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Adenocarcinomas of the nasal cavity and the paranasal sinuses after occupational exposure to sawdust from oak and beech have been listed as occupational diseases in Germany since 1988. Given that modes of treatment have changed, we analyzed the guidelines based on the recommendations of Hartung et al. for developing an expert assessment on reduced earning capacity.A retrospective analysis of 43 cases which had been evaluated between March 1994 and February 2007 for an occupational disease #4203, in the Ear-Nose-Throat clinic of the Münster University Hospital, Germany.Following the guidelines of Hartung et al., it was impossible to formally classify 21 of 43 cases (48.8 %) in an unambiguous manner. This was primarily due to the assessment of the results of radiotherapy, either adjuvant or therapeutic, as well as the grading of postoperative dysfunction in the area of the sinuses operated on (Rhinitis, Ozaena). Suggestions for a revision of the classification system include a modified assessment of radiotherapy as well as evidence for grading post-therapeutic inflammations of the sinus operated on based on the need for further care. These changes enable all cases in question to be classified unambiguously.The use of the revised guidelines is recommended for expert assessment of adenocarcinomas of the nasal cavity and the paranasal sinuses caused by wood dust.

In der vorliegenden Arbeit wurden unterschiedliche land- und forstwirtschafliche Brennstoffe (Holz, Stroh, Getreideganzpflanzen, Heu, Rapspress-kuchen) und deren Aufbereitungsformen (Häckselgut, Pellets) praxistypisch an einer Kleinfeuerungsanlage (50 kW) untersucht. Weitere Einflussgrößen waren der Wärmeleistungsbereich (30 bis 100 % der Nennwärmeleistung) sowie der Brennstoffwassergehalt. Zielgrößen für die Beurteilung waren die Emissionen von Kohlenstoffmonoxid (CO), Staub, Gesamtkohlenstoff (Gesamt-C) und Stickstoffoxiden (NOx), die Partikelgrößenverteilung des Staubes, die Emissionen von polyzyklischen aromatischen Kohlenwasserstoffen (PAK), chlorhaltigen Schadstoffen (Dioxine und andere) und Schwermetallen sowie der Wirkungsgrad der Feuerungsanlage. Zusätzlich wurden eine Reihe von Qualitätsmerkmalen im Brennstoff und in den Aschen (Nähr- und Schadstoffgehalte, einschließlich Schwermetalle, Chlor, Dioxine, PAK) betrachtet. Unterschiede zwischen den landwirtschaftlichen Brennstoffen und Holz bestanden vor allem bei den Staub- und NOx-Emissionen. Letztere waren mit circa 330 bis 480 mg pro Nm3 (Normkubikmeter bei 13 % Sauerstoffgehalt) beim Halmgut (Stroh, Ganzpflanze, Heu) um den Faktor 2 bis 3 höher als beim Holz. Staub lag mit circa 170 bis 250 mg/Nm3 sogar um etwa das 3- bis 5-fache höher. Der Feinstaub (aerodynamischer Durchmesser, dae < 10 µm) hat mit circa 65 bis 95 % den höchsten Anteil an der gesamten Staubemission; bei Halmgut setzt sich die Feinstaubfraktion sogar größtenteils aus Korngrößen des Submikronbereiches (dae < 1 µm) zusammen. Die Emissionen von polyzyklischen aromatischen Kohlenwasserstoffen sind eng mit den CO- und Gesamt-C-Emissionen korreliert, wobei auch hier die Einjahrespflanzen-Brennstoffe Nachteile gegenüber Holz aufweisen. Die am CO-Ausstoß gemessene Verbrennungsqualität scheint jedoch keine wesentliche Auswirkung auf das Niveau des Ausstoßes von Dioxinen (PCDD/F) zu haben. Dafür ist vor allem der Chlorgehalt im Brennstoff entscheidend. Er bewirkte, dass das PCDD/F-Emissionsniveau, das bei der Holzverbrennung bei circa 51 pgTE/Nm3 lag, bei den Halmgutbrennstoffen um bis zu 17fach höher war. Diese Brennstoffwirkungen lassen sich jedoch nicht ohne Wei-teres auf die anfallenden Aschen (gemessen wurden Feuerraum-, Wärmeübertrager und Kaminaschen) übertragen. Insgesamt zeigt sich, dass bei allen betrachteten Nicht-Holzbrennstoffen bei der Mehrzahl der Parameter ein erhöhtes Schadstoffbildungsrisiko besteht, welches weitergehende Emissionsminderungsmaßnahmen erforderlich erscheinen lässt. In the present investigation various forestry and agricultural fuels (wood, straw, whole plant grain, hay, rape seed expeller) in different treatments (chopped, pelleted) were investigated under practical conditions in a small-scale multi-fuel furnace (50 kW). Additionally, power range (30 to 100 % of the nominal power output) and fuel moisture effects were investigated. Target values were the emissions of carbon monoxide (CO), dust, total organic carbon (TOC) and nitrogen oxides (NOx), the size distribution of dust particles, the emission of polycyclic aromatic hydrocarbons (PAH), harmful substances containing chlorine (dioxins and others) and heavy metals, as well as the efficiency of the furnace. Additionally, a number of quality characteristics in fuels and ashes were considered (plant nutrient concentrations and harmful substances such as heavy metals, chlorine, dioxins and PAH). Differences between agricultural crops (herbaceous fuels) and wood were mainly observed for NOx- and dust emissions. The latter ranged between 330 and 480 mg/m3 (at standard flue gas conditions and 13 % oxygen), which is around 2 to 3 times higher than for wood. Dust emissions were approximately 170 to 250 mg/m3 for herbaceous fuels, which is even 3 to 5 times higher than for wood. The fine dust particles (aerodynamic diameter, dae < 10 µm) has the highest share of the total dust in the flue gas (65 to 95 %); with herbaceous fuels, these fine dust emissions are even mainly below the sub micron fraction (dae < 1 µm). The emissions of PAH are closely correlated to CO and TOC emissions. Here the disadvantages of fuels from annual crops compared to wood fuel clearly show. The quality of combustion as shown by the CO-emission level does not seem to have an effect on the output level of dioxins (PCDD/F). This proves that the content of chlorine in the fuel is crucial. The results for the PCDD/F-emission of herbaceous fuels are approximately 17 times higher than for wood fuel, which ranged around 51 pgTE/m3. However, these fuel effects cannot easily be transferred to the quality of the accumulated ashes, which were differentiatedly measured for three fractions, the combustion chamber, the heat exchanger and the chimney fraction. Generally it can be concluded, that for the majority of the para-meters all regarded non-wood fuels are associated with a largely higher risk of pollutant formation, therefore particular action for emission reduction should be taken.

Sinonasal carcinomas are usually of the squamous cell or transitional cell type. Adenocarcinomas of the inner nose and the paranasal sinus correlate with exposure to wood dust. However, this is only true for adenocarcinomas of the intestinal type and not for salivary gland carcinomas or polymorphous low-grade adenocarcinomas. Of 160 cases with a history of wood dust exposure and malignant tumors of the inner nose, 134 were sinonasal adenocarcinomas of the intestinal type (SNAIT). In addition, there were 24 other carcinomas as well as 1 malignant melanoma and 1 malignant synovial tumor. The SNAIT showed various subtypes with great morphological similarities to colorectal adenocarcinomas (papillary tubular cylinder cell: 72.4%; alveolar goblet cell: 5.2%; signet ring cell: 3.7%; transitional type: 18.7%). Highly differentiated adenocarcinomas (G1) and mucinous adenocarcinomas were relatively frequent: they accounted for 23.1% and 29.1% of the 134 SNAIT, respectively. Apart from wood dust, wood additives are discussed as a carcinogenic factor. With the development of SNAIT, a metaplasia-dysplasia-carcinoma in situ sequence is probable. If the clinical course shows few symptoms, the first manifestation of such a tumor often occurs in an advanced stage.

A 52 year old farmer was referred to us for investigation of suspected farmer's lung. For many years the farmer had been exposed to hay, straw, pigeons, and fuel chip dust. Under exertion he suffered from shortness of breath. In the farmer's own fuel chips we could identify Aspergillus fumigatus, Paecilomyces species and Mucor species. In the farmer's blood we found IgG-antibodies against his own fuel chips, thermophilic actinomycetes, Penicillium species, Mucor species and Aspergillus fumigatus. We did not detect any IgG-antibodies against pigeon serum or pigeon faeces. In order to determine the responsible allergen we performed two challenge tests. In the first test the farmer had to inhale his own hay and straw dust for one hour. This provocation was negative. A second one-hour inhalative challenge was carried out 16 days later using his own fuel chips. This time he experienced significant pulmonary and systemic reactions: body temperature rose by 3.3 degrees C, leucocytes by 12,200/mm3; PO2 fell by 39.4 mmHg, vital capacity by 52%, DLCO by 36%. After the challenge the farmer complained of coughing and dyspnoea. Rales could be heard on auscultation, and an interstitial infiltrate was seen to develop on chest x-rays. After the challenge the patient had to be treated with oxygen and systemic corticosteroids. We diagnosed a fuel chip-induced exogenous allergic alveolitis (EAA). Eight days later the parameters were back to normal and the farmer was discharged from our hospital with further corticosteroid medication. This method of inhalative provocation is very important in diagnosing an EAA. Problems arise when the mode and duration of exposure to substances has to be chosen. Because of the risk of severe reactions, inhalative provocations relating to EAAs should only be performed in special centres with an intensive care unit. In this paper we present a diagnosis of fuel chip lung, which is rarely seen in Germany. However, with the rising use of fuel chips as heating material it is necessary to consider this use as a cause of EAA among farmers.

Since there is evidence that wood dust may cause adenocarcinoma of the nose and sinuses, the question is whether carcinomas of the remaining upper respiratory tract especially of the larynx might be induced or promoted by occupational exposure to wood dust. We reviewed available evidence and found ten case control studies suggesting a causal relationship, whereas in five case control studies regarding this question such a relationship could not be demonstrated. Six cohort studies did not reveal such a relationship either. It should be mentioned that two cohort studies were designed as registry-based studies including cases without fatal outcome. Even these studies failed to reveal a causal relationship. We conclude that the question as to whether laryngeal cancer might be caused by wood dust exposure is still open. Under these circumstances we cannot recommend classifying this disease-exposure-constellation as an approved occupational disease.

Asbestos is a well known inhalant cancerogenic substance, causing not only mesothelioma but also cancer of the respiratory mucosa of the bronchi. Exposure can also cause non-malignant alterations of the pleura or lung, which can be assessed radiologically. Since asbestos can also induce malignant tumors of the nose and sinuses, we identified 50 patients from the files of the ENT Department Münster and tried to complete questionnaires concerning occupation and occupational hazards using informations from insurance companies as well as at least one chest x-ray. This material could be obtained in 19 patients. Nine of the 19 patients had x-ray findings that could be associated with asbestos exposure, but in none of these 9 cases was massive occupational exposure to asbestos probable. In only two of the nine cases was definite occupational exposure to asbestos not able to be excluded. A control group was not established, since statistical calculations of significance would have been problematic in a number of the 19 patients even if a control group did exist. From the questionnaires we have found an unexpected incidence of dusty workplaces (as seen with textile workers, wood-dust workers, cement workers, quarrymen and millers). A correlation between various types of sinonasal tumors and asbestos exposure could not be made.

We report on a 37-year old patient with a simple viral infection who presented with acute bronchitis with bronchospasm, a productive cough and severe dyspnoea. Because of his specific occupational history--the patient is a forester and was exposed to wood dust and fungi--he was at high risk for extrinsic allergic alveolitis with mucoid impaction, so that the cause of hypoxemia and cyanosis was obvious. Repeated immunological parameters including gel-precipitations were negative: The lung function pattern (reduced vital capacity, a reduced FEV1, reduced flow values at low vital capacity and with the characteristic shape of the flow volume-curve but normal airway-resistance) suggested the diagnosis of intrinsic asthma limited to the small airways - "bronchiolar asthma" - severe small airway disease.

The clinical signs and symptoms of health hazards caused by wood are discussed together with their etiology and pathogenesis. 165 such cases were reported to the SUVA (Swiss Accident Insurance Association) up to the end of 1978. Disorders were most common among workers having the greatest exposure to the fine wood dust produced by tropical woods (in particular during grinding and cutting processes). 130 patients suffered from allergic contact eczema or non-allergic contact dermatitis. 35 patients suffered from respiratory tract disorders, 12 of these being classic bronchial asthma. Reference is made to the literature which points to the sharply increased incidence of adenocarcinoma of the paranasal sinus after long-term exposure to wood dust.

In a retrospective epidemiological study, 127 patients with malignant tumours of the nose and paranasal sinuses were studied during a period of ten years. There was a remarkable coincidence between adenocarcinomas and adenocystic carcinomas on the one hand, and patients who were occupationally exposed to wood dust on the other; it was established that the duration of this exposure in the course of their professional life had been between 15 and 35 years. Adenocarcinomas represented 22.8% of the total amount of malignant tumours. The share of the woodworkers in the total number of occupationally active patients in our area of examination was 2.14%, whereas 17.2% of the patients with adenocarcinoma and adenocystic carcinoma had been occupationally exposed to wood dust. The statistical examination of the postulated connection between exposure to wood dust and the occurrence of malignant tumours of the histological type of the adenocarcinoma and adenocystic carcinoma, showed a highly significant correlation.

Wood preservation products have been applied in the domestic field for many years. Until 1977, formulations containing the insecticide lindane and the fungicide pentachlorophenol (PCP) had been used. In 90% of 217 households examined, wood protection products of this type had been applied and between 25 and about 1000 g lindane and between 5 g and about 10 kg PCP (including contaminating substances) had been used in a single house. Consequently, these active ingredients (e.g. PCP) could be detected increasingly in the environment and the organisms of persons living in the respective homes, i.e. in the air and in dust sampled indoors, in foodstuff and in urine. In comparison to samples of indoor air samples of domestic dust seem to be a much better indicator for exposure, as regards representativeness over an extended period. House dust is especially suitable for screening purposes because of its easy sampling and high biocide contents.

68 mean values of airborne shift concentration of total dust were measured at 9 factories of woodworking industries. The values varied from 0.18 to 59.3 mg/m3 for area sampling. But at 63% of the woodworking machines with exhaustion the area sampling shift concentration of total dust reached fewer values than 5 mg/m3. This is a significant decrease of dust concentration in the last ten years.

Squamous cell carcinomas are the most frequent malignancies of the inner nose, followed by adenocarcinomas, adenoid cystic carcinomas, and other malignant neoplasms. Carcinomas of the nose can be recognized as occupational diseases if there has been a professional exposition to ionizing rays, certain arsenic compounds, hexavalent chrome compounds, nickel, oak or beech wood dust. The sources of danger relevant in industrial medicine are indicated. At present, adenocarcinomas induced by dust of wood are of special significance: 16 out of 22 carcinomas of the nose recognized as occupational diseases between 1978 and 1986 are due to oak and beech wood dust.

Adenocarcinoma of the nose and of the paranasal sinuses occurring in employees in the wood processing industry is recognized as an occupational illness in Great Britain and France. This report illustrates a case of adenocarcinoma which has also been recognised and compensated by the responsible trade association. The article draws attention to this disease and to the responsibilities of the ENT specialist.

Wood dust is known as a cause of asthma and chronic bronchitis. From 1979 to 1983 we observed 115 patients with chronic lung diseases, who were exposed to wood dust during many years. We found an irritative pathogenesis in 101 patients with asthma or bronchitis. Twenty nine patients had got a positive skin test, especially with makoré, beech, koto, ash, pine. The inhalation test was positive in 7 of them. The occupational etiology was verified in 5 patients. Besides wood dust itself chemicals for wood protection or wood adhesives can have importance in the pathogenesis of these diseases. Fourteen patients had got alveolitis or lung fibrosis after wood-dust exposition. In each case we found precipitating antibodies against moulds, which could be cultivated from wood dust to which the patients were exposed.

It is well known that cell-mediated allergic reactions can cause tissue destruction, for example, the tuberculin-like allergic reactions. Moreover, this type of allergy can be the starting point of malignant lymphomas in the sense of the theory of the dysregulative development of malignant lymphomas. After all, the inflammation around the tumour is the expression of cell-mediated defense of the body against the neoplastic cells and corresponds to the same immunologic mechanisms as cell-mediated allergy. Therefore, both are rich in lymphoid cells. That is why they are important diagnostic and differential diagnostic criteria. This is illustrated by two cases with cell-mediated contact allergic reactions in the nose and paranasal sinuses. In one of these cases, the transition to malignant lymphoma had just occurred.

After longterm exposition (30.5 years) to beech and oak wood dust in woodworking, a formation of adenocarcinomas of the inner nose is possible in joiners, parquet layers and similar professions. They develop after a latency of 39 years on an average. These tumors appear generally in the area of the middle nasal concha and the ethmoid bone and invade continually into the orbit, the paranasal sinuses and the intracranial space. The incidence of regional and hematogenous metastases is low. Among the various forms of adenocarcinomas of the nose only those adenocarcinomas which are very similar to gastrointestinal carcinomas have been developed after an exposition to dust of wood. The most frequent tumors are adenocarcinomas of cylindrical cells with a papillary tubular structure. Alveolar goblet cell carcinomas with much mucous secretion and carcinomas of the signet ring cells are less frequent. There are evident correlations between the differentiation degree and the development of these tumors. In some of them polypeptide hormones have been demonstrated by histochemical and electron-optical methods. This report is based on 177 cases compiled by the professional association of woodworkers in the Federal Republic of Germany.

A 59-year-old carpenter, 44 years in his profession had an adenocarcinoma of the ethmoids. Similar cases have been described previously in foreign literature. This disease has been accepted as an occupational disease in England. The question is whether this disease, provoked by fine wood-dust may be observed in Germany too; whether the chemical wood ingredients and those being produced during fine-sanding may be carcinogenic. In gaschromatograms the wood ingredients have been demonstrated using oak and beech wood. It is proposed that comparable cases be collected in Germany in order to have a sufficient number of cases for a statistic base. This would make it possible to add this disease to the German list of occupational diseases.