[Unilateral ptosis--orbital complication? Aneurysm of the left internal carotid artery with complete oculomotor paralysis left].
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Adult↗
Biomedical subjects
H G Kempf
Publications and source records attributed to H G Kempf.
Mastoiditis and acute otitis media in children with cochlear implants: recommendations for medical management.
Acute otitis media (OM) or mastoiditis is a very dangerous condition for the ear after cochlear implantation. However, acute OM is very common in childhood and can occasionally occur in an implanted ear. Most cases of acute OM can be successfully treated with intravenous high-dosage antibiotics. In cases of mastoiditis and clinical signs of mastoid abscess, retroauricular drainage is necessary to prevent infection of the implant bed. In a series of 366 children given implants (1 to 14 years), acute OM occurred in 5.6% during a follow-up period of 1 to 8 years. Seven ears had to be opened by means of myringotomy. Five ears were opened by retroauricular incision with mastoid revision on the implanted side. Adenoidectomy and use of ventilation tubes before cochlear implantation, as well as careful subtotal mastoidectomy during the implantation, can reduce the incidence of acute OM in children after implantation. Early and subsequent treatment with operative mastoid drainage can prevent implant loss and should be performed at the implantation center.
Acute Disease↗
[Temporal bone fracture after head trauma causing rhinoliquorrhea and meningitis].
We report our experience in managing a temporal bone fracture after head trauma that had no apparent clinical signs. Recurrent CSF rhinorrhea and meningitis lead to extensive diagnostic procedures. Operative exploration of the temporal bone demonstrated a fracture line along the horizontal part of the carotid artery. The location of the fracture did not cause such typical symptoms as hearing impairment, facial paralysis, vertigo or tinnitus. Only CSF liquorrhea through the Eustachian tube indicated a fracture at the lateral skull base.
Cerebrospinal Fluid Rhinorrhea↗
Complications in pediatric cochlear implant surgery.
In a retrospective analysis we evaluated the intra and postoperative complications in children who underwent cochlear implantation between 1984 and 1993 at the Medizinische Hochschule Hannover. The data and records of 366 children were collected and analyzed. Relevant parameters were major complications such as significant infection, intraoperative bleeding, facial nerve injury, implant loss and device failure, as well as lesser complications, including delayed wound healing, chronic pain and vertigo. Late complications such as cholesteatoma or electrode dislocations were also registered. Cases of acute otitis media were managed with conservative treatment. Data presented indicate that cochlear implant surgery in children is a reliable and safe procedure with a low percentage of severe complications. Problems related to ear surgery can occur and should be manageable with standard procedures. Careful operative techniques and sufficient personal experience can help avoid severe post-operative problems.
Adolescent↗
[Complications of cochlear implant surgery in children and adults].
BACKGROUND: In a retrospective analysis we evaluated the complication rate in 697 patients after cochlear implantation between 1985 and 1995 (366 children, 331 adults; 604 Nucleus, 50 Clarion and 42 other implants). RESULTS: Intraoperatively in 74 cases (10.6%) total or partial cochlear obliteration was found, a CSF gusher occurred in 7 cases. Minor complications such as seroma (8 adults), wound infections (14 patients), emphysema, and swelling were successfully treated with conservative methods and drugs. Seven (2.1%) adults showed facial nerve palsy postoperatively with incomplete recovery only in 2 of them (0.6%). No permanent facial nerve palsy was observed in children. Cholesteatoma developed in 18 adults (5.4%), which was treated by revision surgery. CONCLUSIONS: In conclusion, cochlear implant surgery is a safe procedure with a low complication rate. However, Cochlear implantation should be performed by well experienced ear surgeons who can properly handle intraoperative and postoperative problems. The patients should be informed about the typical risks of ear surgery including implant removal due to infection or technical defects, facial nerve palsy, vertigo and, especially in adults, increased tinnitus.
Adolescent↗
[Sonographic diagnosis of metastatic renal cell carcinoma to the head and neck region].
In the area of the head and neck metastases from distant primary tumours are rare in comparison to the common squamous cell carcinomas of the upper respiratory and digestive tract. Thus correct preoperative diagnosis may be difficult. Two cases with distant metastases of renal cell carcinoma to the head and neck region are presented in this report. In a 60-year-old male patient, diagnostic evaluation of unilateral epistaxis revealed a radioopacity of the maxillary sinus, six months after removal of a renal cell carcinoma. In the second case a slowly progressive indolent swelling of the left neck developed in a 56-year-old man six years after resection of a renal cell carcinoma and two years after surgical treatment of a pancreatic carcinoma. Following clinical examination, modern imaging techniques with special emphasis on colour Doppler sonography with a Siemens Quantum 2000 were used for diagnostic evaluation in both patients. Sonography of metastatic renal cell carcinoma to the maxillary sinus revealed complete opacity of the antrum. The cervical mass proved to the inhomogeneous and hypoechogenic and was difficult to distinguish from the lower parotid lobe and the vessel sheath. A common feature of both tumours was a high degree of perfusion which could be confirmed by superselective angiography. The histological examination of the surgical specimen showed an isolated metastasis of a renal cell carcinoma in both cases. In patients with a history of renal cell carcinoma the possibility of distant spread to the head and neck region should be taken into account even after a long period of complete remission. Colour Doppler sonography facilitates the distinction between the normally well perfused secondary tumours and squamous cell carcinomas which usually only have a minimal blood supply. Because of the high risk of profuse bleeding a biopsy should only be performed in the operating theatre.
Carcinoma, Renal Cell↗
[Ultrasound evaluation of characteristics of cervical lymph nodes with special reference to color Doppler ultrasound. A contribution to differentiating reactive from metastatic lymph node involvement in the neck].
BACKGROUND: Cervical mass due to lymphadenopathy is a common cause for consultation of an ENT specialist by patients. In many cases exact differentiation without biopsy between reactive and metastatic lymphnodes is difficult but crucial and necessary for each patient. Ultrasound is the imaging system with the highest sensitivity for the evaluation of pathological lymph nodes. However, differentiating benign and malignant lesions remains a problem. PATIENTS: In a prospective study, 138 cervical lymph nodes of 62 patients were evaluated according to conventional ultrasound criteria such as size, shape, brightness, demarcation, etc., and according to parameters of color doppler sonography such as intensity and localization of perfusion. The so called Pourcelot or resistance index, an objective parameter, was measured in order to examine a possible improvement of specificity in differential diagnosis of both entities. All lymph nodes were surgically removed and histologically examined after ultrasonography. RESULTS: 133 lymph nodes were evaluated in the study. Lymphadenitis was demonstrated in 72 cases, whereas 61 of the lumps showed metastases of squamous cell carcinoma of the head and neck region. Three patients with primary malignant lymphoma were excluded from the study. The conventional ultrasound parameters such as size, homogenity, shape and brightness did not reveal any substantial difference between the two groups. However, lymph node metastases significantly showed higher Doppler signals than the reactive ones. Most of the metastases were perfused in the periphery or had a diffuse spread of blood flow. The most valuable parameter from the prognostical point of view proved to be the Pourcelot Index with a threshold value less than 0.6 for metastases, which increased the specificity to 92% with a probability of p = 0.001. CONCLUSIONS: The results of this study demonstrate an increase of the ultrasound specificity in differentiation of pathological cervical lymph nodes using color flow imaging. Unfortunately, this method does not enable the physician to correctly diagnose the findings in all patients. Therefore histological evaluation is mandatory in all doubtful cases.
Adolescent↗
[Interesting case no. 24. Focal, poorly differentiated adenocarcinoma in a pleomorphic adenoma of the right parotid gland].
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Adenocarcinoma↗
[Tullio phenomenon after cochlear implantation].
The Tullio phenomenon is defined as an acoustically inducible vestibular disorder that was first described in 1929. In an animal experiment Tullio provoked acoustic oscillations at the labyrinth followed by signs of imbalance. In the literature this phenomenon can be found in healthy but sensitive persons as well as in patients with Meniere's disease and patients with lesions between the stapes, footplate and the membranous labyrinth caused by fractures, stapes dislocations, labyrinthitis or perilymphatic fistulas. In this case report a patient complained about vertigo after cochlear implantation provoked by acoustical stimulation at a sound pressure level above 90 dB independent of the cochlear implant (CI). During tympanoscopy we found scar tissue surrounding the ossicles after CI. After disconnecting the ossicular chain no vertigo or nystagmus could be provoked. After CI regular ENT examinations and appropriate explorations of postoperative complaints are necessary. Vertigo especially requires very careful diagnostic procedures.
Acoustic Stimulation↗
[Interesting case no. 11. Giant cell granuloma of the mandibular bone].
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Adolescent↗
[Congenital subglottic laryngeal stenosis in 2 brothers with chondrodysplasia syndrome (Keutel-Gabriel syndrome)].
BACKGROUND: Keutel-Gabriel syndrome (chondrodysplasia) is a rare autosomal recessive disease. The patients have characteristic malformations such as midfacial hypoplasia, brachytelephalangia, and hearing loss as leading symptoms. PATIENTS: We report about two brothers with clinical and radiological features of Keutel-Gabriel syndrome. Congenital subglottic laryngeal stenosis was also present in both. In the younger brother an emergency tracheotomy had to be performed. In a staged procedure the stenosis was successfully treated with laryngotracheoplasty according to Cotton. CONCLUSIONS: This is the first description of a congenital subglottic laryngeal stenosis with Keutel-Gabriel syndrome. To avoid long-term tracheotomy, a tracheoplasty with autologous cartilage should be performed.
Adolescent↗
[Otogenic brain abscess].
BACKGROUND: Otogenic complications are rare but typical following acute or chronic ear infections like mastoiditis and cholesteatoma. A life-threatening sequela is the otogenic brain abscess located in the temporal lobe or cerebellum. PATIENTS: At the ENT Department of the Medical University of Hannover/Germany we treated 8 patients suffering from otogenic brain abscesses in the temporal lobe during the last three years. The average age of the 6 male and 2 female patients was 48 years. In 5 patients the abscess developed due to a cholesteatoma with superinfection. Three cases showed acute mastoiditis. All patients were operated using an otosurgical retroauricular approach, in five cases a classical radical mastoidectomy was performed. In two cases the abscess was reached via mastoidal approach and was subsequently drained. In two other cases the abscess was drained some days later by neurosurgical approach due to increased neurological symptoms. The other patients were treated with high-dosed antibiotics under regular clinical and radiological control. RESULTS: In 7 cases complete regression of the abscess was achieved. Five patients were discharged without further otological or central-nervous problems. One female patient developed severe meningitis with generalized thrombosis of the central blood sinus system and died in central circulatory failure. Two other patients developed a moderate psychopathologic syndrome and were admitted to rehabilitation institutions. CONCLUSIONS: The analysis of our patients shows that otogenic brain abscesses should be regarded especially as a severe complication of the untreated cholesteatoma. It is important to use modern imaging modalities like computer tomography or MRI for early detection of the intracerebral lesion and to perform an early otosurgical intervention. Under antibiotics and CT control, healing of this severe complication can be achieved in most cases. However, the danger of acute and chronic ear diseases has to be kept in mind in all medical disciplines.
Adult↗
[Patients with trauma-induced deafness--rehabilitation using a cochlear implant].
Deafness due to bilateral temporal bone fractures is a dramatic consequence for the injured patients. Out of more than 1000 patients in Hannover which received a cochlear implant we analyzed the medical history of 44 patients (36 male, 8 female, average age of adults: 41 years) which were implanted after posttraumatic deafness (Nucleus device n = 33, Clarion device n = 11). Postoperatively the patients underwent an auditory rehabilitation program. Most of them (84%) reached open set speech understanding. Results are different caused by additional damage of auditory nerve fibers and posttraumatic central lesions. Due to the risk of posttraumatic fibrosis of the cochlea, implantation should be performed early and can be recommended to the patient if bilateral deafness is diagnosed. In the case of auditory nerve damage brain stem implants offer new possibilities.
Adolescent↗
Complications of cochlear implant surgery in children.
OBJECTIVE: To evaluate the intraoperative problems and postoperative complications in children receiving cochlear implants. STUDY DESIGN: A retrospective analysis of the clinical records of 366 children, aged 1 to 14 years, who had received cochlear implants. RESULTS: Intraoperatively, obliteration of the cochlea occurred in 66 patients, cochlear dysplasia in 8, and CSF leakage in 7, and nearly 5% of patients had signs of infection in the mucosa of the middle ear. Postoperatively, early complications occurred in 1% to 2.5% of patients: flap complications, electrode dislocation, facial nerve problems, and incorrect insertion of the electrode. Delayed complications included otitis media and stimulation of the facial nerve. CONCLUSION: Proper preparation of the implantation site, experienced and well-trained surgeons, and awareness of the operative and postoperative risks are necessary.
Adolescent↗
Preservation of the non-rectangular cuticular plate/cell axis angle of outer hair cells.
Motile properties of outer hair cells (OHCs) may contribute to sharp tuning and amplification in the mammalian cochlea. Shape changes of isolated OHCs in response to various physical and chemical influences have been investigated intensively. However, determinations of shape may have been influenced by unanticipated effects of preparation and preservation of the OHCs investigated. Thus, in a first step, lengths of freshly isolated OHCs from the guinea pig cochlea were determined using a video-enhancing magnification system. The cuticular plate/cell axis angle (CP/CA angle) was then measured in native cells and under the influence of potassium chloride and potassium gluconate incubation. To show the influence of glutaraldehyde (GA) fixation on the isolated OHCs, fixative-dependent changes on cell length and CP/CA angle were recorded in native and preincubated OHCs. In these experiments, the cell length of vital isolated OHCs was between 41.5 micrometers, in the basal turn, and 103.7 micrometers, in the apical turn. The average CP/CA angle was 106 degrees +/- 4.2 degrees (n = 324 cells, turns 1-4) with no statistically significant differences for the four turns. Under the influence of potassium chloride, cell length was reduced by 8.1%. Potassium gluconate incubation led to a shortening of cell length, followed by a 5.3% increase after 5 min. The CP/CA angle under potassium chloride was decreased (97.0 degrees) and was then increased under the influence of potassium gluconate (110.7 degrees) as a result of cuticular plate tilting. Cell shrinkage after fixation depended on the fixative's osmolarity and on the GA concentration. Increased GA levels amplified cell shrinkage from 34% for hypo-osmolar solutions to 15% in iso-osmolar and 29% in hyperosmolar solutions. The CP/CA angle of native and incubated OHCs was not different from those fixed with GA. The present data provide a rational basis for isolated OHC shape parameters. Moreover, functionally induced changes can be better interpreted when OHCs are influenced by fixatives, as shown in the GA experiments.
Animals↗
[Ionomer cement in cochlear implant surgery--applications and long-term outcome].
Over the last ten years about 850 cochlear implant operations were performed at the ENT department of Hannover Medizinische Hochschule. In most cases, intracochlear nucleus implants were used. For about two years the intracochlear Clarion device has also been used in 150 adults and children. For several years we have used ionomeric cement (lonocap, supplied by lonos, Seefeld/Germany) to fix the electrode array in the region of the posterior wall and the facial recess. Previously, the implant package was fixed by ionomeric cement. To evaluate the outcome of cement application, we conducted a prospective study of our implant patients during the period from 1991 to 1993. During regular reexamination over a period of two years postoperatively in 244 patients (122 male and 122 female patients, average age 17.6 years), we did not observe any complication related to the cement. Nearly all revision cases (n = 8) showed a stable contact between electrode array, bone, and cement. With increasing experience, we reduced the cement application and fixed the package with vicryl sutures in a precisely drilled bony bed. Contact of the cement with neural and cerebral structures should be avoided. In our experience ionomeric cement is a helpful tool in cochlear implant surgery with long-term stability and no rejection reactions.
Adolescent↗
[Reconstructive surgery in the head-neck area with regional and free tissue transfer].
BACKGROUND: Operative treatment of head and neck cancer requires radical resection of the tumor with not only severe impairment of important functions like swallowing speech, and respiration but also aesthetic mutilation because of the exposed character of the head and neck region. Therefore the rehabilitation from a functional and cosmetic standpoint is an essential goal of treatment in addition to control of the malignant disease. Fortunately regional plastic surgery offers a variety of options for reconstruction of the defects to receive a solution tailored to each individual patient. PATIENTS: Between the years 1986 and 1996, 107 patients with advanced head and neck cancer were treated surgically by radical resection of the tumor and plastic reconstruction. In this study we made a retrospective analysis of the functional and aesthetic outcome of the techniques of reconstructive surgery we used for rehabilitation. The sex ratio was 79 males to 28 females. Average age was 59.4 years (ranging from 39 to 78 years). Most of the patients suffered from squamous cell carcinoma of the upper digestive tract (97 cases). The others included an adenocarcinoma of the paranasal sinuses (three cases), adenoid cystic cancer of the palate (two cases), squamous cell carcinoma of the temporal bone (two cases), two deep infiltrating basaliomas in the area of the nose and forehead and one chondrosarcoma of the neck. Our oncological concept includes a radical resection of the tumor and a onestep reconstruction of the defect, if the patient's general condition enables this approach. The surgical techniques we used include the approved pedicled myocutaneous flaps like the pectoralis major flap, latissimus dorsi flap (which can be also applied as a free microvascular tissue graft), temporalis muscle flap, and the free radial forearm flap. RESULTS: In previous years, the pedicled myocutaneous pectoralis-major- and latissimus-dorsi-flaps were used for reconstruction (n = 67), but the arc of rotation and the huge bulk of the graft are limiting factors for the indication of these techniques. The free forearm flap has increasingly been used to provide an excellent closure of large pharyngeal defects (n = 16), whereas the temporalis flap is useful for restoration after limited resection of the palate (n = 18). Beside these rather invasive procedures, aesthetic rehabilitation may be achieved with bone-anchored epithesis especially after exenteration of the orbit and ablation of the external ear in case of elderly patients with multiple morbidities (n = 5). In most cases, sufficient rehabilitation from the anatomical and functional point of view was possible even after large tumor resections. A main problem can be longstanding aspiration after resection of large areas of the pharyngeal mucosa (n = 8). Complications included eight cases of necrosis of the flaps and seven patients who developed significant seromas at the donor site. CONCLUSIONS: The potential of modern regional reconstructive surgery enables the surgeon to achieve anatomically and functionally rehabilitation in a one-step procedure in most cases, even after extended resection for head and neck cancer. One should be aware of the fact that these techniques do not offer a significant improvement of prognosis. As such, the aggressiveness of surgical therapy should remain in reasonable relation to the prognosis of the malignant disease.
Adenocarcinoma↗
[Indications for middle ear obliteration within the scope of cochlear implant management].
BACKGROUND: Cochlear implants have gained worldwide acceptance as a reliable method of rehabilitation of profoundly hearing-impaired patients. Due to thorough patient selection major postoperative complications rarely occur and are flap related in most cases. Deafness can develop during chronic suppurative otitis media, either coincidentally or secondary to the medical treatment; normally this condition is regarded as a contraindication for cochlear implantation. In cases with a mastoid cavity after surgical treatment for cholesteatoma, the electrode covered only by the epithelial lining will likely become exposed or extruded. Therefore we suggest the obliteration of the middle ear cleft with abdominal fat and the blindsac closure of the external ear canal before cochlear implantation in these conditions. PATIENTS: The average age of our 12 patients was 48 years, whereas the youngest was 2 1/2 years of age. Due to chronic inflammatory ear disease. 11 patients had a mastoid cavity on both ears. Eight patients had a cholesteatoma, the chronic bone destroying process in the temporal bone of two female patients was considered as a fibroinflammatory pseudotumor. The child had a congenital deafness in both ears with a Mondini dysplasia in CT scan. She had already developed two episodes of pneumococcal meningitis which was caused by a defect in the stapes footplate through which a liquor-filled cystic sac herniated in the middle ear. Because of a massive liquorrhoea after opening of the sac, we decided to obliterate the middle ear cleft after successful insertion of the electrode array. RESULTS: All active electrodes of 10 Nucleus implants (Cochlear) and two Clarion devices (Advanced Bionics Corp.) were successfully inserted in the cochlea of the 12 patients. After an average follow-up of 15 months, a temporary facial palsy in one patient and an insufficient closure of a retroauricular fistula over the mastoid cavity in two cases were observed as postoperative complications. One patient with a fibroinflammatory pseudotumor developed a massive inflammatory reaction in the implanted ear two months after cochlear implantation, which could not be controlled by conservative treatment. The implant had to be removed and local conditions settled after administration of immunosuppressive treatment with cyclophosphamide. The patient received a new implant seven months ago. CONCLUSIONS: Implantation of a foreign body in a potentially infected space which communicates intracranially means a surgical challenge which can be managed by obliteration of the middle ear after subtotal petrosectomy with abdominal wall fat combined with a reliable closure of the external ear canal. In case of massive inflammation we would prefer a two-stage procedure.
Adipose Tissue↗