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Background and Aims: We aimed to investigate the clinical characteristics of patients presenting with sarcoidosis of the head and neck as the initial manifestation and to provide recommendations fo...

Sarcoidosis is a granulomatous multisystem disease of unknown etiology and relatively rare. The heterogeneous clinical picture is a diagnostic challenge. We are investigating whether the superficially visible cutaneous lesions can lead to the differential diagnosis of sarcoidosis and what systemic manifestations are present.As part of our exploratory retrospective investigation (eight years) a total of 32 patients with cutaneous sarcoidosis were identified and analyzed.In many cases the dermatologists considered the differential diagnosis of sarcoidosis even before biopsy (71.8%); in our previous study with ENT-patients the diagnosis wasn't considered in a single case by the attending doctors at this time and without any prevoius suspicion. Sarcoidosis of the skin in the head and neck area is the second most common cutaneous manifestation. After biopsy (Gold standard) the search for further possible organ manifestations is essential (e.g. lungs, heart) to treat them in an early stage and to prevent complications of a possible chronic course (including cardiac arrhythmias, pulmonary fibrosis).Die Sarkoidose ist eine granulomatöse Multisystemerkrankung unklarer Ätiologie und stellt durch ihre relative Seltenheit sowie ihr heterogenes Krankheitsbild eine klinisch diagnostische Herausforderung dar. Wir gehen der Frage nach, ob bei oberflächlich sichtbaren Läsionen der Haut die Differenzialdiagnose einer Sarkoidose in Betracht gezogen wird und welche systemischen Manifestationen vorliegen.Im Rahmen unserer explorativen retrospektiven Untersuchung wurden in einem Zeitraum von 8 Jahren insgesamt 32 Patienten mit einer Sarkoidose der Haut identifiziert und die Daten analysiert.Wir konnten in unserer Erhebung zeigen, dass die Differenzialdiagnose einer Sarkoidose durch die dermatologischen Kollegen in vielen Fällen schon vor der Biopsie in Erwägung gezogen wurde (71,8 %); dies war in einer vorangegangenen Studie an Patienten in der HNO-Heilkunde nicht der Fall. Bei insgesamt 90,6 % der Patienten wurde dann sogar die Erstdiagnose durch die anschließende Hautbiopsie gestellt. Die Sarkoidose der Haut im Kopf-Hals-Bereich kann durchaus auch dem HNO-Arzt begegnen; in unserer Erhebung handelt es sich sogar um die zweithäufigste kutane Manifestation. Nach erfolgter Biopsie (Goldstandard) ist die Suche nach weiteren möglichen Organmanifestationen besonders wichtig (bspw. Lunge, Herz), um die Komplikationen eines möglichen chronischen Krankheitsverlaufs (u. a. Herzrhythmusstörungen, Lungenfibrose) frühzeitig zu erkennen und zu behandeln.

Sarcoidosis is a chronic disease, which predominantly affects the lung. Since sinonasal sarcoidosis is rare, little is known about the sarcoidosis manifestation at this site. Therefore, the aim of our study was to detect the prevalence of sinonasal sarcoidosis, its clinical occurrence, diagnosis, and therapy. The database of all patients having visited the otorhinolaryngology departments of the universities in Gottingen and in Bonn between 2003 and 2016 was searched for the diagnosis of sinonasal sarcoidosis. Thirteen patients with a biopsy-proven sinonasal sarcoidosis were identified. Most patients presented non-specific clinical symptoms, which are also found in acute and chronic sinusitis. None of the patients was suspected to have sinonasal sarcoidosis by the ENT doctor before histological validation. The mean diagnostic delay was 262 (± 195) days. An additional pulmonary involvement was detected in four of six patients. Sinonasal sarcoidosis is presenting with heterogeneous clinical presentations. An early biopsy of granulomatous lesions is mandatory. A multidisciplinary approach is needed to exclude serious lung or heart manifestations, because even asymptomatic organ involvement is possible. A CT-scan may be useful even if unspecific. Local or systemic therapy has to be prepared individually using local and systemic corticosteroids, antimetabolites, or anti-TNF-alpha.

Objective: Sarcoidosis is a multisystemic granulomatous disease of unknown cause which affects the lung or bilateral hilar lymphadenopathy in over 90% of the cases. Neurosarcoidosis (NS) is rare an...

Amyloidosis in the upper aerodigestive tract is a very rare disease with mainly case reports documented so far. In the pathogenesis, amyloid protein fibers are deposited in organs and tissue. In the upper aerodigestive tract, mostly localized amyloidosis occurs with unspecific symptoms, e.g., dysphagia. We conducted a retrospective multicenter study with two study centers in Germany (tertiary referral hospitals), the University Hospital of Bonn and the University Hospital of Goettingen. For a period of the last 7 years, data were analyzed and patients were recruited consecutively. 14 cases were included to the study. The most common manifestation was in the larynx (n = 11); in one case each localized amyloidosis was found in the tongue, trachea and in the pharynx. Since the majority of our cases (n = 13; 92.6%) presented with unspecific symptoms, biopsy results confirmed the diagnosis of localized amyloidosis. Resection of the lesion was only performed in patients reporting of symptoms, in asymptomatic patients only a non-invasive biopsy was done. In two patients (14.2%), in addition to the focal lesion a systemic amyloidosis was found. Amyloidosis in the upper aerodigestive tract is a rare disease. Nonetheless, every otorhinolaryngologist should be aware of this disease. When detected it is a straight forward to treat illness. The appearance of a systemic amyloidosis needs to be ruled out; thus, there is a chance to develop a multiple myeloma. Given the slow progressive character of amyloidosis, a long-term follow-up up to 10 years is inevitable.

Epistaxis is one of the more common reasons for emergency room visits. The main risk factor for epistaxis is anticoagulant therapy. Until recently, the main culprit was oral intake of a vitamin K antagonist, such as warfarin, which has a number of side effects. Even more recently, several direct oral anticoagulants, rivaroxaban and dabigatran, have been approved for use. We investigated the possible differences between treatment of epistaxis with direct oral anticoagulants and vitamin K antagonists.We conducted a retrospective cohort study at a tertiary referral center in Germany. All patients who were admitted within a 1-year period were included. Patient files were used to obtain the information.Overall, 677 patients were included in our study. Of these, 159 had been treated with vitamin K antagonists and 49 with direct oral anticoagulants. There were no significant differences in terms of age (p = 0.592), sex (p = 0.372), vital signs, bloodwork, or location of bleeding (p = 0.372). Management of epistaxis between the groups was also comparable (p = 0.399), with similar hospital admission rates (37.1% vs 24.5%; p = 0.145) and duration of stay (3.5 ± 2.1 days vs 3.8 ± 3.3 days; p = 0.650).We found no evidence to suggest epistaxis is more severe or requires more invasive therapy in patients given direct oral anticoagulants. A significant proportion of patients on vitamin K antagonists were not within the target range for international normalized ratio, highlighting one of the main issues with oral anticoagulation by vitamin K antagonists.

Damage of peripheral nerves results in paralysis of skeletal muscle. Currently, the only treatment option to restore proper function is electrical stimulation of the innervating nerve or of the skeletal muscles directly. However this approach has low spatial and temporal precision leading to co-activation of antagonistic muscles and lacks cell-type selectivity resulting in pain or discomfort by stimulation of sensible nerves. In contrast to electrical stimulation, optogenetic methods enable spatially confined and cell-type selective stimulation of cells expressing the light sensitive channel Channelrhodopsin-2 with precise temporal control over the membrane potential. Herein we summarize the current knowledge about the use of this technology to control skeletal muscle function with the focus on the direct, non-neuronal stimulation of muscle fibers. The high temporal flexibility of using light pulses allows new stimulation patterns to investigate skeletal muscle physiology. Furthermore, the high spatial precision of focused illumination was shown to be beneficial for selective stimulation of distinct nearby muscle groups. Finally, the cell-type specific expression of the light-sensitive effector proteins in muscle fibers will allow pain-free stimulation and open new options for clinical treatments. Therefore, we believe that direct optogenetic stimulation of skeletal muscles is a very potent method for basic scientists that also harbors several distinct advantages over electrical stimulation to be considered for clinical use in the future.

Having one hand occupied with the endoscope is the major disadvantage for the surgeon when it comes to functional endoscopic sinus surgery (FESS). Only the other hand is free to use the surgical instruments. Tiredness or frequent instrument changes can thus lead to shaky endoscopic images.We collected the pose data (position and orientation) of the rigid 0° endoscope and all the instruments used in 16 FESS procedures with manual endoscope guidance as well as robot-assisted endoscope guidance. In combination with the DICOM CT data, we tracked the endoscope poses and workspaces using self-developed tracking markers.All surgeries were performed once with the robot and once with the surgeon holding the endoscope. Looking at the durations required, we observed a decrease in the operating time because one surgeon doing all the procedures and so a learning curve occurred what we expected. The visual inspection of the specimens showed no damages to any of the structures outside the paranasal sinuses.Robot-assisted endoscope guidance in sinus surgery is possible. Further CT data, however, are desirable for the surgical analysis of a tracker-based navigation within the anatomic borders. Our marker-based tracking of the endoscope as well as the instruments makes an automated endoscope guidance feasible. On the subjective side, we see that RASS brings a relief for the surgeon.

Hintergrund Die Notwendigkeit der routinemasigen histologischen Untersuchung von operativ gewonnenem Tonsillengewebe zum Ausschluss eines okkulten Malignoms wird kontrovers diskutiert.

Tonsillectomy is a frequently performed surgical procedure in children and adults. Postoperative bleeding is the most severe complication; however, the factors leading to postoperative haemorrhage are still discussed controversially. 1,522 tonsillectomies were retrospectively reviewed. Histopathological tonsil composition was correlated with the incidence of postoperative haemorrhage. Patient charts were analysed with regard to demographic data, characteristics of postoperative haemorrhage and indication for surgery. Patients with post-tonsillectomy haemorrhage were compared with uneventful cases. Histopathological signs of cryptic tonsillitis and actinomyces infection displayed a statistically significant correlation with the risk of postoperative haemorrhage (P = 0.018 and P = 0.02), but the odds ratio was low (1.9 and 2.0). 7.7% of all patients had postoperative bleeding and 3.5% had to return to theatre for haemostasis. The incidence of haemorrhages within hospitalization (5 postoperative days) was 45% and after discharge 55%, respectively. In 11% of cases bleeding occurred on the fourth or fifth day after surgery. While gender, season of surgery, abscess tonsillectomy “en chaud” in comparison with elective tonsillectomy were not associated with an increased rate of postoperative haemorrhage (P > 0.05), significant more postoperative haemorrhages were detected in the group of adults (P = 0.02). Despite significant correlation of cryptic tonsillitis and actinomyces infection with postoperative haemorrhage, the risk for postoperative bleeding is only slightly elevated and, therefore, the predictive value is low. Because a multifactorial aetiology of post-tonsillectomy haemorrhage has to be assumed, large multicenter studies are necessary to evaluate the significance of different risk factors.

Optogenetic stimulation allows activation of cells with high spatial and temporal precision. Here we show direct optogenetic stimulation of skeletal muscle from transgenic mice expressing the light-sensitive channel Channelrhodopsin-2 (ChR2). Largest tetanic contractions are observed with 5-ms light pulses at 30 Hz, resulting in 84% of the maximal force induced by electrical stimulation. We demonstrate the utility of this approach by selectively stimulating with a light guide individual intralaryngeal muscles in explanted larynges from ChR2-transgenic mice, which enables selective opening and closing of the vocal cords. Furthermore, systemic injection of adeno-associated virus into wild-type mice provides sufficient ChR2 expression for optogenetic opening of the vocal cords. Thus, direct optogenetic stimulation of skeletal muscle generates large force and provides the distinct advantage of localized and cell-type-specific activation. This technology could be useful for therapeutic purposes, such as restoring the mobility of the vocal cords in patients suffering from laryngeal paralysis., Nerve damage can lead to skeletal muscle paralysis. The authors show that localized photostimulation of skeletal muscle expressing the light-sensitive channel Channelrhodopsin-2 generates contraction in the absence of neural impulses and prove that this strategy can be used for optogenetic opening of explanted murine vocal cords.

Numerous neurological diseases lead to paralysis of intact skeletal muscles. Electrical stimulation of these to restore contraction is problematic due to side effects, the lack of cellspecificity and simultaneous activation of antagonist muscles.Optogenetic stimulation of skeletal muscles expressing the light-sensitive cation channel Channelrhodopsin2 (ChR2) could overcome these limitations. Therefore we have generated a transgenic mouse line with expression of ChR2 fused to EYFP in skeletal muscles under the control of the chicken-β-actin promotor. Soleus muscles showed membrane bound EYFP fluorescence and light induced force was analyzed by isometric force measurements upon illumination (470nm) with different durations, intensities and repetition rates. Using single light pulses, the highest force generation (52.7±3.4mN, sd, n=4) was reached by 100ms long pulses with a light intensity of 0.51mW/mm2. For tetanus stimulation we found that 5ms pulses at 30Hz and 1.4mW/mm2 were most efficient and led to the force of 69.1±7.7mN (sd,n=4). This was ∼70% of the force generated by electrical tetanus stimulation.Bilateral laryngeal paralysis is a severe disease resulting in immobility of the vocal cords and life-threatening dyspnea. In this disease electrical stimulation is problematic due to electrode corrosion, recognition of the stimuli and non-selective stimulation of agonist and antagonist muscles (Zealer DL et al., Laryngoscope 2003,113:1149-1156). We therefore tested the feasibility of selective optogenetic stimulation of the posterior cricoarytenoid muscle, which is the only intralaryngeal muscle opening the vocal cords. Larynges were isolated from ChR2-transgenic mice and locally stimulated with a light guide (O400μm,NA=0,48) in the postarytenoid region. Application of light pulses (470nm,50ms,35.7mW/mm2) led to a repetitive opening of the vocal cords. The distance between vocal cords during illumination was 230±38% of baseline (sd,n=3).Thus optogenetic muscle stimulation is a promising method for therapy of nerve lesions and might be useful to treat bilaryngeal paralysis.