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Background: Microvascular anastomosis remains one of the most critical aspects of free tissue transfer. Since microsurgical suture techniques are complicated and time-consuming, other techniques of anastomosis have been created. One of these is the ring-pin system., Methods: Between January 1996 and October 2001, 48 patients underwent reconstruction with a free radial forearm flap. In 20 patients the venous anastomosis was carried out using a ring-pin system with end-to-end technique. The clinical results were compared to the other 28 patients in whom the anastomosis was sutured with 9-0 prolene., Results: In the group using ring-pin anastomosis ( n=20), two flaps showed venous congestion within 24 h postoperatively. After revision the flaps were well perfused. In the other group with sutured vessels ( n=28), a transplant became ischemic in one patient due to venous thrombosis and had to be partly removed. The time of anastomosis was considerably shortened by the use of the ring-pin system., Conclusions: The venous end-to-end-anastomosis using the ring-pin system can be carried out relatively easily and rapidly after a comparatively short period of training. Long-term results have shown good tissue tolerance of the material and sufficient blood circulation of the grafts.

Purpose: This is a prospective analysis of the value of MRI in suspected inner ear malformations., Materials and Methods: In 50 patients (43 children and young adults, 7 adults) with suspected inner ear malformation MRI (1.5 T) was performed. In addition, 42 of these patients underwent CT. For the analysis of the inner ear structures, the constructive interference in steady state (CISS) sequence with 0.7 mm slice thickness was used. Functional tests revealed a sensorineural hearing loss or deafness in 82 temporal bones (TB) and a combined hearing loss in 4 TB. The hearing loss was unilateral in 14 patients. MRI and CT findings were compared., Results: Imaging findings were normal in 58 TB. The pathological findings included inner ear malformations (35 TB), inflammatory changes (4 TB), partial obliteration of labyrinth (2 TB) and congenital aural atresia (1 TB). An isolated absence of the cochlear nerve (1 TB) could only be found by MRI. In the remaining cases, an inner ear malformation was diagnosed by MRI and CT with the same confidence but MRI was superior in displaying the fine details., Conclusions: MRI will become the method of choice in the diagnosis of inner ear malformations.

Background: Simultaneous radiochemotherapy (sRCT) is the treatment of first choice in locally advanced head and neck cancers. We have tested a very aggressive combination protocol with cisplatin and escalated paclitaxel in combination with accelerated hyperfractionated radiotherapy to assess the maximum tolerated dose (MTD), dose-limiting toxicity (DLT), overall toxicity, and response rate., Patients and Methods: The trial recruited 24 patients (21 males, three females, mean age 57 years) treated at our department from 1998 through 2001. Irradiation was administered in daily doses of 2 Gy up to 30 Gy followed by 1.4 Gy twice daily up to 70.6 Gy to the primary tumor and involved nodes and 51 Gy to the clinically negative regional nodes. The chemotherapy schedule included cisplatin in a fixed dose of 20 mg/m(2) on days 1-5 and 29-33 and paclitaxel at increasing dose levels of 20, 25, 30 mg/m(2) twice weekly over the whole treatment time. Patients were recruited in cohorts of three to six, and the MTD was reached if two out of six patients in one cohort developed DLT. DLT was defined as any grade 4 toxicity or any grade 3 toxicity requiring treatment interruption or unplanned hospitalization or any grade 3 neurotoxicity. We recruited mainly patients with large tumors for this protocol; all patients were stage IV, and the mean tumor volume (primary + metastases) amounted to 72 +/- 61 cm(3). The mean follow-up was 30 months (range 4-39 months)., Results: One early death (peritonitis and sepsis at day 10) occurred, and 23 patients were evaluable for acute toxicity and response. The MTD of paclitaxel was reached at the third dose level (30 mg/m(2) paclitaxel twice weekly). The DLT was severe mucositis grade 3 (n = 1) and skin erythema grade 4 (n = 2). After determining the MTD, another 14 patients were treated at the recommended dose level of paclitaxel with 25 mg/m(2) twice weekly. In summary, 13/23 patients (57%) developed grade 3 and 10/23 (43%) grade 2 mucositis. Two patients (9%) had grade 4, five (22%) grade 3, and 16 (69%) grade 2 dermatitis. One patient died at day 30 of neutropenic infection. In one patient, a grade 2 nephrotoxicity appeared requiring cessation of cisplatin chemotherapy. 18/23 patients (78%) required blood transfusion (1-3 units) and 16/23 (70%) i.v. antibiotics. 14 patients (61%) achieved a complete and nine (39%) a partial remission, yielding an overall response rate of 100%. In summary, six patients died of local tumor progression (n = 2), distant metastases (n = 2), or therapy-related complications (n = 2) during follow-up. The 3-year overall survival was 71%. Tumor volume was not a risk factor for failure in this protocol (mean tumor volume in relapse-free vs. progressive patients 71 +/- 65 cm(3) vs. 64 +/- 38 cm(3)). All patients have, so far, developed only slight late effects (fibrosis, lymphedema) with no grade 3-4 late sequelae., Conclusions: This very aggressive sRCT protocol yielded excellent response and survival figures but was associated with a very high rate of acute toxicity (8% therapy-related deaths). A maximal supportive treatment is therefore required.

Background: Extranodal non-Hodgkin's lymphoma are mostly localized in the gastrointestinal tract. A small number of these lymphoma arise from specialized lymphoid cells, the so-called mucosa-associated lymphoid tissue (MALT). We describe one case with a metachronous occurrence of a MALT-type lymphoma of the conjunctiva of both eyelids and supraglottic larynx., Patient and Method: A 56-year old woman was first treated in August 1990 for a low-grade B-cell lymphoma in the conjunctiva of the left eyelid. 42 months later an extranodal B-cell lymphoma, located in the conjunctiva of the right eyelid, was found. After a father period of 48 months a MALT-type lymphoma arose in the supraglottic larynx. The findings of staging examinations were normal. The final diagnosis was low-grade B-cell lymphoma of the MALT-type, limited to the conjunctival eyelids and supraglottic larynx, with the clinical staging of IE A. Treatment consisted of a LASER-resection followed by a locoregional radiotherapy, with the dose of 40 Gy., Results: Currently no evidence of disease (NED) at all sites can be proven., Conclusions: Extranodal, primary low grade B-cell MALT-type lymphoma are rare. In the literature only few cases of each larynx- and conjunctival eyelid involvement described. The radiotherapy has been reported to achieve a long time of relapse-free interval. The present case demonstrates, that even the recurrence of an extranodal, primary low-grade B-cell MALT-type lymphoma responds well to local radiotherapy and can also have a long period of no evidence of disease.

Pyoderma gangrenosum belongs to the chronic, neutrophilic and necrotic dermatoses. These very painful, inflammable and purulent skin-ulcers often arise after injury or surgical intervention. About half of the patients suffer from systemic disease, for example hematological, gastrointestinal or rheumatic diseases. Our report includes a 77-year-old female with a multilocular emergence of pyoderma gangrenosum following surgery for an orbital pseudotumor. An additional lesion was detected on her anterior neck. Because the possibility of wound-infection was suspected, the lesion was treated locally and with a systemic antibiotic therapy. After this treatment the condition of the wound deteriorated. Upon dermatological examination, pyoderma gangrenosum was identified and a immunosuppressive therapy with corticosteroids and cyclosporin was initiated. As a result of this treatment the lesion healed slowly--with the formation of typical, atrophic and reticular scars. A connection between the pyoderma gangrenosum and the orbital pseudotumor can, on the basis of similar clinical and structural characteristics, not be excluded. A related disease was not diagnosed in this patient. Recurrence can be predicted in patients who have had skin injuries, therefore strict observation is required.

Background: The role of sensitive parts of the cervical plexus for the development of neuropathic pain is not yet clear. Our study investigated the correlation between shoulder pain and cervical plexus damage after different types of neck dissection (ND)., Material and Methods: The sensitivity for warm/cold and sharp/blunt was tested in the dermatomes of C2, C3, C4, and the minor occipital nerve. Shoulder pain was measured semiquantitatively by a rating scale., Results: Motion-dependent shoulder pain was observed 6 months postoperatively in 50% after resection and in 29.2% after preservation of these structures. Pain occurred more frequently following radical ND than after modified radical types 1 and 3 ND., Discussion: Our investigations showed that the superficial cervical plexus function is assessable by cutaneous sensitivity tests. The minor occipital nerve seemed to be less affected. Fewer pain symptoms in cases with preserved cervical plexus could be demonstrated. We can conclude that preservation of the superficial cervical plexus is important to diminish postoperative shoulder pain.

Background: Tumor hypoxia has proven prognostic impact in head and neck cancers and is associated with poor response to radiotherapy. Hyperbaric oxygenation (HBO) offers an approach to overcome hypoxia. We have performed pO2 measurements in selected patients with head and neck cancers under HBO to determine in how far changes in the oxygenation occur and whether a possible improvement of oxygenation parameters is maintained after HBO., Patients and Methods: Seven patients (five male, two female, age 51-63 years) with squamous cell cancers of the head and neck were investigated (six primaries, one local recurrence). The median pO2 prior to HBO was determined with the Eppendorf histograph. Sites of measurement were enlarged cervical lymph nodes (n = 5), the primary tumor (n = 1) and local recurrence (n = 1). Patients then underwent HBO (100% O2 at 240 kPa for 30 minutes) and the continuous changes in the oxygenation during HBO were determined with a Licox probe. Patients had HBO for 30 minutes (n = 6) to 40 minutes (n = 1). HBO was continued because the pO2 had not reached a steady state after 30 minutes. After decompression, patients ventilated pure oxygen under normobaric conditions and the course of the pO2 was further measured over about 15 minutes., Results: Prior to HBO, the median tumor pO2 in the Eppendorf histography was 8.6 +/- 5.4 mm Hg (range 3-19 mm Hg) and the pO2 measured with the Licox probe was 17.3 +/- 25.5 mm Hg (range 0-73 mm Hg). The pO2 increased significantly during HBO to 550 +/- 333 mm Hg (range 85-984 mm Hg, p = 0.018). All patients showed a marked increase irrespective of the oxygenation prior to HBO. The maximum pO2 in the tumor was reached after 10-33 minutes (mean 17 minutes). After leaving the hyperbaric chamber, the pO2 was 282 +/- 196 mm Hg. All patients maintained an elevated pO2 for further 5-25 minutes (138 +/- 128 mm Hg, range 42-334 mm Hg, p = 0.028 vs the pO2 prior to HBO)., Conclusions: Hyperbaric oxygenation resulted in a significant increase in the tumor oxygenation in all seven investigated patients. A significant increase at the point of measurement could be maintained for several minutes after decompression and after leaving the hyperbaric chamber.

Aim: Aesthetic and reconstructive surgery of the upper eyelid attempts to restore aesthetic or functional deficits. Knowing of the anatomic relationships in these structures is very important. The aim of our study was to assess by ultrasound the upper eye lid tarsal curvature changes depending on movement of the bulbus., Methods: In 50 people with healthy eyes we measured the diameter of the upper eyelid tarsal plate, the cornea, the bulbus and additionally the intraocular pressure. In measuring the upper eyelid tarsal plate we used transpalpebral ultrasound in a non contact mode with a 7.5 MHz linear array scanner, with the bulbus in median and in abduction position., Results: In healthy eyes the diameter of the upper eye lid tarsal plate changes depend on movement of the bulbus. The mean diameter of the upper eye lid tarsal plate over the bulbus in medium position was 19.3 +/- 3.8 mm versus 30.1 +/- 6.3 mm in abduction position. This difference is statistically significant (p < 0.05)., Conclusions: The results of the study indicate, that using ultrasound with a 7.5 MHz linear array scanner is appropriate for objective evaluation of relative changings of the upper eye lid tarsal plate diameter. The obtained data showed significant differences and must be taken into account when considering cosmetic and functional surgery of the upper eye lid, f. e. lidloading in facial palsy with gold or platinum implants.

Background: The question arised whether saliva can be included in populations monitoring of high risk groups for the development of head and neck squamous cell carcinomas. Cytotoxic mechanisms strongly influence the carcinogenesis of squamous cell carcinomas., Patients and Methods: Saliva specimen of 131 abusing and non-abusing probands were tested on their biological (cytotoxic) effects to draw conclusions on the individual cancer risk. To determine the cytotoxic activity of saliva, we used the "plating efficiency index" of lungfibroblasts of the chinese hamster., Results: We found significantly increased cytotoxic effects in the saliva of smoking probands (p < 0.002). Regularly combined smoking and drinking of alcohol led to a highly significant increased risk of cytotoxic saliva in the tested persons (odds ratio: 17.4; p < 0.005)., Conclusions: Including patients with head and neck squamous cell carcinomas, ongoing studies must prove the practical relevance of this biomarker for estimating the relative cancer risk in the upper aerodigestive tract.

Background and Objective: The incidence of squamous cell carcinomas in the upper aerodigestive tract has increased worldwide. The main risk factors are chronic tobacco and alcohol consumption. The detection of high-risk persons is important because early diagnosis of these tumors provides a good chance for permanent healing. Biomonitoring programs may help to give precise information about the individual cancer risk among smoking and drinking persons. The aim of this study was to evaluate the Ames test as a biomarker to detect the genotoxicity of saliva., Patients and Methods: Saliva specimens of 131 probands were investigated for their genotoxic effects using the Ames test., Results: Our results showed an increased trend of genotoxic activity in the saliva of smokers. A highly significant additional increase of genotoxicity was measured in smoking and drinking individuals., Conclusions: Our study shows that the Ames test could be used to show genotoxic effects in saliva specimens. In combination with other biomarkers, this test may help to develop a valid concept for detecting cancer-endangered people.

During the period 1992-1998,we diagnosed orbital tumors in 23 cases at the MLU Halle-Wittenberg. In the intraconal compartment we mostly saw cavernous hemangiomas and neurogenic tumors. Lymphomas and a primary meningioma were located in the extraconal space. Beneath the periosteum, bony processes, tumors of the sinuses, dermoid-and epidermoid-cysts normally occur, but we only observed metastases and hematomas. Furthermore,tumors of the lacrimal gland and inflammatory lesions were diagnosed. Orbital tumors are uncommon lesions, whose location in the orbit gives an important hint to differential diagnosis, because a high percentage of various pathologies is located in special compartments of the orbit. According to our results,the MRI-scan is usually sufficient for differentiation and for preoperative planning in order to reduce the X-ray dose of the lens. CT-scans with contrast are sometimes necessary for examining bone destroying processes and for planning the surgical approach to removing the tumor. X-rays of the skull widely lost their importance in the exact diagnostic of orbital tumors. B-scan ultrasonic imaging is reserved for screening and follow-up examination. Despite the use of MRI and CT scanning, the histological examination remains necessary.

Background: Necrotizing fasciitis of the head and neck is a rare occurrence. It spreads rapidly along fascial planes causing extensive necrosis; it often results in gangrene of the overlying skin. Mostly involved are immunodeficient patients with banal infections of the upper aerodigestive tract, small traumas, but also after surgical procedures. The "Federal Health Agency" of the Federal Republic of Germany estimates a number of 40 cases a year in Germany for all regions of the body. The mortality is about 20%-50% dependent on the localisation of this soft tissue infection., Patients: Four cases of necrotizing fasciitis of the head and neck region, which were treated at the ENT-Department of the Martin Luther University Halle-Wittenberg since 1995, were described., Results: Despite aggressive surgical debridement and intensive care medicine two patients died because of streptococcus-associated-toxic-shock-syndrome. In all patients we found a diabetes mellitus as a known risk factor for this necrotizing soft tissue disease. In two of four patients with cervical involvement mediastinitis was diagnosed as a complication. The CT-scan showed this mediastinal spread only in one case., Conclusions: Only rapid diagnosis and surgical treatment with radical debridement can influence the disease positively. Thoracal CT-scan is necessary in all cases of cervical necrotizing fasciitis because of the high risk of mediastinal involvement. A strong complication is a streptococcus-associated-toxic-shock-syndrome, which should be prevented because it is often associated with a lethal outcome. Penicillin G and clindamycin are advocated for antibiotic treatment.

A lot of different endogenous and exogenous factors are accused to promote squamous cell carcinomas in the upper aerodigestive tract. Main risk factors are the chronic tobacco- and alcohol consumption. The fact, that many patients develop syn- or metachronic carcinomas in this area was first described by Slaughter et al. 1953 and explained with the phenomenon of field cancerisation. Concerning to this hypothesis the whole mucosa of the upper aerodigestive-tract is premalignant damaged. In our study the micronucleus-frequency was determined as a biomarker for the genetic injury to prove the fieldcancerisation on the cellular level at 159 people (control-group, abuser, patients with HNSCC). Our results confirm the hypothesis of fieldcancerisation of the mucosa of the upper aerodigestive-tract at strong tobacco- and alcohol consumers and patients with head and neck squamous cell carcinoma. Furthermore there is a highly statistically significant correlation between increasing micronucleus frequency and increasing tobacco abuse. As a final result of our study the micronucleus assay seems to be of good value to show a genotoxic damage in healthy mucosa at people with a high risk to develop HNSCC, but it's not usable to give any answer if and when such carcinomas arise.

Background: Esophageal perforations are the most frequent complications of endoscopy of the upper gastrointestinal tract. Life-threatening consequences such as mediastinitis, septic disease, or multiple organ failure are possible. Traditional surgical and conservative methods of treatment should be distinguished. In serious cases, thoracotomy in particular is a high-risk operation., Patients and Results: This case demonstrates the successful endoscopic treatment of an esophageal perforation with mediastinal empyema by fibrin gluing., Conclusions: Esophageal perforations up to 20 cm aboral and a maximum diameter of 1.5 cm could be treated by rigid endoscopical fibrin gluing. High-risk patients could be managed effectively avoiding extensive surgery.

Epidermolysis bullosa acquisita (EBA) is a rare, chronic, acquired bullous autoimmune dermatosis. It is characterized by the formation of IgG autoantibodies against type VII procollagen of anchoring fibrils with subepidermal formation of bullous lesions and consequent scarring. The epidemiology of this disease and its characteristic clinical findings cannot be completely surveyed at present due to the limited number of available publications. In general, bullous lesions form on the entire integument and can also involve mucosa. The development of scar-related adhesions on the mucosa of the upper airways and esophagus can lead to serious complications that are difficult to treat. We report our experience in managing a 44-year-old male patient in whom the diagnosis of EBA was established in 1993 on the basis of multiple persistent bullous lesions involving the eye, nose, skin and oral, pharyngeal and laryngeal mucosa. After failing previous medical and surgical therapies, interdisciplinary management resulted in the control of active lesions with extracorporal phototherapy and cyclosporin A.