected tissues. Surgical excision and fine-needle aspiration biopsy usually lead to the diagnosis. Since puncture of these cysts may cause an anaphylactic reaction due to spillage of hydatid fluid and/or dissemination of infection, the use of fine-needle aspiration biopsy is controversial at present. We report on a patient with a cystic neck mass who developed an allergic reaction after diagnostic fine-needle aspiration biopsy. Cytological examination of the specimen was inconclusive. The allergic reaction led to the diagnosis of echinococcosis, which was confirmed by serological examination. We describe a possible diagnostic procedure for a cystic mass of unknown etiology. If imaging and serological tests are not conclusive, we believe that fine-needle aspiration biopsy is justified. However, this should only be performed in a setting that provides sufficient management for anaphylactic reactions.

In addition to mucositis and myelotoxicity as well known early reactions after radiotherapy or radiochemotherapy in advanced head and neck tumors, late toxicity following treatment is an often underestimated problem. Between 1992 and 1995, 68 patients with advanced oro- and hypopharyngeal tumors were treated primarily with accelerated concomitant boost radiochemotherapy (total dose irradiations of 66 Gy and carboplatin as chemotherapy). Ninety-three per cent of the patients had stage IV disease according to the UICC-TNM classification. Monitoring of follow-up included late toxicity with special attention given to laryngeal edema. In 37 patients (54%) edema of the larynx as a late complication of radiochemotherapy was observed by clinical investigation and CT scan. The median onset of laryngeal edema was found 121 days after completion of therapy, with a median time of observation of 250 days. Observations in these patients demonstrated the chronic character of this edema. An increase in the laryngeal edema in 5 cases resulted in tracheostomy. Laryngeal edema in 10 patients was associated with recurrence of tumor. These results show that after xerostomia laryngeal edema is the main late toxicity in the head and neck after radiochemotherapy and should lead to further investigations to exclude possible recurrent tumor.

Anatomy and perfusion of the nasal septum and inferior turbinate mucosa can be visualized with B-mode and power-Doppler ultrasound. The transducer is placed externally on the nasal ala parallel to the pyriform crest and directed towards the head of the inferior turbinate of the opposite side. An individually prepared dental splint keeps the transducer in position and allows assessment of dynamic changes in mucosal swelling and perfusion. Perfusion changes are evaluated by computerized quantification of power-Doppler color pixels. Coupling of ultrasound across the nasal lumen is achieved by introducing gel into one nasal vestibule and flooding the anterior nasal cavity of the side to be visualized with isotonic aqueous solutions. Perfusion could be visualized in 23 of 30 subjects, while B-mode sonographic anatomy was visualized in 16 subjects. The effect of isotonic saline solution (10 healthy subjects), naphazoline (10 patients with chronic nasal obstruction) and allergen extracts (10 patients with allergic rhinitis) on mucosal perfusion and swelling was studied. Isotonic saline solution induced a maximum drop in power-Doppler color pixel density by 10% and a maximum increase by 27%, but no change was seen in mucosal swelling. Naphazoline induced a 10-57% decrease in power-Doppler pixel density and decongestion of the inferior turbinate and septum mucosa by 17-43% and 4-27%, respectively. Allergen extracts induced an increase in power-Doppler color pixel density by 24-181% and an increase in mucosal thickness by 4-31%. These preliminary results encourage further studies of nasal mucosal perfusion changes using power-Doppler sonography after pharmacologic and allergen provocations.