Potential approaches to the treatment of allergic rhinitis are the avoidance of allergens and medication with chromone compounds, antihistaminics and glucocorticosteroids. The sole causally effective treatment is specific immunotherapy. Leukotriene receptor antagonists, anti-IgE antibodies and monoclonal CD-4-molecules, as also soluble cytokine receptors are potential therapeutic options, the value of which currently remains unknown.

The allergic rhinitis is the most common allergic condition. The causes of allergic rhinitis are still much debated, but there is now a consensus on the need to initiate treatment as early as possible in order to avoid the spreading of the infection to the bronchi. In addition to allergy prevention, the aim of treatment is medical control of the allergic inflammatory reaction and thus improvement of the clinical symptoms. Depending on the severity of the disease and the predominant symptoms, this can be achieved with mast cell stabilizers, local and systemic H1 antagonists, local steroids and anticholinergic drugs. The WHO also recommends hyposensitization, which may be subcutaneous (SIT) or sublingual (SLIT).

Two types of allergic rhinitis are differentiated: seasonal rhinitis caused in particular by pollen allergens, and the perennial form caused by such year-round allergens as house dust (mites), moulds and animal hair. The diagnosis is based on a comprehensive history (family/occupation/environment), clinical symptoms, a rhinoscopic examination, and testing for allergens, e.g. conjunctival tests, prick test or nasal provocative test. The treatment of choice is elimination of the allergens as completely as possible. An additional causal therapeutic option is specific immune therapy (SIT) which, however, is contraindicated in the presence of intercurrent infections, use of beta blockers and immunodeficiency. Available medications include mast cell stabilizers, antihistaminic agents and corticosteroids, which are applied in stepped fashion, depending upon severity. In addition, adjuvant surgical measures may improve obstructive symptoms.

Pneumosinus dilatans is a rare disorder of the frontal sinus most commonly found in 20- to 40-year-old males. The deformity is caused by an abnormal enlargement of the frontal sinus by hyperpneumatization. A valve mechanism raising the pressure inside the sinus is regarded to be responsible for this condition. The diagnostic and surgical approach is presented in a 25-year-old male. A preoperative computed tomography (CT) scan in three planes illustrates the anatomical conditions and possible etiologic mechanisms. The surgical procedure is supposed to correct the esthetic deformity and the cause of the disorder. A bicoronal incision allows the best exposition of the frontal sinus. The osteoplastic correction is stabilized by titanium micro-osteosynthesis plates, which do not have to be removed. Functional endoscopic sinus surgery should be performed concomitantly in order to remove the cause of pneumosinus dilatans.

Fluorescence diagnosis aims to improve the management of oral cancer via early detection of the malignant lesions and better delimitation of the tumor margins. This paper presents a comparative study of normal inspection, combined fluorescence diagnosis (CFD) and its 2 main components, autofluorescence and 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PPIX) fluorescence. Biopsy-controlled fluorescence imaging and spectral analysis were performed on a total of 85 patients with suspected or histologically proven oral carcinoma both before and after topical administration of 5-ALA (200 mg 5-ALA dissolved in 50 ml of H(2)0). Fluorescence excitation was accomplished using filtered light of a xenon short arc lamp (lambda = 375-440 nm). As for CFD, a "streetlight" contrast (red to green) was readily found between malignant and healthy tissue on the acquired images. In terms of tumor localization and delimitation properties, CFD was clearly favorable over either normal inspection or its 2 components in fluorescence imaging. The performance of CFD was found to be impeded by tumor keratinization but to be independent of either tumor staging, grading or localization. In spectral analysis, cancerous tissue showed significantly higher PPIX fluorescence intensities and lower autofluorescence intensities than normal mucosa. There is a great potential for CFD in early detection of oral neoplasms and exact delimitation of the tumors' superficial margins and an advantage over white light inspection and each of its 2 main components. The method is noninvasive, safe and easily reproducible.

Background: Since the early 80's, chronic nasal obstruction due to hyperplastic turbinates is treated by laser light. Comparative clinical studies were performed to assess the clinical outcome of laser assisted endonasal turbinate surgery in longterm.Methods: By means of a pulsed Ho:YAG laser emitting light at lambda=2100 nm (0.8-1.2 J/pulse, 4-8 Hz), 69 patients suffering from nasal obstruction due to allergic rhinitis (46%) and vasomotor rhinitis (54%) were treated under local anesthesia. Furthermore, 50 patients (52% with allergic rhinitis and 48% with vasomotor rhinitis) were treated by means of a GaAlAs-diode laser (c.w. lambda=940 nm, 8-10W). The treatment time took 3-10 min/ turbinate and nasal packing was not necessary after the laser procedure. The study was conducted by a standardized questionnaire, photo documentation, allergy test, mucociliar function test, rhinomanometry, and acoustic rhinometry.Results: Within 4 weeks after laser treatment, an improvement of nasal airflow correlating to the extent of the ablated turbinate tissue could be determined in more than 80% of the patients. Rhinomanometry revealed a significant improvement of the nasal airflow 6 months and 1 year after the laser treatment compared to the preoperative data. Side effects like nasal dryness and pain were rare (<5%). Diode laser treatment revealed more effective results than Ho:YAG laser treatment, however there was no significant difference between the two investigated groups. Patients suffering from vasomotor rhinitis showed far better results in long term in comparison to allergic rhinitis patients.Conclusions: Ho:YAG and diode laser treatment can be performed as an outpatient procedure under local anesthesia in a short treatment time with promising results. It could become a time and cost effective treatment modality in endonasal laser surgery.

Einleitung: Die Computertomographie (CT) der Nasennebenhöhlen (NNH) gilt als Standarddiagnostik vor Operationen der NNH. Die zur Beurteilung der Rhinobasis oder des Infundibulumbereiches notwendige koronare Schichtführung ist aber bei polytraumatisierten oder älteren Patienten oftmals nicht möglich. Eine Lösung könnte die koronare Sekundärrekonstruktion primär axial akquirierter Bilder darstellen, die jedoch mittels der bisher gebräuchlichen Computertomographen eine nur unbefriedigende Auflösung erzielte. Studienziel war die Beurteilung der Qualität koronarer Sekundärrekonstruktionen aus primär axial akquirierten Datensätzen, die mit der neuesten Gerätegeneration, der so genannten Multidetektor-Computertomographie (MDCT), gewonnen und der Auflösung der konventionellen Spiral-Computertomographie vergleichend gegenübergestellt wurden. Material und Methoden: Koronare Sekundärrekonstruktionen primär axial akquirierter Aufnahmen der MDCT (n = 10) wurden mit primär koronaren Aufnahmen der konventionellen Spiral-CT (n = 10) verglichen. Beurteilt wurde die Qualität der Auflösung anhand anatomischer Landmarken. Resultate: Die koronare Rekonstruktion axial akquirierter Bilder mittels MDCT zeigte gegenüber der konventionellen Spiral-CT eine gleichwertige Auflösung, Stufenartefakte wurden auf ein Minimum reduziert. Darüber hinaus ermöglichte die MDCT eine Abbildung anatomischer Strukturen ohne Beeinträchtigung durch Aufhärtungsartefakte aufgrund von Zahnfüllungen, was letztendlich zu einer besseren Beurteilbarkeit führte. Diskussion: Die vorliegende Studie belegt die ausgezeichnete Auflösung der MDCT bei Sekundärrekonstruktionen im Rahmen der computertomographischen Diagnostik der Nasennebenhöhlen, die eine Abbildung der Anatomie ohne Qualitätsverlust im Vergleich zur axialen Schichtführung ermöglicht. Im Vergleich zur primär koronaren Schichtführung mittels konventioneller Spiral-CT sind darüber hinaus keine Artefakte durch Zahnprothetik zu verzeichnen.

Rhinogenous complications may manifest in the region of the orbits, bone or soft parts of the wall of the frontal sinus, or endocranially. With regard to orbital complications, a differentiation is made between edema, periostitis, subperiosteal abscess and phlegmon--depending on severity and extent. A possible sequela of frontal sinusitis may be osteomyelitis. If the frontal bone is involved, there is a danger that the infection may spread to the endocranium via medullary spaces and blood vessels. The diagnostic basis for deciding appropriate treatment is CT or MRI. While orbital edema and periostitis usually respond to conservative treatment, subperiosteal abscess, orbital phlegmon and abscess of the brain require immediate operative treatment under antibiotic cover. The treatment of choice for osteomyelitis of the frontal bone is the liberal removal of affected bone, also under antibiotic cover.

INTRODUCTION:Before sinus surgery, computed tomography (CT) of the paranasal sinuses and anterior skull base is a standard procedure in the diagnostic evaluation. However, coronal sections necessary for the analysis of the complex anatomy of this region are often not applicable in multiple injured or elderly patients due to the impossibility to maintain the required position for the coronal scans. Secondary coronal reconstruction of primary axially acquired scans could help to overcome this problem. This technique was, however, hampered so far by an insufficient resolution in case of conventional CT. We therefore compared the quality of primary coronally acquired conventional CT images with the resolution of multiplanar reformatted coronal images of primary axially acquired scans by means of a new CT generation, the Multidetector Computed Tomography (MDCT). MATERIAL AND METHODS:10 patients were each examined with conventional CT or MDCT respectively. The quality of primary coronally acquired conventional scans (CT) versus secondary coronal reconstructions (MDCT) was compared by evaluating typical anatomic landmarks. RESULTS:As compared to conventional CT, the coronal reconstruction of primary axially acquired scans by means of MDCT revealed an equal resolution and additionally no essential impairment by amalgam artefacts. CONCLUSION:Our results demonstrate the excellent quality of secondary coronal reconstructions by means of MDCT in the CT evaluation of the paranasal sinuses and the anterior skull base as compared to primary coronally acquired images via conventional CT.

Over the past years, the incidence of acute and chronic forms of rhinosinusitis has been increasing, and between 10 and 15% of the population of Central Europe are affected annually. Accordingly, the economic significance of rhinosinusitis is considerable. This makes the need for appropriate diagnostic and therapeutic strategies all the more urgent. In addition to case history and a physical examination, a helpful diagnostic strategy also includes rhinoendoscopy and--in particular in preparation for surgery--a CT scan. A plain radiograph does not suffice to confirm chronic sinusitis. The major therapeutic pillar in the treatment of acute rhinosinusitis is medication in conformity with accepted guidelines (proof of efficacy!). In the majority of cases chronic courses can be managed by minimally invasive surgery.

Introduction: Functional endonasal sinus surgery has gained significant importance in the treatment of chronic inflammatory sinus disease over the past 20 years. Still, the risk of jeopardizing adjacent structures, i.e. the anterior skull base, optic nerve or carotid artery, is increased, especially in revision cases. Several attempts have been made in the past to reduce the risk of iatrogenic injuries due to this kind of surgery and to increase the safety of the procedure, one of them being the introduction and clinical application of image guided and computer assisted surgery (CAS) respectively. A new method of patient registration for the CAS is the non-contact laser registration (z-touch(TM) laser). The main advantage of the laser registration device, is that it is no longer necessary to equip the patient with special markers or with a headset for the registration scan, therefore additional CT scans can be avoided.Material and Methods: In this study we summarize our experience with the Vector Vision compact navigation system. The study population contained 102 patient, treated over a period of 18 months (Sept. 2000-Dez. 2001). The indications for the CAS were mainly revision operations of recurrent nasal polyps, mucoceles or other chronic rhino-sinus diseases, especially of the frontal sinus. In 35 cases the headset registration was applied, in all other cases we used the z-touch(TM) laser registration.Results: The preoperative planning time was significantly lower for z-touch(TM) laser registration (empty set 5,2 min) compared to the headset registration (empty set 20,2 min), the set-up-time in the operation room was nearly the same, 7 min for z-touch(TM) laser registration and 6 min for headset registration. The most important criterion for CAS, of course, is accuracy during surgery; here we also observed an increased accuracy for the z-touch(TM) laser registration.Conclusions: Our data confirm earlier observations indicating that CAS enhances safety during endoscopic sinus surgery especially in revision cases. In addition it might be a helpful adjunct for the beginner and even advanced surgeon during routine sinus procedures. Nevertheless, CAS should not be misinterpreted as a substitute for thorough and meticulous studying of this delicate area including cadaver studies. Our results further demonstrate that the faster and simple registration method allows us to use the system more frequently, thereby increasing the number of navigated cases. The accuracy we can achieve varies between 0.9 and 2.4 mm, with a mean value of 1,3 in the x- and y-axis and 1,4 in the z-axis. In addition it is also possible to use imaging data sets obtained prior to the intent to operate. This not only reduces the cost for imaging studies, but also minimizes the manpower needed to place the fiducials, organize and perform additional acquisition of images.

INTRODUCTION:Functional endonasal sinus surgery has gained significant importance in the treatment of chronic inflammatory sinus disease over the past 20 years. Still, the risk of jeopardizing adjacent structures, i. e. the anterior skull base, optic nerve or carotid artery, is increased, especially in revision cases. Several attempts have been made in the past to reduce the risk of iatrogenic injuries due to this kind of surgery and to increase the safety of the procedure, one of them being the introduction and clinical application of image guided and computer assisted surgery (CAS) respectively. A new method of patient registration for the CAS is the non-contact laser registration (z-touch trade mark laser). The main advantage of the laser registration device, is that it is no longer necessary to equip the patient with special markers or with a headset for the registration scan, therefore additional CT scans can be avoided.MATERIAL AND METHODS:In this study we summarize our experience with the Vector Vision compact navigation system. The study population contained 102 patient, treated over a period of 18 months (Sept. 2000 - Dez. 2001). The indications for the CAS were mainly revision operations of recurrent nasal polyps, mucoceles or other chronic rhino-sinus diseases, especially of the frontal sinus. In 35 cases the headset registration was applied, in all other cases we used the z-touch trade mark laser registration.RESULTS:The preoperative planning time was significantly lower for z-touch trade mark laser registration ( 5,2 min) compared to the headset registration ( 20,2 min), the set-up-time in the operation room was nearly the same, 7 min for z-touch trade mark laser registration and 6 min for headset registration. The most important criterion for CAS, of course, is accuracy during surgery; here we also observed an increased accuracy for the z-touch trade mark laser registration.CONCLUSIONS:Our data confirm earlier observations indicating that CAS enhances safety during endoscopic sinus surgery especially in revision cases. In addition it might be a helpful adjunct for the beginner and even advanced surgeon during routine sinus procedures. Nevertheless, CAS should not be misinterpreted as a substitute for thorough and meticulous studying of this delicate area including cadaver studies. Our results further demonstrate that the faster and simple registration method allows us to use the system more frequently, thereby increasing the number of navigated cases. The accuracy we can achieve varies between 0.9 and 2.4 mm, with a mean value of 1,3 in the x- and y-axis and 1,4 in the z-axis. In addition it is also possible to use imaging data sets obtained prior to the intent to operate. This not only reduces the cost for imaging studies, but also minimizes the manpower needed to place the fiducials, organize and perform additional acquisition of images.

OBJECTIVE:To determine typical locations for traumatic lesions of the anterior skull base during endoscopic sinus surgery.STUDY DESIGN:In this retrospective study 12 patients were included who had undergone endoscopic sinus surgery for nasal polyposis and were referred to the author for revision surgery after iatrogenic trauma of the anterior skull base during the procedure. Each patient had been operated by a different surgeon, all of the physicians being in an advanced stage of their surgical career and being board certified otolaryngologists.RESULTS:During endoscopically controlled revision surgery, all lesions could be detected, 10 of them being located in the ethmoid roof, while one injury had occurred in the lateral lamella of the cribriform plate and another one in the olfactory groove between the medial turbinate and the nasal septum.CONCLUSION:In contrast to reports in the literature, the preferred site for anterior skull base injuries during endoscopic sinus surgery in our group was not the lateral lamella of the cribriform plate, but the anterior part of the ethmoid roof, just behind the frontal recess. Apparently the course of the ethmoid roof might be misinterpreted during sinus surgery even by surgeons who are familiar with the operative technique.

Obstructive sleep apnea syndrome is defined by the American Academy of Sleep Medicine as a combination of at least five obstructive events per hour of sleep and such other symptoms as daytime sleepiness, ischemic heart disease and stroke. In addition to weight reduction, the use of oral appliances, and continuous positive airway pressure (CPAP), a number of surgical interventions such as uvulopalatopharyngoplasty and maxillomandibular advancement are also available for the treatment of sleep apnea. Since no prolongation of life has yet been shown for most of the therapeutic options, treatment needs to be individualized on the basis of symptoms, clinical findings and compliance.