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Die transnasale fiberoptisch-endoskopische Laryngoskopie mit Schluckuntersuchung (FEES) hat die Untersuchungsmoglichkeiten und das therapeutische Management bei kindlichen Schluckstorungen grundlegend verandert. Dieser Artikel soll eine Ubersicht uber die Untersuchungsmoglichkeiten geben und die Vorgehensweise bei der Anwendung der FEES darstellen. Hierbei erfolgt eine detaillierte Beschreibung des standardisierten Vorgehens unter Berucksichtigung der Erfahrungen der Autoren. Die FEES stellt eine geeignete Methode zur funktionellen Beurteilung des Schluckaktes und zur Beurteilung der laryngopharyngealen Strukturen unter direkter Sicht dar. Aufgrund vielfaltiger Vorteile wie die Verfugbarkeit und Wiederholbarkeit der Untersuchung, die fehlende Strahlenbelastung im Vergleich zu radiologischen Verfahren und wegen der okonomischen Uberlegenheit nimmt die Bedeutung der FEES zu. Bei einer steigenden Anzahl von kindlichen Schluckstorungen sollten mehr Arzte die FEES erlernen.

PHENOTYPING SPECIFIC LANGUAGE IMPAIRMENT IN KINDERGARTEN CHILDRENOBJECTIVE: For phenotyping specific language impairment (SLI) in kindergarten children in clinical practice and research issues, we need a valid diagnostic method for dichotomous classification (language impaired, normal developing). PATIENTS AND METHODS: 27 kindergarten children belonged to SLI-group, 36 to control-group. The diagnostic accuracy of a composed language test battery was examined in comparison to a clinical assessment. The test battery was composed of 8 subtests of German norm-referenced, standardized tests. RESULTS: Several discriminant analyses showed acceptable levels of accuracy with over 80% for sensitivity and specificity. Using a single subtest the subtest „Phonologisches Arbeitsgedachtnis fur Nichtworter” (phonological short-term memory of nonwords) from Sprachentwicklungstest fur drei- bis funfjahrige Kinder (SETK 3-5; Grimm, 2001) showed best classification rates between the two groups using a Cut-off point of −0,39 SD. Means of the 8 used subtests showed significant differences for the two groups. CONCLUSION: The described method for phenotyping SLI can identify children with normal language and those with impaired language with acceptable levels of diagnostic accuracy. When using a norm-referenced standardized test for the assessment of language abilities, it is important to have empirically derived information about diagnostic accuracy (sensitivity, specificity, Cut-off score).

Durch seine anticholinerge Wirkung nimmt Botulinumtoxin in der Hals-Nasen-Ohren-Heilkunde eine wichtige Stellung ein. Patienten mit fazialen Hyperkinesien (z. B. Blepharospasmus, Spasmus facialis), komplexen Dystonien (oromandibulare Dystonie, spasmodische Dysphonie, zervikale Dystonie) sowie mit gustatorischem Schwitzen, Hypersalivation und Krokodilstranen werden damit behandelt. In der Behandlung von Spannungskopfschmerzen und Migrane ist Botulinumtoxin eine Alternative. Eine neue Indikation konnte sich bei nasaler Hypersekretion durch die Toxinwirkung auf die nasalen Drusen ergeben. Die Botulinumtoxinwirkung setzt nach wenigen Tagen ein und halt bei den muskularen Erkrankungen kurzer an als bei den Fehlfunktionen des autonomen Nervensystems. Der positive therapeutische Effekt ist passager, sodass erneute Behandlungen notwendig sind. Nebenwirkungen sind bei richtiger Anwendung selten. Unter Beachtung einiger spezieller Aspekte ist Botulinumtoxin ein effektives und nebenwirkungsarmes Therapeutikum bei zahlreichen muskularen Dysfunktionen und Erkrankungen des autonomen Nervensystems.

In otorhinolaryngology, botulinum toxin is a suitable therapeutic option in the muscular and the autonomic nervous system concerning dysfunctions. Respecting some special aspects, it is an effective treatment for disorders of different etiology with very few side-effects. The positive therapeutic effect is temporarily limited, so that the patients need further treatment. Beside the classical indications like the facial hyperkinesias (i.e. blepharospasms, hemifacial spasm) the treatment of complex dystonias (oromandibular dystonia, laryngeal dystonia, cervical dystonia), gustatory sweating, hypersalivation and crocodile tears is successful. Botulinum toxin is an alternative treatment of tension type headache and migraine. A new indication of botulinum toxin application may lay in the treatment of nasal hypersecretion through the effect on the nasal glands.

In this study we evaluated the disease specificity of bronchoalveolar lavage fluid angiotensin-converting enzyme (BALF-ACE), its correlation with cellular constituents of bronchoalveolar lavage fluid (BALF), and for sarcoidosis, with other proposed markers of disease activity. Furthermore, the question of the clinical value of BALF-ACE determinations in in interstitial lung diseases or any of its subgroups was addressed. The study population consisted of 222 patients, 69 with biopsy proven sarcoidosis, 3 with hypersensitivity pneumonitis, 4 with acute histoplasmosis, 27 with idiopathic pulmonary fibrosis (IPF), 4 with rheumatoid arthritis-related interstitial fibrosis, 9 with pulmonary drug toxicity, 16 with pulmonary malignancies, 26 with other parenchymal lung disease entities, and 30 in whom the final diagnosis remained indeterminate. Elevated BALF-ACE concentrations were seen in all diagnostic categories. In sarcoidosis BALF-ACE levels correlated well with lavage lymphocyte counts (r = 0.49; p less than 0.0001), in contrast to IPF where they correlated well with lavage neutrophil counts (r = 0.51; p less than 0.007). The correlation of BALF-ACE and serum-ACE was significant. In sarcoidosis the mean BALF-ACE level was lower for patients with Stage-I chest roentgenographic patterns (0.664 U/L), compared to those with Stage II (1.112 U/L) and Stage III (1.083 U/L). It was concluded that elevated BALF-ACE levels are not specific for sarcoidosis. The correlations of BALF-ACE levels with different cellular constituents of BALF suggest a different cellular origin of BALF-ACE. In sarcoidosis BALF-ACE levels correlate well with other proposed markers of disease activity and seem to reflect pulmonary activity better than serum ACE.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum angiotensin-converting enzyme (SACE) levels were measured in 44 subjects six weeks after acute pulmonary histoplasmosis. All patients were infected in a common-source outbreak of histoplasmosis which occurred on one day. All patients had both strictly defined clinical and serologic evidence of infection. The SACE activity was elevated at six weeks compared to normal controls, and seven of the 44 had levels more than 2 SD above the normal mean. SACE levels were also measured at three and 24 weeks after acute infection in a smaller number of the same subjects. Serial observations demonstrated that all subjects (including those with normal and elevated SACE at six weeks) had a rise and fall in SACE activity following symptomatic acute pulmonary histoplasmosis. Our findings suggest that elevated SACE does not reliably separate sarcoidosis from histoplasmosis, although elevations in histoplasmosis are much less common and may occur only briefly following acute pulmonary histoplasmosis. More important, it seems that SACE activity rises acutely in all patients with symptomatic acute histoplasmosis and then falls gradually toward baseline over several months, coinciding temporally with the granulomatous response.

Twenty-four patients with sarcoidosis had normal serum angiotensin converting enzyme (SACE) values at time of diagnosis. Sixteen patients were in stage I and eight of these underwent complete remission and four followed a stable course. Seven of eight patients in stages II and III experienced improvement while receiving glucocorticoid treatment. In six, serial SACE measurements fell significantly, paralleling the clinical improvement. The data suggest that a normal SACE in stage I indicates a good prognosis. Patients in stages II and III with normal SACE levels may still have active disease potentially responsive to glucocorticoid treatment. The reduction of SACE while receiving treatment may be viewed as the "suppressible" SACE compartment, representing that portion of the enzyme elaborated by the granuloma or its cellular precursors. The level remaining after suppression by glucocorticoids may be considered "basal" SACE, probably related to normal turnover of SACE producing cells in vascular endothelium.

Cotton bract tannin, a major organic component of cotton dust, was tested for mitogenic activity upon human T lymphocytes. Tannin caused polyclonal activation of human T lymphocytes in vitro. The pattern of T-cell response to tannin was similar to the pattern seen in lymphocytes stimulated with the well-known plant lectin T-cell mitogens, PHA and ConA. The response to tannin was shown to be dependent upon tannin dose and presence of monocytes. The maximum response occurred after 3–4 days in culture with the magnitude comparable to the one achieved by ConA. Lipopolysaccharide from Enterobacter agglomerans, a major contaminant of cotton dust, was shown not to be a mediator of tannin mitogenicity in vitro. A role for tannin as a polyclonal cell activator and, therefore, a possible etiologic agent of byssinosis is suggested by these observations.

Thirty-five patients with sarcoidosis were serially monitored for serum angiotensin-converting enzyme activity by a simple radiochemical assay, and we analyzed the relation of such activity to the clinical status as judged from changes in chest roentgenograms, pulmonary function, or symptoms. Converting enzyme levels closely paralleled and occasionally antedated changes in clinical status in patients either undergoing spontaneous remission or being treated with prednisone. Converting enzyme activity seems to be a sensitive index for evaluating the clinical course of sarcoidosis. Converting enzyme determinations may be helpful in corroborating the diagnosis, assessing the likelihood of spontaneous remission, confirming the clinical status of the patient, and determining the adequacy of glucocorticoid therapy.

• Serum angiotensin-converting enzyme (SACE) was measured in 14 patients (eight women and six men) with sarcoidosis and hypercalcemia. Thirteen patients were treated with prednisone, and 12 achieved normal or nearly normal serum calcium values. Two patients had coexistent hyperparathyroidism. Seven of eight patients with serial SACE measurements exhibited parallel falls in SACE and serum calcium levels. Eleven patients were successfully treated with alternate-day prednisone regimens. The data suggest that serial SACE measurements are useful in the evaluation and management of sarcoidosis with hypercalcemia. In patients with sarcoidosis, the reduction of SACE levels during glucocorticoid treatment may be due to a suppression of granuloma formation. Concomitant falls in serum calcium level suggest an important role of the granuloma or its cellular precursors in vitamin D metabolism. (Arch Intern Med1985;145:677-679) Hypercalcemia occurs in sarcoidosis with variable frequency, estimated from 5% to 10% of cases. At times, hypercalcemia may be the

To determine disease specificity and sensitivity of anticytoplasmic autoantibodies (ACPA) for Wegener granulomatosis, as well as their value as a marker of disease activity.Blind analysis of serum samples, retrospective analysis of clinical data on patients, and prospective follow-up of a subgroup of patients with Wegener granulomatosis.The study included 277 patients with Wegener granulomatosis (222 with biopsy-proven disease) and 1657 control patients.University hospital and academic medical center. LABORATORY INVESTIGATIONS: Analysis of 2653 serum samples from 1934 patients for ACPA. Antibody detection was by indirect immunofluorescence and a new type of enzyme-linked immunoadsorbent assay (ELISA). Prospective follow-up was on 172 patients with Wegener granulomatosis.Specificity of ACPA for Wegener granulomatosis measured by indirect immunofluorescence was 99% (CI, 98.9% to 99.7%) and 98% (CI, 97.4% to 99.2%) by ELISA. Sensitivity of ACPA depended on disease activity and extent: It was 67% (CI, 38% to 89%) by immunofluorescence and 60% (CI, 32% to 84%) by ELISA for patients with active locoregional symptomatology (n = 15); and 32% (CI, 14% to 54%) by immunofluorescence and 40% (CI, 21% to 61%) by ELISA for patients in full remission after initial locoregional symptoms (n = 25). The sensitivity was 96% (CI, 89% to 99%) by immunofluorescence and 93% (CI, 86% to 98%) by ELISA for patients with active generalized disease (n = 92). Serial testing was done; every patient with active generalized disease eventually had at least one positive serum sample. Sensitivity decreased to 41% (CI, 22% to 62%) by both immunofluorescence and ELISA for patients in full remission after active generalized disease (n = 27). Levels of ACPA expressed both as immunofluorescence titers and ELISA values (U/mL) correlated well with disease activity.Testing for ACPA in serum of patients with Wegener granulomatosis is valuable for differential diagnosis; furthermore, APCA can be used as a marker to follow disease activity. A new type of ELISA yielded the same results as indirect immunofluorescence for the specificity, sensitivity, and correlation with disease activity of ACPA.

Excerpt To the editor: Lieberman and Rea (1) have recently shown that elevated levels of serum angiotensin-converting enzyme are not confined to patients with sarcoidosis but can also be found in p...