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OBJECTIVE: Vagus nerve stimulator (VNS) implantation is an established therapy for pharmacoresistant epilepsy that is not amenable to curative epilepsy surgery. Historically, VNS implantation has been performed by neurosurgeons, but otolaryngologist involvement is increasingly common. In this retrospective study, we aimed to evaluate the efficacy and safety of VNS implantation in children and adolescents from the otolaryngologists' perspective. METHODS: This study included children and adolescents who had undergone VNS implantation at the study center between 2014 and 2018. Patient files were analyzed with regards to the durations of device implantation and hospitalization, postoperative complications, and clinical outcome, including seizure frequency, clinical global impression of improvement (CGI-I) score, and quality of life (QoL). RESULTS: A total of 73 children underwent VNS surgery. The median age at implantation was 9.3 ± 4.6 years, and median epilepsy duration before VNS surgery was 6 ± 4 years. Lennox-Gastaut syndrome was the most common syndrome diagnosis (62.3%), and structural abnormalities (49.3%) the most frequent etiology. Operation times ranged from 30 to 200 min, and median postoperative hospitalization length was 2 ± 0.9 days. No complications occurred, except for four revisions and two explantations due to local infections (2.7%). Among our patients, 76.7% were responders (≥ 50% reduction in seizure frequency), 72.1% showed improved CGI-I scores, and 18.6-60.5% exhibited considerable improvements in the QoL categories energy, emotional health, and cognitive functions. CONCLUSION: Our results indicate that VNS implantation is a highly effective and safe treatment option for children and adolescents with AED-refractory epilepsies who are not candidates for curative epilepsy surgery.

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AIMS: The aim of this study was to compare laser surgery, conventional endoscopic surgery and radiotherapy in the treatment of early T1a glottic cancer. METHODS: We conducted a retrospective analysis of patients with early vocal cord cancer (who underwent either conventional surgery via endoscopy or laryngofissur, or primary radiotherapy) at the Medical University of Vienna. By univariate and multivariate Cox regression models the influence of treatment and other parameters on survival and locoregional control were analysed. RESULTS: 337 Patients were analyzed with a mean follow-up period of 133.8 months. Overall survival rates where similar in all three treatment groups. Five-year, 10-year and 15-year estimates of disease specific survival for laser-treated patients were 100%, for conventional surgery were 100%, 98% and 98%, and for radiotherapy were 96%, 92% and 91%, respectively. Locoregional recurrences were observed after laser surgery in 10%, after conventional surgery in 13% and after radiotherapy in 30% of the patients treated. According to the log-rank test, time to relapse was significantly shorter for irradiated patients compared to patients who underwent surgery (p < 0.0001). Mortality caused by the laryngeal tumour was significantly higher in the radiotherapy group (p = 0.003). CONCLUSION: Patients undergoing laser or conventional surgery have a significantly lower incidence of locoregional recurrences and longer disease-free intervals when compared to patients treated by radiotherapy.

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OBJECTIVE: To describe our experience with superimposed high-frequency jet ventilation (SHFJV), which does not require any endotracheal tubes or catheters, for performing laryngeal and tracheal surgery. DESIGN: A case series of 500 patients. SETTING: A university medical center. PATIENTS: Four hundred sixty adult patients and 40 children in a consecutive sample who required laryngeal or tracheal surgery under SHFJV. INTERVENTIONS: The SHFJV uses 2 jet streams with different frequencies simultaneously and is applied using a jet laryngoscope. Ventilation was performed with an air-oxygen mixture, and intravenous agents were used for anesthesia. Arterial blood gas values were analyzed. MAIN OUTCOME MEASURES: Reported values of oxygenation and ventilation during the application of SHFJV and laryngotracheal surgery. RESULTS: In 497 patients, adequate oxygenation with a mean +/- SD PaO2 of 91.8 +/- 22.9 mm Hg and ventilation with a PaCO2 of 29.7 +/- 5.5 mm Hg were achieved using SHFJV. The average duration of the application of ventilation was 27 minutes, and the longest duration was 118 minutes. No complications due to the ventilation technique were observed. Laser surgery was performed in 150 patients. CONCLUSIONS: The use of SHFJV in combination with the jet laryngoscope provides patients with sufficient ventilation during laryngotracheal surgery. Even in patients at high risk because of pulmonary or cardiac disease, this technique can be applied safely. In patients with stenosis, the ventilation is applied from above the stenosis, reducing the risk of barotrauma. The SHFJV can be used for tracheobronchial stent insertion, and laser can be used without any additional protective measures.

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We present the first use of tubeless superimposed combined high- and low-frequency jet ventilation (SHFJV) with a jet laryngoscope in laryngotracheal surgery in infants and children. Twenty-eight patients underwent 53 operative procedures. The average age of the patients was 7.3 years. The most common diagnoses were laryngeal papillomatosis and subglottic stenosis. The duration of jet ventilation averaged 33 min. The gas exchange was sufficient in each case. The advantages of SHFJV in the surgery of the laryngotracheal area in infants and children are optimal view at the larynx and trachea, maximum space for the handling, application of the laser without risks, no time limitation, suitability for stenosis, and neither anesthetic nor surgical complications.

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Since 1983, 90 autologous jejunal transplantations for reconstruction of the upper digestive tract have been performed in 89 patients (9 females, 80 males, average age 56.3 years). 73 patients were operated primarily, in 16 patients a recurrent tumor had been treated. One patient received a second jejunal graft after necrosis. In these heterogenous patients, the primary tumor was located in the hypopharynx 48 times, in the larynx 21 times, in the oropharynx 19 times and twice in the oral cavity. There was nearly always tumor stage III or IV without distant metastases. Following locoregional tumor resection, speech restoration was achieved 35 times by a siphon-like tube, and the upper digestive tract was reconstructed using a patch 18 times and by a tube 28 times. A combination of tube or patch with a siphon-like tube was employed 9 times. In only two of 16 patients with recurrent tumor, speech reconstruction was performed, in the other 14, the upper digestive tract was reconstructed. In those patients, in whom speech reconstruction (by siphon tube or by combination with tube/patch) was intended, this was achieved in 81.5%. Successful functional reconstruction of the upper digestive tract (by patch, tube, combination) could be achieved in about 60% of these patients.

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In laryngectomized patients a tracheo-esophageal artificial fistula can be used to achieve air flow from the trachea to the esophagus during speech. A one-way plastic valve is often used for the fistula. A free jejunal graft between the trachea and the esophagus can also be used. To avoid aspiration the transplant is attached to the submental area giving the graft a siphon-like shape. We performed 23 videoradiographic examinations using high-density barium in 14 such patients. The aim was to evaluate the protective function of these grafts against aspiration. Penetration of the bolus and a small amount of residual contrast material in the ascending limb of the graft was a normal finding. If the standard barium bolus reached the descending limb at any time during the examination, this was a sign of aspiration hazard. To avoid aspiration, the vertex of the speech siphon should be higher than the level of the hypopharyngeal anastomosis.

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In a 35-year old male patient with laryngeal carcinoma an acute respiratory insufficiency with early hypoxaemia developed due to massive laryngeal stenosis. An endotracheal intubation was not possible since the available lumen was too small. Tracheotomy using local anaesthesia was not possible since spontaneous respiration with a Venturi mask applying 100% oxygen was not sufficient and the patient was becoming restless and agitated due to the hypoxaemia. Transcutaneous jet ventilation was considered to be too risky since the needle would have to pass highly vascularised tumour tissue and the detection of such a small rest lumen would have been quite difficult. Ventilating the patient using a percutaneous catheter would have been very risky as well since, due to the massive stenosis, a sufficient expiration would not be likely and therefore was considered to carry a high risk of barotrauma. The patient was ventilated under general anaesthesia via a specially designed endoscopy tube with integrated jet nozzles applying superimposed high frequency jet ventilation above the stenosis. Since it was possible to achieve sufficient ventilation during the inspection of the larynx the jet laryngoscope was left in place and the supporting apparatus was covered with sterile drapes. The tracheotomy was performed using the superimposed high frequency jet ventilation. Throughout the procedure oxygenation and ventilation were adequate. The laryngectomy performed several days later revealed a cauliflower type protrusion into the tracheal lumen and a 5 cm long stenosis of the larynx with a lumen of 3 mm.

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In laser surgery of the larynx the surgeon and the anaesthesist have to compete for the limited space available. The surgeon requiring good visibility and an undisturbed operating area whereas the anesthetist has to ensure sufficient ventilation of the patient. Further, complications of anaesthesia and laser must be avoided. These requirements are met by using the jet-tube (jet-laryngoscope) with two integrated nozzles applying simultaneously low- and high-frequency jet-ventilation giving the surgeon total access to the area operated on, and at the same time enables safe ventilation of the patient. Of 334 operations with the tubeless ventilation technique 76 cases were laser surgical interventions. In 6 patients stenoses were enlarged. The average duration of the jet-ventilation was 25 +/- 10 minutes. The maximum duration of a laser surgical intervention was 140 minutes. The age distribution of the patients was 18 months to 82 years. In all patients pulmonary gas exchange was satisfactory. We believe that the advantage of the tubeless jet-ventilation is: optimal visibility and surgical freedom for the surgeon, no time limitation, even in very severe stenoses. Since no volatile anaesthetics or any type of endotracheal tube are applied there is no danger of interaction with the laser when using the SHFJV via the jet-laryngoscope. Application of the tubeless jet-ventilation technique is however limited if patients suffer from severe pulmonary obstruction; likewise highly obese patients and patients in whom massive bleeding occurs are not amenable to tubeless jet-ventilation.

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The tendon of the human stapedius muscle was studied in normal post mortem material and in clinical otosclerotic patients, using light and electron microscopy. Cross section profiles of collagen fibrils were measured in various regions of the tendon and the amount of elastin was estimated. The normal stapedius tendon consisted of three concentrically arranged portions: A cylindrical central part, a tube-like mid-portion, and a cortical layer. The central part was made up of collagen fibrils with only a few elastic fibers, the mid-portion contained collagen fibrils together with significantly more elastic material, while the cortical layer, again, showed a smaller amount of elastic fibers. Mean diameters of collagen fibrils in the central part of the tendon were 65.12 +/- 11.89 nm, in the intermediate layer 41.00 +/- 9.63 nm, and in the cortical layer 70.28 +/- 19.58 nm. Stapedius tendons from clinically otosclerotic patients, though showing the same construction, were characterized by significantly altered collagen fibrillar diameters (Mann-Whitney U-test). In the central part, mean diameters were reduced to 61.05 +/- 14.70 nm, in the mid-portion increased to 50.90 +/- 10.08 nm, and in the cortical layer reduced to 61.09 +/- 8.49 nm. The changes of collagen cross section profiles estimated for the entire tendon were significant as well: 59.68 +/- 18.74 nm in controls versus 57.82 +/- 12.53 nm in otosclerotic patients. Elastin content in the mid-portion of control stapedius tendons increased with age (13% at 35 years of age to 35% at 70 years of age).(ABSTRACT TRUNCATED AT 250 WORDS)

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In this article, we report about the experiences at our ENT-University Clinic in Vienna in 76 patients with free transplanted microvascularly anastomosed autologous jejunum used for reconstruction following extensive resection of mainly stage IV carcinomas in the head and neck. Jejunum was inserted as a siphon-like tube between the trachea and the hypopharynx in 43 patients primarily for restoration of speech (in 10 cases the pharynx was also reconstructed). In 33 patients, the upper digestive tract was reconstructed, as either patch or tube. They were then evaluated according to functional results of speech and swallowing, aesthetics as well as 5-year survival rates. We achieved good results in 35 speech patients (81.4%) and in 22 swallowing patients (66.6%). The aesthetic function was influenced favourably because the volume of the jejunal transplant fills up the defect in the neck after resection and creates a tolerable neck-shape. The 5-year survival of all available 54 patients was 26%, patients for speech restoration 31.7% and patients for swallowing restoration 17.5%. These results are to be considered under the aspect that patients with swallowing restoration primarily had more severe disease. Complications such as like perioperative mortality and total necrosis can be avoided by careful evaluation of the patients to be operated on. With the experiences gained from this study, we now have exact indications for the use of jejunum grafts and thus can expect very high rates of success.

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The expressions and cellular distributions of two pairs of adhesion molecules CD2/LFA-3 (leukocyte function-associated antigen-3) and LFA-1/ICAM-1 (intercellular adhesion molecule-1) were examined in inflammatory cellular infiltrates of advanced squamous cell carcinomas of the head and neck by immunohistochemical techniques including double-staining methods. Thirteen patients were investigated using the following monoclonal antibodies (mAbs): CD2, LFA-3 (CD58), ICAM-1 (CD54), LFA-1 (CD11a), the alpha/beta and gamma/delta T-cell receptor, pan T cells and broadly distributed monocyte/macrophage (m/m phi) [Fc gamma RII (CD32), 25F9, RM3/1]. LFA-3 staining was observed on a high number of cells (968 +/- 112 cells/mm2), correlating to the number of Fc gamma RII (CD32; P < 0.01), 25F9 (P < 0.05) and RM3/1 (P < 0.05) positive m/m phi. Its ligand CD2 was found on 365 +/- 126 cells/mm2, representing about 50% of CD3+ cells (730 +/- 286 cells/mm2). CD2 positivity correlated to CD3 and CD8 (P < 0.01) but not to CD4+ T cells. LFA-1 and ICAM-1 were expressed on lymphocytes as well as on m/m phi. ICAM-1+ cells (902 +/- 205 cells/mm2) correlated to CD3+, CD8+ and RM3/1+ cells (P < 0.01). LFA-1 positivity (803 +/- 255 cells/mm2) showed correlations to nearly all investigated antigens, as well as to CD4+ T cells (P < 0.05). These results show that different m/m phi subsets display distinct patterns of adhesion molecule expressions suggesting different pathways of regulation. The CD3+ lymphocyte population revealed a lack of CD2 expression that was more pronounced in the CD4+ subset and indicated impaired lymphocyte function.

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The effect of free transplanted jejunum autografts, inserted after resection of extensive squamous cell carcinoma of the larynx and hypopharynx is evaluated in terms of survival and the development of local and regional recurrences. In a matched-pair analysis, 22 patients with jejunum transplants were compared with 44 patients with the same performance status, in whom after laryngopharyngectomy, the pharynx had been closed with local mucosa. The cumulative survival rate was calculated using the Kaplan-Meier method; the statistical comparison of the survival curves of the two groups was made with the Mantel-Haezel test. Patients of the study group had a statistically significant (p less than = 0.01) better survival rate than those of the control group, the 50% survival rate being 36 and 11 months, respectively. Local recurrences occurred in 9.1% of the patients in both the study group and in controls, and regional recurrences in 40.8 and 43.2%, respectively. This militates against the possibility that the surgery in patients in whom reconstruction with jejunum was possible might have been more radical. Further, it may be speculated that the statistically significant better survival rate is due to the jejunum itself, presumably to a tumourprotective effect of the lymphatic tissue of the transplant.

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Autologous jejunum, transplanted as a functional replacement immediately after radical dissection of advanced stages of squamous cell carcinomas of the head and neck and subsequently irradiated, was examined by immunohistochemistry (APAAP/PAP-technique). Biopsies from 9 patients were taken at the time of transplantation and up to 24 months thereafter (group 1) and from 5 patients only once after transplantation (group 2). Twenty-six monoclonal antibodies (mAbs) were used as surface markers to give an overview about phenotypical changes with respect to T-, B- and M phi-antigens. 1) B cells: a general increase of CR2+ (CD21, p less than 0.01) could be noticed after transplantation, immunoglobulin positive cells remained unchanged expect for a significant decrease of IgM+ (p less than 0.01) and IgA1+ (p less than 0.01) cells. 2) The number of T cells (CD3+) showed no significant differences although TcR gamma/delta+ cells decreased (p less than 0.01) in the autotransplant. ICAM-1 (CD54) and IL-2R (CD25) were found on a significant (p less than 0.01) higher number of cells after transplantation. 3) Cells with M/M phi morphology showed increased expression of the Fc gamma receptors (CD64, p less than 0.001; CD32, n.s.; CD16, p less than 0.001), of the complement receptors CR1 (CD35, (p less than 0.001) and CR3 (CD11b, p less than 0.02), of HLA-DQ (p less than 0.01), and of the antigens 25F9 (mature M phi; p less than 0.01) and CD4 (p less than 0.02). Correlation analyses of data obtained from the biopsies of the 14 autotransplanted jejunum cases revealed a CD35+ and a 25F9+ subpopulation of M/M phi. Our findings indicate that despite irradiation autotransplanted jejunum contained cells with immunological capacities. Therefore, the replacement of larynx by autologous jejunum may facilitate not only mechanical but also immunological functions.

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For surgical voice rehabilitation after pharyngolaryngectomy we use the technique of placing a siphonlike jejunal interposition in order to create a tracheohypopharyngeal shunt. In this paper we present the functional benefits of this method of voice rehabilitation. The best results achieved are compared with a normal voice using the following test parameters: electroacoustic sound analyses and voice status. The findings show that the siphon voice is adequate for everyday purposes and can achieve useful social verbal communication.

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After the reconstruction of defects resulting from the resection of advanced tumors from the upper aerodigestive tract using free microvascular anastomized jejunum, the autotransplant is influenced by local radiotherapy (cumulative dose 50-70 Gray). Biopsies were taken from 15 patients, stained with haemotoxilin-eosin and Giemsa and compared by means of light microscopy with jejunum taken at the time of transplantation. It was possible to observe a widened mucosal and submucosal space two to three months after radiotherapy, similar to the clinical impression of a radiogenic enteritis. The villi were flat and shortened with no or slight epithelial lesions. Additionally, it was possible to observe an inflammatory infiltration consisting mainly of neutrophilic granulocytes, edemas, and telangiectases. The latter were also evident in nonirradiated autotransplanted jejunum and are therefore not only caused by irradiation. One year after radiotherapy the mucosal membrane was atrophic. Fibrosis was to be seen in the lamina propria, accompanied by widened muscularis mucosae. The submucosal space was also widened and fibrotic to a varying degree. It was possible to detect varying stages of alteration in the vascular system up to a complete obliteration. After two years, changes were more pronounced. At no time could any alteration in the nervous system of the plexus submucosus be observed. All of these changes have to be interpreted as a consequence of irradiation. However, lubrication of the mucosal surface and the motility of the transplant are not altered severely by irradiation and therefore the desired functions of the free transplanted jejunal grafts, such as swallowing and phonation, are carried out sufficiently.(ABSTRACT TRUNCATED AT 250 WORDS)

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UNLABELLED: The influence of smoking with regard to the development and course of laryngeal dysplasias was examined. The case histories of 63 patients with histologically proven dysplasias of the larynx were evaluated in the light of their answers to a questionnaire covering their lifetime smoking habits. RESULTS: 1. The percentage of smokers in the patient group significantly exceeds the percentage of smokers in the general population. 2. The disease is more likely to lead to deteriorated histological findings in smokers. 3. A change in smoking habits at the time of diagnosis has no significant effect on the further course of disease. 4. Non-smokers have higher levels of dysplasia at first biopsy, but the disease is less likely to progress. The development of malignancy was not observed in the non-smoker group.

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In this retrospective study the value of sonography in the preoperative staging of malignant tumours of the tonsils was evaluated in 36 patients. According to our results sonography is indicated in small tumours. In greater tumours, especially if bone destruction could be expected, MR or CT should be performed additionally to sonography. Good results were achieved in assessing the infiltration of the tongue with or without crossing the midline (accuracy 92 to 97%) and the detection of cervical lymph node metastasis (accuracy 94%).

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The significance of tobacco smoking, alcohol consumption and occupation as risk factors for the development of vocal chord dysplasia was evaluated in a case-control study. Twenty-seven male patients with dysplasia of the vocal chords were chosen from the I. ENT-University Clinic in Vienna (1985-1988) and compared with 54 controls. The main results are: The relative risk (RR) of a smoker compared to that of a non-smoker for vocal chord dysplasia is 7.27 (6.81-7.73); the RR adjusted for occupation is 3.58 (2.31-4.84). The most important risk factor, however, is occupational exposure. The relative risk of a blue collar worker compared to that of a white collar worker is 11.04 (10.61-11.46), which is reduced only to 10.02 (10.61-11.46) after stratification according to smoking habits.

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