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The artwork of making the epithesis by the dedicated anaplastologist is the prerequisite of acceptance by the patient and the key for success of this approach. However, computer science is helping with virtual planning and rapid prototyping, and it is likely to revolutionize this process in the near future. One of the advantages of the auricular prostheses is that it can be manufactured as a mirrored replica of the opposite side (if normal or near normal). Furthermore, the results are predictable, and may be shown to the patient before surgery. The developments of various implant systems allow secure retention even in unfavorable anatomic situations as in the ideally pneumatized mastoid process. The advantage of the plate systems is that they spread the loading forces to multiple smaller bone screws, rendering it thereby resistant to torque with abutment insertion or magnet change. Auricular prostheses fulfill three roles: (1) temporary measure, (2) rescue procedure in failed auricular (re)construction, and (3) definitive treatment option. Conventional retention by medical adhesives, sometimes helped by making use of the remnant, keeps its place in the use as a temporary measure or if the patient declines surgery. Today, implant-retained auricular prostheses made of silicone are state of the art for prosthetic rehabilitation of patients with auricular defects., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Cytotoxic ribonucleases such as the leopard frog derivative Ranpirnase (Onconase(®)) have emerged as a valuable new class of cancer therapeutics. Clinical trials employing single agent Ranpirnase in cancer patients have demonstrated significant clinical activity and surprisingly low immunogenicity. However, dose-limiting toxicity due to unspecific uptake of the RNase into non-cancerous cells is reached at relatively low concentrations of > 1 mg/m(2). We have in the present study generated a dimeric anti-EGFR Ranpirnase-diabody fusion protein capable to deliver two Ranpirnase moieties per molecule to EGFR-positive tumour cells. We show that this compound mediated far superior efficacy for killing EGFR-positive tumour cells than a monomeric counterpart. Most importantly, cell killing was restricted to EGFR-positive target cells and no dose-limiting toxicity of Ranpirnase-diabody was observed in mice. These data indicate that by targeted delivery of Ranpirnase non-selective toxicity can be abolished and suggests Ranpirnase-diabody as a promising new drug for therapeutic interventions in EGFR-positive cancers., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: By virtue of direct bone conduction, percutaneous bone-anchored hearing implants offer a high level of wearing comfort, as well as audiologically superior signal transmission due to less dampening. Over the years, titanium implants have been optimized and the surgical technique developed into a minimally invasive intervention without soft tissue reduction. This study aims to investigate the success rates of the various percutaneous implant systems., Materials and Methods: This retrospective study includes 191 patients who received a total of 283 percutaneous titanium implants for bone conduction hearing systems during the period from 01.01.1989 until 31.12.2013. Patient age ranged from 2 to 81 years (mean 36 years). The mean follow-up duration was 5.2 years., Results: The overall osseointegration success rate was 92.6% and ranged from 90.5 to 100% for the various implant systems (p = 0.6). For children and adolescents, the success rate was 86.8%, compared to 95.2% in adults (p = 0.023). Classical soft tissue reduction was received by 185 patients, mainly via the dermatome technique. The linear incision technique was used in 3.8% of cases and the technique without soft tissue reduction in 3.7% of cases. Revision surgery for soft tissue problems was performed in 4.2% of cases., Conclusion: Success rates in adults were significantly higher than those in children and adolescents. Although success rates improved with the development of new systems, this did not reach statistical significance. Minimally invasive surgery without soft tissue reduction is considered state of the art.

A New Implant System for Orbital Prosthetic Rehabilitation: "Epiplating Mono" Prosthetic or episthetic rehabilitation of ear, eye and nose are currently most common performed using magnetic fixation. While at the beginning single implants have been used, now-a-days a more extended approach with plate fixation are recommended to enhance the stability of the anchored magnets. A newly designed implant system epiplating mono is presented that combines the structure of a single implant with additional fixation elements. In a pilot study this new implant system was used in 4 patients for prosthetic orbital rehabilitation. Further experiences with this new implant system are required necessitating long-term experiences of implant stability to define the value of the presented epiplating mono system for prosthetic rehabilitation., (© Georg Thieme Verlag KG Stuttgart · New York.)

The development of efficient strategies for generating fully human monoclonal antibodies with unique functional properties that are exploitable for tailored therapeutic interventions remains a major challenge in the antibody technology field. Here, we present a methodology for recovering such antibodies from antigen-encountered human B cell repertoires. As the source for variable antibody genes, we cloned immunoglobulin G (IgG)-derived B cell repertoires from lymph nodes of 20 individuals undergoing surgery for head and neck cancer. Sequence analysis of unselected “LYmph Node Derived Antibody Libraries” (LYNDAL) revealed a naturally occurring distribution pattern of rearranged antibody sequences, representing all known variable gene families and most functional germline sequences. To demonstrate the feasibility for selecting antibodies with therapeutic potential from these repertoires, seven LYNDAL from donors with high serum titers against herpes simplex virus (HSV) were panned on recombinant glycoprotein B of HSV-1. Screening for specific binders delivered 34 single-chain variable fragments (scFvs) with unique sequences. Sequence analysis revealed extensive somatic hypermutation of enriched clones as a result of affinity maturation. Binding of scFvs to common glycoprotein B variants from HSV-1 and HSV-2 strains was highly specific, and the majority of analyzed antibody fragments bound to the target antigen with nanomolar affinity. From eight scFvs with HSV-neutralizing capacity in vitro,the most potent antibody neutralized 50% HSV-2 at 4.5 nM as a dimeric (scFv)2. We anticipate our approach to be useful for recovering fully human antibodies with therapeutic potential.

Background: In addition to prosthetic rehabilitation, maxillary defects can also be surgically reconstructed. Soft-tissue reconstruction employs a radial forearm or latissimus dorsi muscle flap, while bony reconstruction can be achieved using a fibula, iliac crest, or scapular flap. Reconstruction using a scapular flap is further divided into two subgroups: the traditional scapular flap with the circumflex scapular artery as the donor vessel and the scapular angle flap with the angular artery originating from the thoracodorsal artery as the donor vessel., Materials and Methods: We report on four patients who underwent successful reconstruction with a free scapular angle flap between 2009 and 2011, following maxillary resection due to malignancy., Results: Vertical positioning of the scapular angle flap enables reconstruction of the facial contour, whereas its horizontal alignment and microvascular anastomosis makes a bony reconstruction of the hard palate possible., Conclusions: The versatility, low rate of donor site morbidity and shape of the scapular angle flap--which resembles that of the hard palate--render it ideal for plastic reconstruction. The suitability of bone quality for dental rehabilitation with implants is a topic of controversial discussion. The scapular angle flap represents an alternative to obturator prosthesis for the reconstruction of maxillary defects ≥ grade I according to Okay et al.

Background: Surgery after (chemo)radiation (RCTX/RTX) is felt to be plagued with a high incidence of wound healing complications reported to be as high as 70%. The additional use of vascularized flaps may help to decrease this high rate of complications. Therefore, we examined within a retrospective single-institutional study the peri--and postoperative complications in patients who underwent surgery for salvage, palliation or functional rehabilitation after (chemo)radiation with regional and free flaps. As a second study end point the Karnofsky performance status (KPS) was determined preoperatively and 3 months postoperatively to assess the impact of such extensive procedures on the overall performance status of this heavily pretreated patient population., Findings: 21 patients were treated between 2005 and 2010 in a single institution (17 male, 4 female) for salvage (10/21), palliation (4/21), or functional rehabilitation (7/21). Overall 23 flaps were performed of which 8 were free flaps. Major recipient site complications were observed in only 4 pts. (19%) (1 postoperative haemorrhage, 1 partial flap loss, 2 fistulas) and major donor site complications in 1 pt (wound dehiscence). Also 2 minor donor site complications were observed. The overall complication rate was 33%. There was no free flap loss. Assessment of pre- and postoperative KPS revealed improvement in 13 out of 21 patients (62%). A decline of KPS was noted in only one patient., Conclusions: We conclude that within this (chemo)radiated patient population surgical interventions for salvage, palliation or improve function can be safely performed once vascularised grafts are used.

Craniofacial prostheses (or epitheses) are artificial substitutes for facial defects. Today, prostheses made of silicone are state-of-the-art. They may be fixed anatomically (to already existing structures), mechanically (to spectacle frames), chemically (using adhesives), or surgically (to osseointegrated titanium implants). With the existing extraoral implant systems, prostheses may be securely anchored to the bone regardless of size and location of the defect. The classic atraumatic surgical technique has remained an unchanged prerequisite for successful implantation by avoidance of any heat trauma to the bone. This review outlines the indications and contra-indications as well as advantages and disadvantages of craniofacial prostheses and their retention methods in various facial regions. It summarizes the basic principles of extraoral implantology in respect to implant positioning and the management of children and radiated patients.

An auricular prosthesis is an artificial substitute for the auricle; the term epithesis is used synonymously. A myriad of materials have been used in the long history of anaplastology. However, the breakthrough came with the introduction of modern silicones and their colorings. While there are still indications for noninvasive methods of retention, such as medical adhesives, the best and most reliable method of fixation is bone anchorage. Long-lasting osseointegration with reaction-free skin penetration can be achieved with titanium implants. The first system used extraorally was the Brånemark flange fixture. Later, different solitary titanium implants were introduced, such as the ITI system. A different strategy used the titanium grids (Epitec) or plates (Epiplating) derived from osteosynthesis systems. These systems are fixed subperiostally with several bone screws, and are therefore also labeled as grouped implants. With these modern developments, secure retention can also be achieved in unfavorable anatomical situations. Advantages of implant-retained auricular prostheses include: optimal camouflage, predictable cosmetic results, fast rehabilitation, no donor site morbidity and early detection of tumor recurrence. Depending on the clinical setting, prosthetic rehabilitation can be a viable treatment option, and more than just an alternative to plastic reconstructive surgery., (Copyright 2010 S. Karger AG, Basel.)

An ear episthesis is an artificial substitute for the auricle. The term EAR PROSTHESIS is used synonymously. The breakthrough came with the introduction of the modern silicones and their colorings. Although there are still indications for noninvasive methods of retention such as medical adhesives, the best and most reliable method of fixation is by bone anchorage. Long-lasting osseointegration with reaction-free skin penetration can be achieved with titanium implants. The first system used extraorally was the Brånemark flange fixture. Later, different solitary titanium implants were introduced, such as the ITI system. A different strategy used the titanium grids (Epitec) or plates (Epiplating) derived from osteosynthesis systems. These systems are fixed subperiosteally with several bone screws and are therefore also labeled as grouped implants. With these modern developments, secure retention can be achieved also in unfavorable anatomic situations. The grouped systems are resistant to torque with abutment insertion. The latest development is the subcutaneously implanted double magnet without skin penetration. The advantages of implant retained ear epistheses include optimal camouflage, predictable cosmetic results, fast rehabilitation, no donor site morbidity, and early detection of tumor recurrence. Depending on the clinical setting, prosthetic rehabilitation may be more than just an alternative to plastic reconstructive surgery., (Copyright Thieme Medical Publishers.)

Epitheses, also known as craniofacial prostheses, are artificial substitutes for facial defects. The breakthrough for rehabilitation of facial defects with implant retained epitheses came with the development of the modern silicones and bone anchorage. After the discovery of the osseointegration of titanium in the 1960s, dental implants have been made of titanium. In 1977, the first extraoral titanium implant was inserted in a patient. Later, various solitary extraoral implant systems have been developed. Besides, grouped implant systems have been developed, which may be placed more reliably in areas with low bone offering, as in the nasal and orbital region, or the ideally pneumatised mastoid process. Today, even large facial epitheses may be securely retained. The classical atraumatic surgical technique has remained an unchanged prerequisite for successful implantation of any system. This review outlines the basic principles of osseointegration as well as the main features of extraoral implantology.

Detection of Staphylococcus in humans can be of extremely varying importance ranging from commensal to pathogens of fatal infections. MRSAs in particular are iatrogenic and nosocomial infective pathogens, which are a threat to the success of medical treatment. In this review the causes for occurrence and the spread of MRSA are presented and the heterogeneity of MRSA due to the presence of additional resistant pathogens (VISA, VRSA) and pathogenetic forms (cMRSA) will be discussed. The current diagnostic and therapeutic procedures in various situations for MRSA in the nasal and paranasal sinuses and sputum will be discussed exemplified by an actual case. The danger of colonization by MRSA will be discussed with reference to the literature as nasal colonization can be accompanied by a greatly increased risk of an invasive infection and transmission of the pathogen to other persons.

The knowledge of skull bone thickness would be helpful for a great variety of surgical interventions of the head. Ultrasound (US) can offer this information intraoperatively in real time. A-mode US measurements of skull bone thickness were performed with different pulse characteristics: 1) in water and 2) by directly coupling a 2.25-MHz US transducer integrated in a handpiece with a soft delay line using coded excitation (CE) (SonoPointer). Mechanical measurements by calipers served as controls. The specimen were 16 nonselected human cadaveric skull bones preserved with formaldehyde. The average difference between the bone thickness measured by the SonoPointer and the mechanical control measurements was 0.04 +/- 0.62 mm. The 95% limits of agreement between the two methods were -1.18 and 1.25 mm. However, even the gold standard of two repeated caliper measurements had limits of agreement of -0.4 and 0.42 mm. Using a standard US pulse in water, only 62.5% sample points were measurable, whereas the SonoPointer produced the thickness measurement in 97.9% of points. CE proved to be superior to single burst or needle US pulses. A-mode US measurements of skull bone thickness using the SonoPointer are feasible. It may provide valuable information on skull bone thickness, e.g., for osteosynthesis, calvarial split bone harvesting, implantation of hearing devices, osseointegrated titanium fixtures, and skull base surgery.

Bone anchored hearing aids (BAHA) achieve optimal acoustic coupling by means of direct bone conduction via an osseointegrated percutaneous titanium implant. Currently this system has a record of over 30 years of clinical application and reliability. Patients with bilateral hearing loss with air-bone gaps will benefit from bilateral BAHA fitting. Likewise, unilateral conductive hearing loss with normal hearing on the other side can be treated with a BAHA. New developments in this field include the BAHA Intenso and also novel implant systems, such as the Epiplating system by Medicon, the alpha system by Otomag and the OBC system by Otorix. Due to the advantages of the BAHA system (possibility of preoperative testing, simple surgery without the risk of inner ear damage, MRI compatibility, etc.), the BAHA will keep its important role in hearing rehabilitation even in the era of other partially and totally implantable hearing devices.

Craniofacial prostheses, also known as epistheses, are artificial substitutes for facial defects. The breakthrough for rehabilitation of facial defects with implant-retained prostheses came with the development of the modern silicones and bone anchorage. Following the discovery of the osseointegration of titanium in the 1950s, dental implants have been made of titanium in the 1960s. In 1977, the first extraoral titanium implant was inserted in a patient. Later, various solitary extraoral implant systems were developed. Grouped implant systems have also been developed which may be placed more reliably in areas with low bone presentation, as in the nasal and orbital region, or the ideally pneumatised mastoid process. Today, even large facial prostheses may be securely retained. The classical atraumatic surgical technique has remained an unchanged prerequisite for successful implantation of any system. This review outlines the basic principles of osseointegration as well as the main features of extraoral implantology.

Introduction: Sinus surgery is known to improve olfactory function in patients with nasal polyposis. However, little is known about the kinetics of this process., Material and Methods: Fifty-two adult patients with nasal polyposis underwent endonasal sinus surgery. Olfactory testing was performed with the Sniffin' Sticks assessing threshold (T), discrimination (D) and identification (I) giving the TDI score. Testing was performed 2 days prior to surgery (T1), as well as 1 week (T2), 1 month (T3), 3 months (T4), and 6 months (T5) following surgery., Results: The median TDI score was 15.4 (range 8.0-35.5) at T1, indicating that half the patients were anosmic before surgery, while 13.5% were normosmic. At T2, the median TDI score dropped to 8.0 (range 8.0-32.1). Thereafter, it improved to 21.7 (range 8.0-36.9) at T3 (p = 0.04), 22.8 (range 8.0-38.0) at T4 (p < 0.0005), and 27.0 (range 8.0-37.9) at T5 (p < 0.0005), respectively. 43.1% of patients were normosmic at T5, however, 21.6% remained anosmic. Each subtest followed the same pattern. No significant effect on the kinetics of olfactory function could be found for variables such as systemic steroids, partial resection of the middle turbinate, inferior turbinotomy, and allergic rhinitis., Conclusion: Endonasal sinus surgery significantly improved the severely impaired olfactory function in patients with nasal polyposis. Olfactory function dropped shortly after surgery, and subsequently increased steadily up to the endpoint of the study 6 months postoperatively.

A consequence of the ongoing advances in medical navigation is the development of so-called mechatronic assistant systems. Up to now, medical navigation had been used only for additional intrasurgical orientation. But improvements in accuracy in imaging and medical navigation can exceed the surgeon's possible manual accuracy of surgical manipulation. In such cases, mechatronic assistant systems can supplement certain surgical procedures in order to obtain the required precision, such as for positioning of implants. The development and possible use of such mechatronic assistant systems in the head and neck, as well as improvements in the accuracy of medical navigation, are the focus of several working groups. For coordinating and adapting the various research projects, different research groups were called to present their current projects and results in the context of ASKRA (working group for skull-base and craniofacial surgery of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery) workshops at the German Society for Computer- and Robot-Assisted Surgery (CURAC) convention on 14 October 2006 in Hanover. Different projects were presented, with topics including navigated controlled assistant systems for the frontal and lateral skull base, possibilities for sonographic-induced bone measurement, and requirements for high-precision surgery of the skull base.

Surgical procedures with navigation or robot system support usually require pre-operative planning data. This data can be acquired with imaging techniques such as computed tomography (CT), the current gold standard due to its high precision. With such planning data, access trajectories, implant positions, individual milling paths etc. can be computed. We present a novel ultrasound-based method to generate equivalent 3D image data which is well-suited for many interventions, but less costly than the CT-based method. The method is demonstrated for robot-based implant bed milling in the lateral skull base, in a complete process consisting of infrared navigation registration, manual ultrasound scan path delineation, path smoothing and checking, robot-based ultrasound scan execution, 3D ultrasound volume reconstruction, implant position optimization, robot milling path planning, and intervention execution. This represents, to the best of our knowledge, the first time such a CT-free, 3D-ultrasound-based intervention has been demonstrated in the laboratory.

Septal defects only warrant therapy when symptomatic. If surgical closure is not requested, the defect may be closed by a septal button. Prefabricated buttons are not an option for all sizes of defects. Moreover, they may even increase the size of the perforation. The problem can be elegantly solved by a custom made septal button, which minimizes the button's movements within the defect. With the aid of an intranasal cast, a silicone button is individually fabricated. From 1997 through 2004, 57 patients aged 19-85 years were treated by a custom made septal button. At the time of follow-up, 75% of patients still had the button in situ, and they were most satisfied with subjective all over improvement by 83% (+/-20%) on a visual analogue scale. Main symptoms improved significantly (p<0.05). Even though not all patients can be satisfactorily treated, we believe the custom made septal button to be an alternative if there are contraindications to surgery or in case of patient refusal.

Objectives: Polydimethylsiloxane (PDMS) particles are a nonresorbable material that allows for permanent vocal fold augmentation. This study investigated morbidity and voice quality in patients treated for unilateral vocal fold paralysis by injection of PDMS particles., Methods: Fourteen patients who had neurogenic unilateral vocal fold paralysis of different causes were included in this prospective study. Each patient underwent videostroboscopic assessment before and after operation. Friedrich's dysphonia index (DI), a score system combining subjective and objective parameters, was used to describe voice quality. A DI of 0 reflects a normal voice, and a DI of 3 stands for complete aphonia. The PDMS particles were injected into the paraglottic space by microlaryngoscopy under general anesthesia., Results: The median follow-up was 4.1 months. There was no complication attributable to the injection of PDMS particles. The mean DI was 2.8 before operation. After the operation, voice quality improved significantly in each patient, as reflected by a mean postinjection DI of 1.4., Conclusions: Particles of PDMS provide a relatively safe and minimally invasive option for permanent vocal fold augmentation. The functional results in terms of voice improvement are comparable to those obtained with other techniques, including thyroplasty. In the European Community, PDMS particles are officially approved for use in the human larynx.

First, the general principles for an antibiotic therapy are stated. The indications have to be well thought through. Frequent viral ENT infections, as well as numerous bacterial infections, should not be treated with antibiotics. Due to the current antibiotic sensitivity of the main ENT pathogens, the antibiotic choice for an empiric therapy is emphasized, and also the advantage of an optimized therapy based on the results of Gram stain (supercalculated empiric therapy) and an antibiogram (specific therapy). Pus characteristics may be the first step in diagnosing the pathogens. The degree of severity of an infection determines the oral or parenteral route of administration. As a rule, antibiotic therapy has to be checked after 2-3 days. The grouping of the different ENT infections with a similar spectrum of pathogens gives a better view of the therapeutic principles and reduces repetitions. The current recommendations for antibiotic treatment of numerous ENT infections with different degrees of severity are indicated. After the presentation of the appropriate antibiotics with their current spectrum of efficacy, the initial therapy, treatment in case of penicillin allergy, and of severe cases and complications or therapeutic failure are mentioned.

Due to shortcomings of conventional hearing aid technology, such as unsatisfactory sound quality due to limited frequency range and undesired distortion, occlusion of the outer ear canal, and acoustic feedback with high amplification, but also psychological aspects of stigmatization, a significant of patients in need of hearing aids are actually not wearing them. Active hearing implants can be distinguished in: (1) impedance transformation implants (ITI), (2) cochlear amplifier implants (CAI), (3) cochlear implants (CI), and (4) brain stem implants (BSI). Whereas ITI are designed for patients with middle ear hearing loss, CAI are intended to restore hearing in patients with inner ear hearing loss. Advantages of CAI may be: (1) improved sound fidelity, (2) no occlusion of the outer ear canal, (3) no feedback, and (4) invisibility. However, not all features are true for every device. CI replace inner ear function in deaf or almost deaf patients. This article gives an overview on the range of active hearing implants to restore hearing and outlines the future use of computer and robot aided surgery.

Otoneurosurgery may greatly benefit from enhanced precision through robotics or from new procedures only made possible with robotic aid. Different implant cavities were milled by a serial robot (Stäubli RX 130) in formaldehyde fixed human skull bones. A variety of sensor data (force, momentum, temperature,...) were measured and evaluated. Ultrasound probes of different frequencies were used to measure skull bone thickness. With a serial robot Stäubli RX 130 it was possible to mill an exact implant cavity for various CI main modules in a human skull specimen. While milling with speed controlled by force feedback, the heat production was tremendously reduced as compared to the non controlled mode. Using coded excitation and a matched-filter technique, a 3D ultrasound scan of the skull bone could be performed in order to plan the drilling task for the robot by means of local navigation. This is the first functional robotic milling procedure for otoneurosurgery with force-based speed control in an experimental setting. Force feedback smoothes the robot's movements and reduces heat damage to surrounding tissues. Ultrasound navigation may replace the need for CT scanning in the future.

Objective: In some surgical specialties (eg, orthopedics), robots are already used in the operating room for bony milling work. Otological surgery and otoneurosurgery may also greatly benefit from the enhanced precision of robotics., Study Design: Experimental study on robotic milling of oak wood and human temporal bone specimen., Methods: A standard industrial robot with a six-degrees-of-freedom serial kinematics was used, with force feedback to proportionally control the robot speed. Different milling modes and characteristic path parameters were evaluated to generate milling paths based on computer-aided design (CAD) geometry data of a cochlear implant and an implantable hearing system., Results: The best-suited strategy proved to be the spiral horizontal milling mode with the burr held perpendicular to the temporal bone surface. To reduce groove height, the distance between paths should equal half the radius of the cutting burr head. Because of the vibration of the robot's own motors, a high oscillation of the SD of forces was encountered. This oscillation dropped drastically to nearly 0 Newton (N) when the burr head made contact with the dura mater, because of its damping characteristics. The cutting burr could be kept in contact with the dura mater for an extended period without damaging it, because of the burr's blunt head form. The robot moved the burr smoothly according to the encountered resistances., Conclusion: The study reports the first development of a functional robotic milling procedure for otoneurosurgery with force-based speed control. Future plans include implementation of ultrasound-based local navigation and performance of robotic mastoidectomy.

Objective: In the field of otorhinolaryngology, a variety of skull implants have been developed to assist hearing-impaired or even deaf patients. The first step in the implantation procedure, and also in lateral skull-base surgery, is to drill the calvarian or mastoid bone. We intended to investigate the hitherto unknown parameters for performing this procedure and to establish the first set-up for robotic milling of the lateral skull base., Materials and Methods: Experimental milling of the skull base was conducted on two human specimens using a hexapod robot., Results: Optimized parameters were determined with a drill speed of 30,000 revolutions/min and a form feed rate of 5 mm/s for the calvarium and 1 mm/s for mastoid bone, respectively, in a spiral-path fashion. While using a cutting burr, mean force levels were 4.81 N for calvarian bone and 6.12 N for mastoid bone, respectively--well below our empirical limit of 10 N. However, maximum levels easily surpassed these limits, reaching 27.7 N., Conclusion: The prerequisites for robotic skull-base surgery were fulfilled. With further work to implement feedback of sensory input, robots may increase precision for various tasks in skull-base surgery.

Background: The rapid development of information and communication technologies has led to a change of many practical aspects of professional and private life. These technologies also influence interactions between hospitals and outpatient units., Methods: This paper provides an overview over current telemedical developments with effects on interactions between in- and outpatient units., Results and Conclusions: Probably the most important application of telemedicine in Germany is not distant patient care but an improved communication structure between different health care providers. Candidates for first routine applications are electronic medical reports and teleconsultations. The widespread use of telemedicine will be accompanied by an increased standardisation in medicine.

The transmissible spongiform encephalopathies (TSE), or prion diseases, constitute a form of degenerative disorders of the central nervous system, which are characterized by a typical spongiform histological pattern and a fatal course. According to Prusiner's theory, its agent consists of a protein without any nucleic acid, the "proteinaceous infectious agent", or prion. This is a pathologically folded form of the normal prion protein (PrPC), and then called PrPSc. TSE are observed in different mammals including humans. In humans, they include Creutzfeldt-Jakob disease (CJD), Gerstmann-Sträussler-Scheinker syndrome (GSS), fatal familial insomnia (FFI), Kuru and the new variant of the Creutzfeldt-Jakob disease (vCJD). The longest known TSE is scrapie in sheep. Since 1984 the bovine spongiform encephalopathy (BSE) and since 1996 the variant Creutzfeldt-Jakob disease have been documented. This paper gives an overview on the pathogenesis, epidemiology and the clinical features of the different prion diseases.

Prion diseases are histologically characterized by a spongiform encephalopathy. The early symptoms of Creutzfeldt-Jakob disease (CJD) and variant Creutzfeldt-Jakob disease (vCJD) are unspecific. To date, the definite diagnosis can only be made by histological examination of central nervous tissue, i.e. brain biopsy or post mortem. Therefore, diagnostic tests are being elaborated that suffice with cerebrospinal fluid or blood. Unlike the sporadic form of Creutzfeldt-Jakob disease, that involves the central nervous system exclusively, in the variant of the Creutzfeldt-Jakob disease the lymphoreticular system including the tonsils is involved, too. Hence, a tonsillar biopsy can be performed instead of a brain biopsy. In particular, the diagnostic criteria of both CJD and vCJD are described.

Excellent precision, miss of retiring, reproducibility are main characteristics of robots in the operating theatre. Because of these facts their use for surgery in the lateral scull base is of great interest. In recent experiments we determined process parameters for robot assisted reaming of a cochlea implant bed and for a mastoidectomy. These results suggested that optimizing parameters for thrilling with the robot is needed. Therefore we implemented a suitable reaming curve from the geometrical data of the implant and a force controlled process control for robot assisted reaming at the lateral scull base. Experiments were performed with an industrial robot on animal and human scull base specimen. Because of online force detection and feedback of sensory data the reaming with the robot was controlled. With increasing force values above a defined limit feed rates were automatically regulated. Furthermore we were able to detect contact of the thrill to dura mater by analyzing the force values. With the new computer program the desired implant bed was exactly prepared. Our examinations showed a successful reaming of an implant bed in the lateral scull base with a robot. Because of a force controlled reaming process locale navigation is possible and enables careful thrilling with a robot.

Background and Objective: Acinic cell carcinoma of the parotid gland is a rare malignant tumor, which is generally regarded as low grade. However, rapidly fatal courses do occur., Patients and Methods: Eighteen patients with acinic cell carcinoma were studied retrospectively who had undergone treatment between 1968 and 1997 at the University Ear, Nose, and Throat (ENT) Hospital in Homburg (Saar), Germany and between 1994 and 1997 at the Marienhospital ENT Hospital in Stuttgart, Germany., Results: The distribution of the T category (UICC 1997) was as follows: T1 n = 8, T2 n = 7, T3 n = 1, and T4 n = 2). Treatment was exclusively surgical in 14 cases and a combination of surgery and postoperative radiotherapy in 4 cases. The recurrence rate according to Kaplan-Meier was 6% after 3 years and 19% after 5, 10, and 15 years. The survival rate was 87% after 3 years and 73% after 5, 10, and 15 years. None of the 12 patients with low-grade tumors according to Batsakis et al. (1979) died from the tumor, whereas survival at 5 years was only 33% for 6 high-grade tumors (p = 0.02)., Conclusions: We recommend complete surgical removal of the tumor, in general by total parotidectomy. Postoperative radiotherapy may be useful in advanced high-grade tumors.

Robots have entered into many aspects of human life, including operative medicine. However, current medical robots have nothing in common with anthropomorphic robots as known in science fiction novels. We distinguish manipulators, working on a master-slave principle, from robots. Robots can be defined as "automatically controlled multitask manipulators, which are freely programmable in three or more axes." The success of robots is based on their precision, lack of fatigue, and speed of action. Potential fields of application for manipulators lie in endonasal surgery and for robots in lateral skull base surgery, including mastoidectomy and drilling a cavity for implantable hearing systems and cochlear implants. We performed a number of experiments at the department of anatomy with respect to robotic lateral skull base surgery. This paper reviews the current use of manipulators and robots in operative medicine and their potential applications in otorhinolaryngology.

Background and Objective: Squamous cell carcinoma of the pinna seems to be associated with a worse prognosis as compared to other locations., Patients/methods: We studied 88 patients treated between 1975 and 1990 for a squamous cell carcinoma of the pinna., Results: Lymph node metastases were present in eight cases (9%) prior to treatment. Treatment was intended to be curative in 83 patients (94%). Tumor therapy was operative in all cases. Radiotherapy was instituted postoperatively in three patients; five patients (5.7%) died due to the tumor. Of 83 curatively treated patients, only 2 died of tumor progression. The survival rate was 98% after 2 years and 95% after 5 years. The recurrence rate was 7% after 1 year, 13% after 2 years, and 18% after 5 years. The outcome with regard to local tumor control and survival was significantly poorer when neck metastases were present., Conclusions: We recommend tumor excision with wide margins (5-10 mm) as first-line treatment. Neck dissection with parotidectomy is indicated when suspicious lymph nodes are detected by ultrasound sonography, the tumor diameter is > 4 cm, cartilaginous invasion is present, and vertical tumor thickness is > 5 mm.

Hyperimmunoglobulin E syndrome (Hiob syndrome or Buckley syndrome) is a rare disorder of the immune system that can show characteristic manifestations in the head and neck. Typical symptoms are fever, recurrent urticarial rashes, lymphadenitis, and bacterial infections of the skin and various parenchymatous organs. Diagnosis is established by elevated serum IgE concentrations with the absence of any signs of allergy or parasitic disease. We present our clinical experiences in managing of a 29-year old woman whose hyper IgE syndrome was diagnosed initially during of the treatment of lymphatic hyperplasia of the base of the tongue although she had typical symptoms of hyper IgE syndrome for some years. High-dose intravenous immunoglobulin therapy (IVIG) was found to be well-tolerated and effective. More than one year after a single course of immunoglobin therapy symptoms markedly improved. Current knowledge and therapeutic options in hyper IgE syndrome are discussed. We recommend that IVIG be considered as one of the first choices in the treatment of hyper IgE syndrome.

Hiccup is defined as involuntary contractions of the diaphragm and the auxiliary respiratory muscles, mostly in irregular series, followed by glottic closure, thereby producing a typical "hiccupping" inspiration. This is a physiologic phenomenon, which already exists in utero. Hiccup is believed to be a gastrointestinal reflex; however, function and the reflex arch are hypothetical. Acute hiccup is distinguished from pathological, chronic hiccup, defined by a duration executing 48 h, or recurrent episodes. Among approximately 100 causes for hiccup, the most common are located in the gastrointestinal tract, with gastro-esophageal reflux as the most important. While the respiratory effect is generally negligible, alkalosis may ensue in tracheotomized patients due to hyperventilation. A stepwise management plan for patients with hiccup is presented. If simple physical maneuvers and causal therapy fail, or causal therapy is impossible, the treatment of choice is medical, with baclofen. Interruption of the reflex arch may be causal therapy or be considered as a last resort.

Even today, a wide variety of techniques are performed in parotid pleomorphic adenoma surgery, ranging from enucleation to total parotidectomy. This study reports the results of our experiences. Among a total of 587 surgically treated parotid lesions at the Homburg/Saar University ENT Department from 1968 through 1991, 205 were parotid pleomorphic adenomas. Among these, 166 patients received primary surgery at our department. Twenty-one enucleations led to 3 recurrent tumors (14%), while 108 superficial parotidectomies had 3 recurrences (2.8%). Fifteen extended superficial parotidectomies also produced 3 recurrences (20%) and 22 total parotidectomies had one recurrent case (4.5%). The overall recurrence rate was 6%, but increased to 8.3% in 5 years, 9.5% in 10 years and 12.5% in 15 years follow-up. The "true" overall recurrence rate after 10 years was estimated to be between 9.5 and 20% and that for lateral parotidectomies between 4.4 and 13%. Patients younger than 30 years of age at the time of primary surgery developed a tumor recurrence in 17% of all cases. The overall recurrence rate following secondary surgery was 13%. Clinical findings and surgical techniques for resections of pleomorphic adenomas and their recurrences are discussed. Segmental parotidectomy is the preferred treatment, but may have to be changed locally to enucleation in some cases in order to preserve the facial nerve.