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Background: Today's available therapeutic options in head and neck cancer patients have led to better treatment modalities tailored to the individually clinical staging of the patients towards a risk adapted tumour management. This, however, is only possible with an accurately pretherapeutic diagnostic regimen and closely posttherapeutic follow-up., Methods: These issues were discussed by nuclear medicine experts, otorhinolaryngologists, oral surgeons, radiologists, radio-oncologists and oncologists in a meeting that took place in Pörtschach, Austria, on 05 May 2006. The aim was to discuss the impact and indications of performing FDG PET/CT in patients with head and neck cancer and to outline possible future perspectives., Results: FDG PET/CT is recommended for a better pretherapeutic staging in stage IV according to UICC and should be the method of choice in CUP with lymph node metastases. FDG PET/CT should be performed 3 - 4 months after radiation-/radiochemotherapy to diagnose viable tumour and to avoid false positive results. To evaluate the position and effectiveness of FDG PET/CT in therapy-monitoring further studies are needed. In case of radiation therapy FDG PET/CT allows a tailored treatment of patients with an accurate design of the target volume to reduce damage to the surrounding tissues., Conclusions: The interdisciplinary consensus reached by the experts is not intended to recommend standard guidelines in the management of head and neck cancer but to summarise and stress the impact of FDG PET/CT on the basis of the present literature and current clinical practise.

Precancer (carcinoma in situ) or laryngeal intraepithelial neoplasia (LIN) is a non-invasive lesion that has genetic abnormalities, loss of cellular control functions, and some phenotypic characteristics of invasive cancer and that predicts for a substantial likelihood of developing invasive cancer. Several classifications have been proposed but none has received a total agreement. With regard to diagnosis, treatment and prognosis, these lesions differ substantially from infiltrating carcinoma. Known risk factors include cigarette smoking, viral infection with subtypes of the human papilloma virus, exposure to asbestos, and probably the gastro-oesophageal reflux disease. The diagnostic work-up usually includes indirect laryngoscopy with rigid telescopes, microlaryngoscopy and biopsies for histological evaluation. Therapeutic options include wait-and-see-strategies, radiotherapy, transoral laser surgery, vocal cord stripping with cold instruments, and open partial laryngectomy. Data from the literature suggest highest local control rate with radiotherapy as initial treatment compared to other standard methods of management of dysplasia. However, transoral laser surgery can be applied repeatedly and yields excellent final results. Therefore it is now considered the treatment of choice for these lesions in the majority of patients. Local recurrences are observed more frequently than with small infiltrative carcinoma, and second primaries may arise within the upper aero-digestive tract following initial treatment. Therefore systematic follow-up is recommended for these patients.

Unilateral recurrent nerve paralysis leads to glottic insufficiency, causing a significant lack of vocal ability. In contrast, bilateral palsies present with stridor on inspiration due to glottic stenosis. 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 aetiology is uncertain a complete diagnostic work-up is mandatory. Indirect laryngoscopy confirms the diagnosis. Laryngeal electromyography is of great value because it differentiates between paralysis and ankylosis of the cricoarytaenoid joint. Moreover, in many cases laryngeal electromyography provides a reliable prognosis of clinical outcome. While unfavorable results can be predicted with high accuracy, correct prognosis of complete recovery is more difficult. Speech therapy is the treatment of choice in case of unilateral recurrent nerve palsy. Only if a significant glottal gap persists medialization procedures may become useful for voice improvement. Endoscopic as well as open approaches are available for this purpose. Bilateral recurrent nerve palsies need to be addressed surgically in the vast majority of cases. Today, a variety of endoscopic techniques for widening the glottic airway are available. Compared to permanent tracheostomy these procedures have much less impact on the patient's quality of life and should be preferred whenever possible. Inevitably, voice quality is traded for airway normalisation. However, modern surgical techniques accomplish very tolerable phonatory results.

Background: Ackerman's tumor, named after the author of the first description in 1948, is a low grade malignant tumor. The aim of this paper is to clarify the role of the carbon dioxide laser therapy in the management of this neoplastic disorder of the larynx., Patients: Twenty-four men and one woman suffering from glottic tumors fulfilled the diagnostic criteria laid down by Ackerman from 1986 to 1998. All patients were treated with transoral laser surgery with a follow-up ranged from 14 to 142 months., Results: Seventeen patients were diagnosed at T1, seven at T2, and one at T3. In T1 lesions, a laser cordectomy or an extended laser cordectomy was performed. In T2 and T3 tumors, partial laryngectomy with a CO2 laser was performed. No patient died tumor-related. In this series, initial failure rate of laser resection was 8%: one patient was salvaged with endolaryngeal laser surgery, another patient (initially T3 tumor) with total laryngectomy. No patient required radiation therapy. No cases of anaplastic transformation were recognized., Conclusions: Based on this material, recommended treatment for T1 and T2 Ackerman-Tumors is oncologic CO2 laser resection in combination with a meticulous follow up for every recognition of local recurrences.

Study Design: A matched-pair study on the relationship between proliferation associated markers Ki-67, PCNA, and p53 and treatment failure in carcinomas of the oropharynx and oral cavity., Material and Method: Fifty-six T1-T3 carcinomas of the oropharynx or oral cavity, treated uniformly with primary surgery and postoperative irradiation, were investigated. Twenty-eight patients had recurrent disease and were matched with 28 patients with nonrecurrent disease regarding stage and location of tumor as well as age and therapy. MIB1 staining was used to determine the Ki-67 labeling index. Immunohistochemical studies determined the p53 status and PCNA labeling index., Results: Where treatment failed, the Ki-67 labeling index was significantly (p = 0.032) higher (mean = 59.1%) than in patients without recurrence (mean = 50.5%). Mean time to relapse was 45 months (n = 25) for carcinomas with a Ki-67 (MIB1) labeling index above the median (53.7%) of the general study population, compared to 61.7 months for those cases (n = 31) below this median (p = 0.029). The PCNA labeling index did not correlate significantly with tumor recurrence, nor with time to relapse. In 46% of all tumors, p53 overexpression was present. No significant correlation could be found between p53 overexpression and tumor recurrence or time to relapse., Conclusion: Examination of Ki-67 is thought to provide useful prognostic information concerning squamous cell carcinomas of the oropharynx and oral cavity. Overexpression of p53 or PCNA status is not of prognostic value, which is consistent with earlier results. We conclude that the detection of Ki-67 is an unfavorable prognostic factor for squamous cell carcinoma of the oropharynx and oral cavity, at least if treated with a combination of surgery and postoperative irradiation.

Background: We conducted a prospective study to investigate voice quality after transoral endolaryngeal laser surgery in terms of ability to communicate effectively. Eighty patients with T1 or T2 glottic carcinoma were enrolled in the study. The main objective was to identify the influence of type and extent of surgery on postoperative voice parameters after endoscopic laser surgery., Material and Methods: The postoperative mechanism of phonation was assessed by videostroboscopy six months after surgery at the earliest. A phonetogram was produced and its area calculated (relative phonetogram, RP) in relation to a gender-specific normal phonetogram. A speech therapist (ST) and a trained otolaryngologist (TO) rated each voice independently for communication ability in a grade from 1 (poor) to 6 (near normal)., Results: After simple cordectomy the mean values were as follows: RP = 24.8%, TO = 3.26, ST = 3.33. When the anterior commissure was completely preserved mean results were better (RP = 34%, TO = 3.92, ST = 3.83). Results were worse following extended cordectomy (RP = 14.7%, TO = 2.82, ST = 3.00) and transglottic resection (RP = 13.7%, TO = 2.30, ST = 2.86), but similar within these two groups. The parameters RP, TO, and ST do not differ significantly between the group who had speech therapy after surgery (N = 33) and the group who did not (N = 47). Voice production at glottic level yields better results for every parameter than supraglottic substitute phonation. The amount of tissue removed was less significant., Conclusion: We conclude that postoperative phonatory results correlate with the postoperative mechanism of phonation. There is no linear correlation with the amount of tissue removed. Comparing similar types of resection preservation of the anterior commissure plays a key role. From the data in this study there is no evidence of a significant benefit from speech therapy. The parameter RP is an effective and relatively simple parameter to complete auditive voice assessment.

Objective: Early detection and adequate and timely rehabilitation of profound deafness in children is accepted as an important aim of preventive child health care. Ideally, rehabilitation of congenital deafness should not be delayed beyond the age of six months. The present study seeks to determine whether this goal has been achieved in Germany in the 1990s., Patients and Methods: The medical charts of 314 profoundly hearing impaired pupils at the schools for the hearing impaired in Cologne, Germany, were reviewed. All available data on the time of first suspicion and the final diagnosis were collected. In addition, the families of these children were interviewed using a standardized questionnaire., Results: The mean age at first suspicion was 2.1 years, the mean age at the time of final diagnosis was 2.6 years (median: 2.0 years). Breaking down the whole cohort into three subgroups according to the year of birth revealed obvious differences between these subgroups. The final diagnosis for those born from 1974 to 1979 (n = 70) was confirmed in 48.6% at the age of two years, in 46.3% for those born from 1980 to 1985 (n = 121), and in 65.8% for those born from 1986 to 1991 (n = 114) at the age of two. The diagnosis was significantly delayed for children of immigrants (n = 96), where the mean age at diagnosis was 3.7 years as opposed to 2.0 years for the native German population. Of the 314 children, 304 where supplied with hearing aids and five with cochlear implants. Once the audiological diagnosis had been established, no further delay in rehabilitation was noticed., Conclusion: Although highly sensitive, cost effective, and non-invasive screening methods (transient evoked otoacoustic emissions and auditory brainstem response audiometry) for the early detection of profound inborn hearing impairment are now available, the current state of early identification of these disorders is inadequate. The reason for this is the lack of a universal and nationwide neonatal screening program. The results of this study indicate that the pure availability of sophisticated screening methods is insufficient if they are not included in a universal screening program.

Background: The possibility of hearing aid induced deterioration was first described in 1939 (Berry 1939, Holmgren 1939). Since then numerous studies discussed this problem controversely. However, it is undisputed that in cases of profound sensorineural hearing loss in childhood powerful hearing aids are necessary for maturation and auditory and speech development. An increase of progressive sensorineural hearing loss in the last three years in children with profound sensorineural hearing loss fitted with hearing aids (2 children in 1993, 6 children in 1996) drew our attention to this problem., Method: Over a period of four years, we collected the data of 16 children with progressive hearing loss., Results: The comparison of the duration of the hearing aid use since fitting and the maximum output level fail to explain this increase. Moreover our strategy in hearing aid fitting remained unchanged during this period especially with regard to SSPL max. We also performed an analysis of the childhood disorders associated with the sensorineural hearing losses. This analysis provided no further information for the increase of hearing loss., Conclusion: There is no evidence that powerful hearing aids damage hearing and induce progressive sensorineural hearing loss in childhood. Therefore we believe that there is no need to change our hearing aid fitting strategy particularly with regard to the maximum output level up to 135 dB SPL measured in situ. The increase in the number of progressive cases in the last two years indicates the necessity of further investigations in this field.

Aspergillosis belongs to the group of mycotic diseases of the paranasal sinuses. The invasive forms, and particularly the fulminant forms, are potentially fatal. Primary surgical intervention with complete removal of the mycotic mass should be performed. Additionally an antimycotic drug therapy with amphotericin B must be started. In a review of the literature, there is no case surviving an extended invasive aspergillosis after failure of the operative therapy and after failure of the postoperative amphotericin B treatment. We report an interesting case of a complete remission of an invasive, partially fulminant aspergillosis of the paranasal sinuses and frontal and basal regions. After incomplete removal of the mycotic mass by an endo- and extranasal approach, we started postoperative drug therapy with amphotericin B. Under this treatment the mycosis progressed. Additionally the patient developed severe renal side effects requiring suspension of the treatment. At this time, we started a combined antimycotic drug therapy with liposomal amphotericin B (AmBisome) and itraconazol. Within 10 weeks there was complete clinical and radiologic remission. The patient died 63 weeks after this treatment because of a fulminant bacterial pneumonia. Post mortem examination showed no aspergillosis in the skull base, the paranasal sinuses, or in the lung. The question arises as to whether this drug combination of liposomal amphotericin B (AmBisome) and itraconazol is a real alternative to high-risk surgical interventions in this region.

Background: Apart from all advances made in the management of central airway infections, Acute Epiglottitis (AE) and Bacterial Tracheitis (BT) continue to be causes of life-threatening airway obstruction in children. The aim of this retrospective study was to evaluate deficiencies in the diagnostical protocol, to clarify the role of airway endoscopy in acute childhood stridor, and to identify current reasons for fatalities in these diseases., Material: In the observation period between 1980-92, we found 12 patients suffering from BT and 21 from AE managed in close cooperation of the involved disciplines at the pediatric intensive care unit of the University of Cologne., Results: Laryngoscopy with fiberoptic or small rigid endoscopes allowed in awake cooperative children accurate diagnose of AE, and the exclusion of supraglottic inflammation in BT without complications. Furthermore, additional endoscopic information of the degree of inflammation was helpful in the next critical decision, whether artificial airway or rigid tracheobronchoscopy was required. Nasotracheal intubation was necessary in 76% of our patients, in one child tracheostomy was performed (5%). Premature extubation necessitating reintubation occurred in 33% of the children suffering from BT. In these patients, our method of advancing a flexible endoscope for tracheoscopy through the respiration tube failed because of a low tube diameter. Another remarkable finding was the high mortality in AE (14%). Affected children were admitted in poor post-hypoxia conditions following outdoor cardiorespiratory arrest., Conclusion: In the analysis of the clinical course we found three decisive turning points in managing the disorder; First, the confirmation of the correct admission diagnosis; second, the decision, as to whether an artificial airway should be established; and third, the proper time of extubation. The most decisive factor in decreasing mortality seems to be timely, appropriate presentation at referral centers if AE or BT is suspected. Clinically, progressive management of childhood stridor requires close cooperation between the Pediatric, Anesthesiologic, and ENT Departments. Fiberoptic endoscopy as a guide to current airway management is a major step forward and should be a part of every established protocol.

Objective: Subtotal cordectomy and posterior cordectomy have repeatedly been recommended as surgical interventions restoring the airway, for the treatment of bilateral vocal cord paralysis. The objective of this study was to assess the effectiveness of transoral laser cordectomy and posterior cordectomy as compared to laser arytenoidectomy and to compare the respiratory and phonatory results of these minimally invasive procedures., Material and Methods: Forty patients with bilateral vocal cord paralysis were included in a prospective study and operated upon to improve their laryngeal airways. Twenty-two patients had cordectomy, 13 had arytenoidectomy, and 5 had posterior cordectomy. Lung function tests and voice analysis were obtained preoperatively and postoperatively. Subclinical aspiration was determined by endoscopic evaluation of the larynx during deglutition. The results were compared to determine the relative effectiveness of the three surgical methods., Results: Flow volume spirograms documented equally improved flow rates in both groups. Final voice evaluation revealed maximum phonation time. Peak sound pressure levels and frequency range were reduced in all 28 patients, but phonatory results varied considerably in each group. Subclinical aspiration was noticed in 5 out of 10 patients after arytenoidectomy, but in none of 18 patients after cordectomy. Four previously tracheotomised patients were decannulated within 2 weeks after surgery, while the other 24 patients had no perioperative tracheotomies., Conclusion: Transoral laser cordectomy and arytenoidectomy are equally effective and reliable in the management of the restricted airway. Cordectomy and posterior cordectomy offer the advantage of uncompromised deglutition after surgery. Although no clinically relevant aspiration occurred in any of the patients, cordectomy should be considered as the method of choice in patients for whom subclinical aspiration could be potentially harmful due to coexisting pulmonary or cardiac disease. Phonatory outcome is not predictable with both surgical procedures. Subtotal cordectomy and posterior cordectomy are easier and faster to perform, and subclinical aspiration is not encountered with these procedures.

Unlabelled: The distinction of the resistance in the nasal vestibule (valve area) and cavity (turbinates, septum deviations, crest, spine) is important for the settlement of the operative course in nasally impaired patients. Collapsed valves, free floating polyps, spines, and other turbulence producing factors in the nose are characterized in active anterior rhinomanometry (AAR) as decreased ¿percentage of flow increase¿ (deltaV150-300). This parameter allows no distinction between underlying anatomical factors. Other patients have increased resistance in the vestibule area that is static; rhinomanometry is unable to document these instances. The aim of this study was to investigate the influence of the vestibule dilator on nasal flow, and to determine if the diagnostic findings of AAR could be improved by the data obtained from the measurement with the dilator., Methods: To prove the influence of the vestibule dilator on the nasal airflow, we determined typical rhinomanometric parameters in 20 nasally healthy and 40 nasally impaired persons with and without the dilator. For the measurements, we used a computer-aided rhinomanometer (Rhinodat K, Heinemann Medizintechnik, D-Hamburg). Tubular vestibule dilators were produced from silicon guide rails of tracheal tubes (Rüschelit, Fa. Rüsch, D-Kernen) and individually adapted to the patient's vestibule, ensuring dilation between the external ostium and the nasal isthmus., Results: Active interior rhinomanometry revealed a significant effect of the vestibule dilator in repeated application (mean variation 3%). Total nasal flow showed a mean increase of about 48% with the dilator. In AAR, we found 5 patients with decreased deltaV150-300 below 25%. To demonstrate the presence of vestibule stenosis, we compared the changes of deltaV150-300 is AAR with and without dilator. In rhinomanometry with the dilator, deltaV150-300 of patients with vestibule stenosis showed physiological values. In these patients, mean difference of deltaV150-300 between conventional rhinomanometry and rhinomanometry with a vestibule dilator was significantly higher (47,2%) than observed in all other persons (3,8%). The static vestibule resistance in the total nasal resistance was obtained by calculating the difference between nasal flows with and without the dilator. CONCLUSIONS; Stenosis in the nasal vestibule could be proved and measured via active anterior rhinomanometry using a vestibule dilator. Data obtained from this method are helpful in functional assessment of nasally impaired patients, particularly to answer the question of whether the vestibule requires surgical treatment.

Until now, radical irradiation has been the treatment of choice for patients with unresectable squamous cell carcinomas of the head and neck. In spite of improved radiation techniques, conventional radiotherapy remains mainly palliative for patients with advanced and unresectable disease stages. Our own results with accelerated radiotherapy (2 x 2.1 Gy/day, day 1-4 in week 1, 2, 5 and 6, total dose of 67.2 Gy) and simultaneous chemotherapy with carboplatin (50 mg/m2/treatment day) suggest that combined radiochemotherapy might improve the poor results achieved with conventional radiotherapy or sequential chemoradiotherapy in these patients. However, further studies are necessary to clarify whether modified radiotherapy or simultaneous chemotherapy or the combination of both are the reason for the improved treatment results. Furthermore, accelerated radiotherapy and simultaneous chemotherapy should also be investigated as an adjuvant postoperative treatment modality in primary resectable patients with advanced stage of disease to improve their poor prognosis.

Dimensions of laryngeal and tracheal cross-sectional areas are not well explored and yet are of definite interest in endoscopic airway restorative surgery for the treatment of bilateral vocal cord paralysis. Twenty fresh, intact human larynges were shock-frozen in liquid nitrogen. Four-millimetre horizontal sections were then produced with a slicing machine. Cross-sectional areas of the vocal cords and arytenoids were measured using a computer-aided morphometry device. In addition, casts of 14 larynges were available for morphometric investigation as well as video-laryngoscopic images of 50 volunteers. The results demonstrate that the glottis is the narrowest part of the larynx even in healthy subjects. Its diameter is reduced approximately by the factor 4 in the bilaterally paralysed larynx. Cordectomy potentially offers more enlargement of the glottic airway (169 +/- 20 mm2 in males and 138 +/- 22 mm2 in females) than arytenoidectomy (42 +/- 12 mm2 in males and 34 +/- 6 mm2 in females). The knowledge of morphometric details of the glottic plane should contribute to an individualized planning of airway restoring surgery in bilateral vocal cord paralysis.

204 patients with carcinoma in situ or infiltrating carcinoma of the larynx were treated with transoral laser partial laryngectomies and, in selected cases, staged neck dissections and postoperative radiotherapy. 169 tumours were glottic, 28 supraglottic and 7 subglottic in origin. Up to now, 21 local and regional recurrences were diagnosed. 16 patients presented with recurrent tumour in the larynx, 3 in the larynx and in the cervical lymph nodes, and two in the neck only with no recurrence at the site of the primary. Out of 19 recurrences in the larynx, 10 were found at the anterior commissure, 5 in the transglottic space, 1 in the arytenoid region and two in the supraglottis. The vast majority of all recurrences were discovered during the first two years after primary treatment. 14 patients were treated with total laryngectomy, two with a second transoral laser resection, one with supraglottic laryngectomy, one with subtotal laryngectomy and two with neck dissections. One patient refused further treatment. 5 patients have so far died due to uncontrollable tumour spread. The analysis of local recurrences demonstrates, that deeply infiltrating tumours at the anterior commissure cannot be steadily removed by transoral laser surgery. Future development of transoral procedures must either focus on complete transoral resection of the anterior part of the thyroid cartilage or at least achieve thermal sterilisation of this area.

The treatment of carcinoma of the oral cavity (tongue, floor of mouth, lips and palate) can lead to different degrees of mutilation. A simple and effective method of evaluation is described, that permits to determine the functional results of different treatments in individual patients. In a special evaluation form, the actual weight of the patient, continuing pain, activities at home and at work, xerostomia, visible mutilation, disorders of tongue mobility and sensitivity, speech impairment, swallowing disorders and psychological problems are assessed. The documentations is completed by application of a score system, that allows a reliable determination of functional results after treatment of oral cavity carcinoma. About 30 minutes are required to complete the investigation. 31 own patients were examined following transoral laser surgery for the treatment of oral cavity carcinoma. The results are demonstrated and compared to those following conventional surgery.

In addition to conventional endoscopic operation procedures for vocal fold lateralisation, laser surgery has been used to perform endolaryngeal arytenoidectomy by individual laryngologists during the past few years. With respect to a regular swallowing function, the endoscopic technique presented in this paper preserves the arytenoid cartilage. Instead, a submucosal cordectomy is performed and the mucosal flap is glued onto the endolaryngeal wound. Tracheostomy is usually not required with this technique. 15 own cases are described, 14 of whom showed a sufficient respiratory result. Indications for endoscopic laser surgery in the treatment of bilateral vocal cord paralysis are discussed.