Search

The prognosis of squamous epithelial cell carcinoma of the upper aerodigestive tract has improved considerably in the last 30 years. Patients presenting with stage I or II disease are treated with surgery or radiation therapy with curative intent. Although the efficacy is comparable between the two methods, surgery is usually preferred so that the side effects and late toxic effects of radiation can be avoided. For the treatment of advanced stages of disease, surgery, radiotherapy, chemotherapy and immunotherapy are usually combined. The introduction of concurrent administration of chemotherapy and radiotherapy (chemoradiotherapy) has been a major advancement. This has resulted in local control and survival rates comparable to those seen following radical surgery and postoperative radiotherapy, but with preservation of the larynx in most patients. However, recent epidemiological observations have shown declining survival rates in laryngeal cancer patients, raising concern about uncritical and too frequent use of this approach. The rationale for choosing treatment options for patients with laryngeal and hypopharyngeal carcinoma is discussed.

Introduction: Olfactory dysfunction has been reported to affect more than 200,000 patients a year in the USA. The aim of this survey was to obtain comparable epidemiological data and treatment information on olfactory dysfunction in German speaking countries., Methods: Questionnaires were sent to all otorhinolaryngology departments in Germany, Austria and Switzerland; 52% of hospitals completed the survey., Results: An average of 46 patients with olfactory dysfunction were treated per hospital every month. Hyp- and anosmia were most commonly caused by inflammatory diseases of the nose/paranasal sinuses (53%), respiratory dysfunction (19%), or postviral conditions (11%). Steroids were used most frequently for pharmacological treatment (topically 82%; orally 65%). Approximately one third of the clinics used B vitamins, or zinc; 80% of the hospitals performed surgery to treat underlying diseases. Acupuncture and smell training was used by approximately 20%., Conclusion: A total of 79,000 patients per year are treated for olfactory dysfunction in German hospitals. The vast majority of these disorders (72%) is caused by sinunasal diseases. The quality control of therapeutic strategies is urgently needed.

Background: Subtotal laryngectomy with Cricohyoido(epiglotto)pexy (CHEP and CHP) is a commonly used surgical procedure in France, Italy and North America, but it is rarely carried out in Germany,where most laryngeal carcinomas staged T1-T3 are resected endoscopically or with total laryngectomy., Objective: To identify indications for the CHEP and CHP in a setting that uses endolaryngeal procedures as a standard approach to organ preserving surgery in laryngeal cancer patients., Patients: Nineteen patients with primary (n=15) or recurrent (n=4), supra- or transglottic carcinoma or carcinoma of the anterior commissure staged (r)T1b-4N0-2cM0 were treated with subtotal laryngectomy with CHEP (with or without neck dissection/radiotherapy) between October 1997 and June 1999., Results: Undisturbed deglutition without aspiration and respiration without tracheotomy was achieved in 17/19 patients. Three patients showed temporary pneumonia from aspiration and two patients needed further treatment for endolaryngeal synechia. Three patients died of unrelated causes. Four patients were diagnosed with local recurrence: Two of them died from tumor, two patients had curative total laryngectomy as salvage surgery. Fourteen patients are living free of disease 24-40 months after therapy., Conclusion: CHEP is a subtotal laryngectomy with increased postoperative morbidity, but good functional results. Assuming a scrupulous indication for the extended tumors the oncological results of the CHEP are satisfying, too.

Background: Subtotal laryngectomy with Cricohyoido(epiglotto)pexy (CHEP and CHP) is a commonly used surgical procedure in France, Italy and North America, but it is rarely carried out in Germany,where most laryngeal carcinomas staged T1-T3 are resected endoscopically or with total laryngectomy., Objective: To identify indications for the CHEP and CHP in a setting that uses endolaryngeal procedures as a standard approach to organ preserving surgery in laryngeal cancer patients., Patients: Nineteen patients with primary (n=15) or recurrent (n=4), supra- or transglottic carcinoma or carcinoma of the anterior commissure staged (r)T1b-4N0-2cM0 were treated with subtotal laryngectomy with CHEP (with or without neck dissection/radiotherapy) between October 1997 and June 1999., Results: Undisturbed deglutition without aspiration and respiration without tracheotomy was achieved in 17/19 patients.Three patients showed temporary pneumonia from aspiration and two patients needed further treatment for endolaryngeal synechia. Three patients died of unrelated causes. Four patients were diagnosed with local recurrence: Two of them died from tumor, two patients had curative total laryngectomy as salvage surgery.Fourteen patients are living free of disease 24-40 months after therapy., Conclusion: CHEP is a subtotal laryngectomy with increased postoperative morbidity, but good functional results.Assuming a scrupulous indication for the extended tumors the oncological results of the CHEP are satisfying, too.

Background: Perioperative mortality is an important factor for quality assurance in surgery. For ENT-surgery only sparse data has been published., Patients and Methods: A retrospective analysis of 1054 interventions performed on 775 consecutive patients treated surgically for benign and malignant tumors of the head and neck was conducted during a 3-year period in 1995-1998., Results: Of these patients, 34.1% were female and 65.9% male. Age ranged from 4-88 years with a mean age of 54.8 years. 489 patients (63.1%) were treated for malignoma and 286 for benign tumors (36.9%). 0.9% (n = 7) of our patients (n = 775) died during the first 30 days after surgery. That means 0.66% of all surgical interventions (n = 1054) were followed by post-operative mortality., Discussion: In otorhinolaryngological surgery, post-operative mortality seems to be acceptable and low compared to other medical disciplines. The challenge for surgery must be to reach and preserve low perioperative mortality rates in the future. Finding the individually correct indication for surgical treatment must be guaranteed in order to reach this aim.

Background: According to German legislature, hospitals have to implement quality assurance (QA) programs, which are of particular importance in times of ongoing structural changes in healthcare. Amongst other internal methods of QA, indicators measuring the quality of total hospital performance can reflect medical outcome and the activities of physicians, nurses, and administrators., Methods: Five indicators for measuring total hospital performance and for controlling total medical outcome were used in this study., Results: Evaluation was time consuming, and some indicators showed a wide range, which could be explained by external reasons independent from internal quality. Valid values could be ascertained in the field of administrative quality, whereas in contrast the assessment of medical quality seemed to be more difficult., Conclusion: Due to current developments in German healthcare, the application of quality assurance methods such as the presented system of indicators is recommended.

This paper seeks to provide the reader with a state-of-the-art review of the aetiology, diagnosis and clinical management of bilateral recurrent nerve paralysis. The recurrent laryngeal nerves are more frequently involved in bilateral paralysis than any other cranial nerve. Most of the underlying lesions are iatrogenic, with thyroid surgery being the single most important causative factor. However, a variety of different reasons can lead to such a condition. Whenever the aetiology is uncertain, a complete diagnostic work-up is mandatory. Massive stridor on inspiration is the key symptom. Indirect laryngoscopy confirms the diagnosis. Laryngeal electromyography is of great value because it differentiates between paralysis and ankylosis of the cricoarytenoid joint. Moreover, in many cases, laryngeal electromyography yields reliable prognosis of clinical outcome. While unfavorable results can be predicted with high accuracy, correct prognosis of complete recovery is more difficult. Clinical management is surgical in the vast majority of cases. A variety of endoscopic techniques for widening the glottic airway are available today and are discussed in detail. Compared to permanent tracheostomy, these procedures have much less impact on the patient's quality of life and should be preferred whenever possible. Since such an operation is irreversible, a decision should be made only in the presence of a reliable electrophysiological prognosis and/or after 6-9 months of watchful waiting. Inevitably, voice quality is traded for airway normalisation. However, modern surgical techniques accomplish very tolerable phonatory results. Timing, type and extent of surgery need to be customised for every patient individually.

Background and Objective: Quality control is of special importance in head and neck oncology since the quality of medical care constitutes a vital parameter for the diseased patient. In contrast to other medical specialties, no quality assurance program for head and neck cancer patients has yet been established in Germany. Therefore, a survey was conducted to assess the quality assurance instruments that are in use today in otorhinolaryngology-head and neck (ORL-HNS) centers., Patients and Methods: In a nationwide survey, questionnaires were sent out to 146 German ORL-HNS departments (the return rate was 75%)., Results: 56% of all departments apply dedicated quality assurance processes, and 38% have appointed a formal quality assurance officer. Interdisciplinary oncological conferences are held in the vast majority of all departments with the participation of radiation oncologists in 86 (78%), medical oncologists in 84 (76%), diagnostic radiologists in 82 (74%), and pathologists in 73 (66%). Morbidity-mortality conferences are held in seven departments (6%). A standardized follow-up of oncological patients is carried out in 95 units (86%), and 53 departments use computer-assisted data bases to organize their follow-up data (48%). A wide variety of documentation systems is in use throughout the country: 78 units (71%) offer formal follow-up to their oncological patients., Conclusions: This survey documents a wide-spread interest in quality assurance procedures. Many individual efforts are being undertaken. However, no uniform quality assurance or auditing system is currently in use in Germany nor is a commonly accepted data base available. The ability to offer oncological follow-up within the national social security system is generally considered indispensable for the maintenance of high-quality oncological care in ORL-HNS departments.

Background: The morphological development of the human larynx during the first years of life has previously not been studied in detail and has mainly been described on a qualitative basis. This study seeks to provide detailed morphometric data on the regular anatomy of the vocal cords, the subglottic airway and the tracheal airway dimensions gained from plastinated whole organ serial sections of 43 infant larynges and to determine morphological changes with age. Such information may be useful for the understanding of pediatric airway disease or for laryngeal surgery in children., Material and Methods: The larynges of 43 children aged 1 to 60 months were plastinated. Whole organ serial sections were obtained by cutting the resulting specimen with a diamond band saw. Morphometry of whole-organ sections was accomplished using a high resolution, computer-based image analyzer. The total length of the glottis, length of the cartilaginous and ligamentous glottis, subglottic cartilaginous cross-section, subglottic airway and tracheal airway were determined for each specimen., Results: The subglottic airway increases considerably in size during the first 2 years of life (from 13 to 28 mm2 in the means). Further growth seems to follow a linear mode. The relative proportion of the mucosal lining of the subglottic airway decreases likewise. While it occupies approximately 50% of the subglottic cartilaginous cross-section during the first two years of age, its relative proportion decreases to some 30 to 40% between age three to five. Other than in adults, and comparable to most mammals, the cartilaginous glottis accounts for 60 to 75% of the vocal folds' length in children under two years of age. The anterior ligamentous part of the glottis outsizes its posterior cartilaginous portion during the third year of life., Conclusion: This study supplies detailed morphometric data on the growth and structure of the human larynx during the first years of life that have not been available to date. Previous studies on the anatomical configuration of the infant larynx have focused on the the perinatal larynx, the prepuberal and puberal larynx, and the development of collagen fibres in the developing larynx. The human larynx has undergone significant evolutionary adaptations. Among them are the descent of the larynx, the capability of vocal fold adjustment in length, tension and shape, and the prominent configuration of the membranous part of the vocal folds as opposed to the cartilaginous part. The infant larynx is not just a miniature of the adult organ. It shows differences in its position relative to the vertebrate column, in the composition of cartilages and soft tissues, and in environmental adaptation. The present study is the first to supply detailed morphometric data on the growth and structure of the human larynx during the first five years of life and on the morphological changes of the larynx during this period. From these data it seems that some of the adaption of the human larynx as opposed to other vertebrates are not fully developed at birth, but undergo postnatal maturation. The relative proportions of the cartilaginous and membranous parts of the vocal folds clearly demonstrate this maturation process: While the posterior "respiratory" glottis accounts for some sixty to 75% of the total glottic length in newborns, its relative proportion decreases throughout the first years of life and finally equals the proportions of the adult larynx. Other than in adults, and in accordance with the literature, no sexual dimorphism of the larynx could be detected in this series of infant larynges. Morphometric data on the growth and structure of the human vocal folds and the subglottic airway during childhood are presented. Plastinated whole organ serial sections were used in the study to show the infant laryngeal morphology. The study provides quantitative anatomical data of clinical interest that light up the anatomy of the pediatric airways.

Background: In many parts of Germany fine-needle aspiration biopsy (FNAB) is still not part of the routine preoperative diagnostic evaluation of salivary gland neoplasms. Most opponents consider the study unnecessary and recommend that all salivary gland neoplasms should be excised., Objective: Because of this an evaluated the ability of FNAB to provide an accurate diagnosis of parotid gland neoplasms., Patients and Method: Between January 1992 and October 1995, 336 patients referred for operative therapy of salivary gland neoplasms underwent retrospective analysis of preoperative FNAB compared with the excised tumor histology., Results: Results showed that the FNAB had a sensitivity of 93.1%, a specificity of 99.2%, a positive predictive value of 93.1%, a negative predictive value of 99.2% and an accuracy of 98.6%. Complications were observed in less than 1%., Discussion: Our findings demonstrated that the FNAB is a safe diagnostic tool that has a reliable sensitivity and high specificity for the assessment of salivary gland pathology. Since many malignant salivary gland neoplasms present with a virtual lack of symptoms indicating actual malignancy we believe that there is need for FNAB in routine preoperative diagnostic testing.

Objective: Olfactory dysfunction is a common finding in patients with chronic rhinosinusitis (CRS). The aim of this study was to investigate the relationship between olfaction and nasal flow as determined by active anterior rhinomanometry (AAR)., Methods: Thirty patients with CRS were included in this series. Patients' histories and subjective assessments of olfaction were documented with questionnaires. Smell tests, assessments of olfaction, AAR, and results of rhinoscopy were recorded, including odor identification, discrimination and thresholds measured with the "Sniffin' Sticks"-test., Results: CRS influenced olfactory performances variably in the different tests: 10% of the patients had pathologic rates of odor discrimination, compared with 34% in odor identification and 73% in thresholds. Statistical analyses (using Spearman's test) indicated a significant correlation between nasal airflow and odor identification screening (r29 = 0.56, P < 0.01) and n-butanol-threshold (r29 = 0.44, P < 0.05), respectively., Conclusion: Olfactory performance in CRS was correlated to several parameters of nasal airflow measured with AAR. The n-butanol threshold test revealed the most frequent pathological results and may best be used for detecting olfactory disorders. However, because a number of factors may influence olfactory dysfunction in CRS, our findings must be evaluated in a lager series.

Facial neuromyography is an objective electrophysiologic measurement used to assess prognosis for recovery from facial paralysis. In the present study variability over time of the amplitude ratio in healthy subjects was investigated. Twenty healthy subjects underwent four neuromyographic tests at intervals of one week. The study group consisted of 12 males and 8 females. Ages ranged from 23 to 36 years. The stimulation intensity required for supramaximal stimulation was 14.6 mA on average. The mean of the intra-individual side-to-side difference of the evoked compound action potential was 32.5%. Results of the four repeated tests ranged from no to 80% side-to-side differences in the same individual. The hypothesis of symmetrical evoked facial compound potentials was not supported by our data. As with previous investigators we found significant side-to-side differences in healthy subjects. Furthermore, we could also show for the first time that the amplitude ratio was not constant in every individual at repeated measurements. We conclude that there is a physiological variability that must be taken into account in the interpretation of facial nerve neuromyography.

In benign laryngotracheal stenosis the amount of respiratory deterioration rather than the crude morphologic appearance will determine whether or not surgical measures such as dilatation or resection should be applied. This review focuses on currently available and newly developed diagnostic tools to assess the functional importance of central airway obstruction. After an outline of upper airway physiology is formulated, spirometric measurements at rest are collected. Among these, Peak Expiratory Flow Rate (PEF) proved to be the simplest and most reliable parameter to monitor an obstructing lesion of the upper airways. A novel technique for fibrobronchoscopic assessment of glottic and tracheal resistance is presented in detail. In contrast to usual tests of total airflow resistance which cannot distinguish between central and peripheral contributions, this test identifies the pressure-flow-relationship created exclusively by the local lesion. In serial stenoses, it indicates which is of higher clinical impact. Patients with upper airway obstruction complain of impaired exercise capacity. They tend to hypoventilate with imminent respiratory muscle fatigue. Therefore, spiroergometry may play a role in defining the point of incomplete compensation of a central load. The decision to operate will depend upon up the degree of physical capacity required to compensate for the stenosis.

According to the law (Section 137 SGBV) in Germany, hospitals have to implement quality-assurance (QA) programs, which are now of particular importance in times of ongoing structural change in health care. External as well as internal methods of QA are well established and can serve as parameters for single processes and outcomes in most cases. However, there is still an urgent need for methods measuring the quality of total hospital performance. Indicators are powerful instruments for this purpose. They reliably reflect clinical outcome, physicians' and nurses' activities, administration and can be regarded as instruments for general hospital performance in otorhinolaryngology. We describe the process of definition, development and application of quality indicators for measuring quality in health care. Furthermore, we present a critical overview of selected indicators in otorhinolaryngology, general medical indicators and indicators concerning administrative problems. Because of current developments in German health care the application of quality assurance methods similar to the system of indicators presented is strongly recommended.

Actinomycosis is currently an uncommonly diagnosed human disease. However, it can still complicate trauma to the respiratory and digestive tracts, including operative procedures. A patient with cervicofacial actinomycosis commonly gives a history of recent dental manipulation which usually, involves extraction of a mandibular molar. The common initial symptoms of infection--such as, sudden onset of cervicofacial pain, swelling, erythema, edema and suppuration--can be absent. Infection due to actinomyces is a well-known mimic of malignancy is clinical, radiological and pathological findings. In the case described a 65-year-old man had a mass in his right parotid area. Because of its painless rapid growth with infiltration of the mandible as demonstrated by clinical findings and CT and MRI scans, we established an initial diagnosis of salivary gland malignancy. Salivary gland biopsy then revealed a histological picture of infection due to actinomyces. Therapy was initiated with intravenous amoxicillin and sulbactam. After 20 days of treatment diseased soft tissues and bone were resected. To prevent a relapse the patient received oral clindamycin for 6 weeks. After a followup of two years, the patient has remained free of disease.

Unlabelled: The present study sought to determine the etiology of bilateral profound hearing losses in children living in Germany. Additionally, a comparison with the data of previous investigations in the available literature was used to update causes now known through medical progress., Patients and Methods: The medical charts of 314 profoundly hearing-impaired pupils at schools for the deaf in Cologne, Germany, were reviewed. All available data on possible etiological factors were collected. In addition, the families of these children were interviewed using a standardized questionnaire., Results: Sixty children were found to have bilateral sensorineural hearing losses averaging 30 to 60dBHL within the frequency ranges of 500-2000 HZ, while 254 had bilateral hearing impairments of 60 dBHL or greater. The etiology of the hearing disorder could be determined in 218 of the children. Eighty-two children suffered from hereditary deafness and 136 from acquired hearing losses. The etiology could not be determined in 96 children. Hereditary causes included 34 children with mendelian autosomal dominant losses, 46 with autosomal recessive losses and two children with genetic but non-mendelian causes. Immigrants to Germany (mostly from Turkey and the former Soviet Union) were found significantly more frequently among the students of these schools, than among the total population of the Cologne area. In this group of students, autosomal recessive deafness was particularly common as compared to the overall native population. Acquired hearing disorders were broken down into three subgroups: prenatal, perinatal and postnatal disorders. A prenatal etiology was considered in 32 children, 21 of whom had known congenital rubella infection. This entity was significantly less common among younger children. A perinatal etiology was considered in 60 children. Causative factors were birth asphyxia, apnea and/or hyperbilirubinemia. Forty-four children had deafness attributed to postnatal causes, with bacterial meningitis (n = 31) being the most important single factor. The findings reported indicate changing trends for causes of hearing loss in children with severe hearing impairment in Germany.

Management of laryngeal carcinoma located at the anterior commissure remains controversial. Local control rates with radiotherapy or surgery are not as good as those seen after treatment of midcord lesions. The vertical partial laryngectomy with epiglottic reconstruction (VPLER) may be a more successful approach to such lesions. The charts of all patients treated for larynx carcinoma between 1991 and 1996 at the authors' institutions were reviewed to identify those patients treated with VPLER as described by Sedlacek in 1965, Kambic in 1976 and Tucker in 1979. Indications for performing surgery and outcome data of patients were collected and analyzed according to the indications for surgery, surgical technique, perioperative complications, oncological outcomes and functional results. Twelve patients were identified that had been treated with VPLER. Indications for surgery included five patients with local recurrences following endoscopic laser partial laryngectomies, four cases with previously untreated primary tumors at the anterior commissure (T2 N0-2 M0), two with local recurrences following radiotherapy, and one with recurrence following frontolateral partial laryngectomy. There were no postoperative complications except for one laryngocutaneous fistula that required secondary repair. All patients were able to swallow at the tenth postoperative day. All had their tracheostomies closed after completion of wound healing, (a mean of 17 days after surgery). Phonatory results were usually poor. Two local recurrences occurred during the follow-up period. However, both patients were salvaged with total laryngectomies and have since been free from disease. All other patients are alive and well. Our findings show that VPLER is an effective surgical approach for carcinoma at the anterior commissure of the larynx that cannot be adequately managed with transoral laser surgery or simple frontolateral partial laryngectomy. This study demonstrates that the procedure can be successfully applied to the treatment of local recurrences following initial radiotherapy or surgery. No major complications occurred in our study.

Unlabelled: A prospective study was performed to compare the sensitivity and accuracy of ultrasound (US), computed tomography (CT), and single photon emission computed tomography (SPECT) as a bone scan to detect subclinical invasion of the mandible by squamous cell carcinoma of the oral cavity and floor of mouth., Methods: The present study reports data on 35 patients with squamous cell carcinoma of the oral cavity. SPECT, mandibular orthopantomography (OPG), US, CT and magnetic resonance imaging (MRI) were performed as well as histologic examination of resected mandibles. Transverse slices of 12 mm thickness were reconstructed for SPECT and semi-quantitative assessment of radionuclide uptake was performed with a scoring system based on comparisons of tracer uptake in the mandible to that in an unaffected part of the mandible. Lesion to non-lesion count ratios in the mandible in 3 h SPECT images were calculated. OPG, US and CT were evaluated for comparison., Results: In 12/35 patients, histologic examination showed carcinoma infiltrating mandibular bone. SPECT correctly predicted mandibular invasion in 11/12 cases, with no false-positive results. CT detected correctly 3/12 lesions, while OPG and ultrasound each demonstrated 2/12 tumors., Conclusion: Bone SPECT was found to provide an accurate means for assessing tumor invasion to the mandible by intraoral squamous cell carcinoma. As a complementary study to one of the other imaging modalities it was shown to have a high specificity, indicating that it should be performed routinely in patients with suspect mandibular bone involvement by causes.

Progressive hearing loss during childhood caused by a hearing-aid induced deterioration has been discussed controversely since 1939. However, it is unchallenged that in cases of profound sensorineural hearing loss in infancy and early childhood powerful hearing aids are necessary for auditory and speech development. Due to an increase of progressive hearing losses during the last 4 years, we discussed the possible causes and the probability of hearing aid induced progressions once more. Our study consists of two investigations: First, all patients since 1993 suffering from progressive hearing loss among all hearing impaired children in the department of Audiology and Pedaudiology of the ENT-Hospital of Cologne were taken into account. Second, all children of the Rheinische school for hearing impaired children were investigated. The evaluated data included the degree of severity and etiology of the hearing loss, the duration of the hearing aids use and the amplification of the hearing aid. 23 children were diagnosed with a progressive hearing loss in the period. We observed a massive increase over these years. No correlation between the duration of the hearing aid usage and the maximum output level was found. Furthermore, there was no difference between the causes of the hearing losses between the children of the school and the children with progressive hearing loss. At the moment, we do not see any reason to change our strategy for fitting hearing aids. The increase of progressive cases in the last 2 years should be the reason for further investigations in this field.

Whole-organ sections of the larynx have evoked the laryngologists' interest for a long time. Established techniques for histological preparation do exist, but these are time-consuming and result in frequent artifacts. Owing to their thicknesses the slices prepared are usually not suitable for a complete histological work-up. The technique of plastination is an established and gentle method for tissue preservation. We describe the technique of sheet plastination to produce whole-organ sections that allow full-scale histological investigation. Deep-frozen larynges are cut into 4-mm-thick sections, dehydrated in acetone and plastinated in epoxy resins. During plastination, fat and lipids are replaced by curable polymer, making decalcification unnecessary. Specimens are cut into thin sections using a diamond-wire saw. An ultra-milling device reduces the section thickness down to about 10 microns. Staining is possible using a variety of special plastination stains, while all routine stains are also applicable after deplastination. Sheet plastination produces artifact- and shrinkage-free whole organ sections in about 1 week. The technique is useful for studies of micromorphometry or tumor spread and can be used to evaluate quickly possible tumor erosion of the laryngeal skeleton after laryngectomy. Since such erosion is one of the criteria for postoperative radiotherapy in many centers, earlier information could make planning easier.

Hospital-acquired or nosocomial infections are infections that are neither present nor incubating at the time of admission. They must become manifest by 48 h after admission. They raise significantly the morbidity, mortality, and economic burden of the underlying disease. Nosocomial infections occur in 2.5-9.5% of all hospitalizations. They are mainly found in intensive care units and surgical wards. Urinary tract infections are the most frequent, followed by wound infections, pneumonia, infections of the skin and mucosa, bloodstream infections and others. The major pathogens causing nosocomial infections are Staphylococcus aureus, Escherichia coli, enterococcus and Pseudomonas. Methicillin-resistant pathogens must be considered. In Germany the direct costs of excessive hospital stays exceed 3 billion DM annually. Preventive measures reduce current nosocomial infections. The CDC suggest that these measures include a trained hospital epidemiologist, an infection control nurse, an active surveillance program and data feedback to surgeons about their wound infection rates.

Nosocomial infections are defined as infections that occur during hospitalization but were not present at admission. Nosocomial infections have been found to occur in 6% of all hospitalizations and are present mainly in intensive care units and surgical wards. These infections extend the time of hospitalization and therefore increase the cost of care. Between July and December 1993, all nosocomial infections occurring in 304 patients of the surgical ward of the University ENT Department, Cologne, were recorded prospectively. These were classified into wound, implant, urinary tract, respiratory, skin or mucosal infections, nosocomial bacteremias and gastrointestinal infections. The overall prevalence of nosocomial infections was 15.4%. Of these, 9.2% were postoperative wound infections, 2.6% respiratory infections, and 2.3% infections of the skin and mucosa. The incidence of urinary tract infections was 0.7%, while bacteremias occurred in 0.3%. No implant or gastrointestinal infections occurred. Microbial analysis demonstrated 9 gram-positive and 15 gram-negative bacterial and 8 candidal infections. Nineteen cultures were negative. Among the bacteria cultured three were methicillin-resistant. The time of hospitalization was extended from a normal average of 9.52 days to 25.7 days. The distinct risk of a nosocomial infection in the treatment of hospitalized patients requires and accurate documentation of all acquired infections. Determination of the source of infection, the method of spread and microbial analysis including the spectrum of organism resistance is necessary in order to decrease the infection rate and to prevent establishment of a nosocomial infection. These requirements at the least are an important part of quality control in the surgical disciplines.

Total organ sections have proven to be useful in the evaluation of the clinical growth behavior of malignant tumors. However, histologic techniques using tissues embedded in celloidin or paraffin are difficult to produce and require extensive amounts of time. Total organ plastination is a method superior to the aforementioned techniques. The number of artefacts is also greatly reduced by avoiding the need for decalcification. After removal of fat and dehydration, specimens can be placed in epoxy resin. Following evacuation and hardening of specimens, parallel sections can be separated with a diamond wire saw for precision slicing, with section thicknesses ranging from several centimeters to as small as 40 microns. The loss in material caused by slicing is as little as 0.3 mm per section. A further benefit of this method is the relatively large amount of time saved. The entire procedure yielding complete plastinated specimens requires a time period of approximately 40 days. The plastinated specimens are transparent, odorless and fixed and are ideal for instructional and research purposes. Deplastination for the purpose of further diagnositic study is also achievable with a minimum of technical effort.

Body plethysmographic and spirometric indices can be used for routine examinations of obstructive lesions of the larynx and upper trachea. Total resistance, forced expiratory volume in 1 sec (FEV1) and the S-shaped flow-pressure loop can show clinically significant extrathoracic stenoses. We have now also measured peak inspiratory flow (PIF) and peak expiratory flow (PEF) with a peak flow meter. Easy handling was compared with good reliability of the measurements and possible detection of laryngeal lesions. Extrathoracic stenoses caused turbulent flow, with a flow-dependent increase in total resistance (Rtot). This resistance increased only with severe stenoses, while mild stenoses were often not detected. Peak expiratory flow reacted earlier than did peak inspiratory flow and seemed to be the most reliable parameter for detecting an extrathoracic stenosis. Testing was easy to perform and was usually reproducible. Patients with additional peripheral obstructive stenoses required a more specific examination.

Between March 1986 and October 1987, 73 patients with advanced squamous cell carcinomas of the head and neck underwent initial chemotherapy before surgery and/or radiotherapy. Chemotherapy consisted of three courses of carboplatin/5-FU or cisplatin/5-FU. Pretreatment tumor states, remission rates and ages of the patients were comparable. Carboplatin as a modification of cisplatin showed significantly less gastrointestinal nerval and ototoxic side effects. After five years of followup, 30% of the patients treated with carboplatin and 33% of the cisplatinum group were alive and clinically free of disease. In contrast, 97% of all patients treated with sequential chemoradiotherapy have died. The data fails to support a "downstaging" of disease. These results document that the only prognostic factor for long-term survival is histologically complete resection of tumor. Further studies must compare the influence of prior chemotherapy and surgery, both followed by conventional fractionated radiotherapy in resectable tumors. Findings show that induction chemotherapy should not be used for unresectable tumors or for sequential chemo-radiotherapy. The use of carboplatin is preferred since oncological efficiency is comparable while side-effects are significantly less.

Tumors can be resected in two different ways using endolaryngeal laser surgery. 1. After taking a biopsy from the lesion for histological purposes, the remaining tumor is completely vaporized. This method is only to be used in the treatment of premalignant lesions, as it does not allow a clear histological examination of the boundaries of such lesions. 2. The laser is used as a "scalpel", allowing a complete resection of laryngeal tumors in one block and a histological assessment of the margins. In the treatment of carcinoma in situ and severe dysplasia, we perform a laser-decortication of one or both vocal cords, leaving the vocal muscle intact (endolaryngeal laser-resection type I). Limited carcinomas of one vocal cord undergo a cordectomy, leaving the anterior commissure behind (endolaryngeal laser-resection type II). Extended and bilateral vocal cord carcinomas are treated by an extended cordectomy, which can comprise resection of one of the arytenoid cartilages if necessary (endolaryngeal laser-resection type III). Vocal cord carcinoma with extension to one or both false cords (stage T2) require a complete resection of one or both vocal and false cords in combination with an arytaenoidectomy, if necessary. The resection comprises the inner perichondrium of the thyroid and cricoid cartilages as well as the cricothyroid membrane (endolaryngeal laser-resection type IV, endolaryngeal exenteration).

From 1986 to 1988 ninety four patients with carcinoma of the larynx were treated by endoscopic laser surgery. Follow-up ranges from 3 to 39 months with a mean value of 23 months. Ninety patients were operated on with curative intent and 4 with palliative intent. In 7 cases of T3 tumors a complete removal of the tumor was not possible, so that a total laryngectomy could not be avoided. In all cases of T2 cancers of the glottic and subglottic level a definite resection was possible. Follow-up investigations showed 3 recurrences in the larynx so far. These were treated by laryngectomy. Recurrences in the cervical nodes were seen in two patients following resection of a supraglottic and a subglottic tumor. The authors believe that laser surgery may obviate the need for total laryngectomies in certain stages of laryngeal cancer, especially in T2 tumors. T3 tumors should not be treated by endolaryngeal laser surgery. At present, the number of recurrences and the rate of survival show no significant difference to those after conventional surgery. The phonatory function is not always predictable, and still needs to be investigated.