ABSTRACT:We report an unusual case of metastatic syringocystadenocarcinoma papilliferum in an 18-year-old man who presented with cervical lymph node metastasis initially diagnosed as dedifferentiated squamous cell carcinoma of unknown primary. Extensive diagnostic workup failed to identify a primary tumor, until reexcision of a childhood scalp lesion revealed a deeply infiltrative adnexal neoplasm with ductal differentiation consistent with syringocystadenocarcinoma papilliferum, and comparison of the lymph node specimens with the scalp specimen showed cytological similarities. This case emphasizes that the working diagnosis should be questioned by the pathologist and the clinician when clinical characteristics do not seem to fit. It furthermore highlights the importance of the inclusion of prior pathology specimens into the pathological workup, and careful evaluation for ductal differentiation in atypical squamous cell carcinoma presentations.

Traumatic auricular amputations present a unique surgical challenge, particularly in cases where microsurgical anastomosis is not feasible due to vessel damage or absence. Traditional reconstruction techniques often yield suboptimal aesthetic or functional results. The pocket technique, as described by Sexton and Mladick, has shown promise in such scenarios, particularly in partial auricular amputations. We report a case of a 52-year-old Caucasian male who presented with traumatic amputation of the cranial third of the auricle following a dog bite. The injury was classified as grade III according to the modified Laskin and Donohue grading system. Owing to the absence of suitable vessels for microsurgical repair, a two-stage reconstruction using a novel modification of the pocket technique was performed. In the first stage, under general anesthesia, the skin was carefully dissected from the amputated auricular cartilage, which was then cleaned, debrided, and sutured to the remaining auricle using an “8”-pattern suture technique. A retroauricular advancement flap, adapted from Mladick’s method, was utilized to create a vascularized pocket for the cartilage. After 2 months, the auricle was elevated from the mastoid, and a full-thickness skin graft was applied to cover the defect. A galea advancement flap, based on the posterior branches of the superficial temporal artery, was harvested to provide vascular support and refine the auricular contour. This case demonstrates the successful application of a modified pocket technique that synergistically integrates principles from Sexton and Mladick’s approaches. The result was a well-perfused, anatomically contoured, and aesthetically pleasing auricular reconstruction without the need for microsurgical anastomosis. This technique represents a viable reconstructive alternative in select cases of partial auricular amputation where vessel quality or availability is compromised.

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic inflammatory condition associated with significant morbidity. While established treatments such as functional endoscopic sinus surgery (FESS) and biologic therapy have demonstrated efficacy, they come with limitations, including cost, accessibility, and patient adherence. Growing evidence suggests that dietary factors, particularly arachidonic acid and salicylic acid, influence inflammatory pathways relevant to CRSwNP, yet real-world data on dietary interventions remain scarce. This retrospective study evaluates the mid-term effects of a structured dietary intervention in patients with CRSwNP who were either unwilling to undergo FESS or biologic therapy. The outcomes were compared to those of patients receiving either FESS or dupilumab. The dietary intervention was based on the avoidance of arachidonic acid and salicylates, an increase in fiber-rich foods, and the exclusion of nonsteroidal anti-inflammatory drugs. A total of 45 patients (mean age 46.5 ± 14.1 years; 25 female and 20 male) were included, with 15 undergoing dietary intervention, 15 FESS, and 15 dupilumab therapy. Disease burden was assessed using the sino-nasal outcome test (SNOT-22), visual analog scale, endoscopy scoring, and the brief smell identification test at baseline and follow-ups at 3 and 6 months. Patients undergoing dietary intervention experienced significant symptom improvement, although the response was less pronounced compared to FESS or dupilumab. At 6 months, mean SNOT-22 scores improved from 69.8 to 19.7 (FESS), 58.0 to 16.1 (dupilumab), and 39.5 to 24.2 (dietary intervention). visual analog scale scores showed a similar trend, decreasing from 8.4 to 2.9 (FESS), 8.1 to 2.2 (dupilumab), and 5.6 to 3.5 (dietary). While objective olfactory scores (brief smell identification test) improved in all groups, it was less pronounced in the dietary intervention group. Notably, patients in the dietary intervention group reported continued adherence and tolerability of the intervention. Dietary intervention may serve as a viable adjunct for CRSwNP patients who are unable or unwilling to undergo surgery or biologics. Despite lower efficacy, its safety and accessibility merit further investigation.

Individualized cochlear implantation (CI) is essential to facilitate optimal hearing results for patients. Influence of cochlear coverage (CC) has been studied, however without consideration of different CI-categories, like single sided deafness (SSD), bimodal, and bilateral separately. Retrospective analysis of preoperative CT scans was performed at a tertiary center. For each patient their individual CC with the selected electrode array was calculated off the complete CDL. Patients were categorized into SSD (n = 30), bimodal (n = 72), and bilateral CI patients (n = 29). Speech perception within the first 12 months post-implantation was compared between patient groups with shorter and longer CC. For subgroup analysis the cutoff between a shorter or longer CC was identified by the median. Cutoff between a shorter or longer CC was identified at 65

Journal of the European Academy of Dermatology and VenereologyAccepted Articles LETTER TO THE EDITOR High-dose intravenous immunoglobulin co-treatment prolongs time-to-treatment escalation in autoimmune bullous diseases: a monocentric retrospective cohort study M. Bertlich, M. Bertlich University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany University Hospital Bonn, Department of Dermatology, Bonn, Germany both authors contributed equallySearch for more papers by this authorI. Bertlich, I. Bertlich University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany both authors contributed equallySearch for more papers by this authorN. Plümacher, N. Plümacher University of Kassel, Department of Electrical Engineering and Computer Science, Kassel, GermanySearch for more papers by this authorE. Hadaschik, E. Hadaschik University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany University of Duisburg-Essen, Department of Dermatology, Essen, GermanySearch for more papers by this authorA. Enk, A. Enk University Hospital Heidelberg, Department of Dermatology, Heidelberg, GermanySearch for more papers by this authorJ. H. O. Hoffmann, Corresponding Author J. H. O. Hoffmann [email protected] orcid.org/0000-0003-1579-626X University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany Correspondence Prof. Dr. med. Jochen Hoffmann, Hautklinik Heidelberg, INF 440, 69120 Heidelberg, Germany. Email: [email protected], Phone: +49 6221 56 8511Search for more papers by this author M. Bertlich, M. Bertlich University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany University Hospital Bonn, Department of Dermatology, Bonn, Germany both authors contributed equallySearch for more papers by this authorI. Bertlich, I. Bertlich University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany both authors contributed equallySearch for more papers by this authorN. Plümacher, N. Plümacher University of Kassel, Department of Electrical Engineering and Computer Science, Kassel, GermanySearch for more papers by this authorE. Hadaschik, E. Hadaschik University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany University of Duisburg-Essen, Department of Dermatology, Essen, GermanySearch for more papers by this authorA. Enk, A. Enk University Hospital Heidelberg, Department of Dermatology, Heidelberg, GermanySearch for more papers by this authorJ. H. O. Hoffmann, Corresponding Author J. H. O. Hoffmann [email protected] orcid.org/0000-0003-1579-626X University Hospital Heidelberg, Department of Dermatology, Heidelberg, Germany Correspondence Prof. Dr. med. Jochen Hoffmann, Hautklinik Heidelberg, INF 440, 69120 Heidelberg, Germany. Email: [email protected], Phone: +49 6221 56 8511Search for more papers by this author First published: 18 August 2023 https://doi.org/10.1111/jdv.19437 This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/jdv.19437. AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat Accepted ArticlesAccepted, unedited articles published online and citable. The final edited and typeset version of record will appear in the future. RelatedInformation

Introduction: Aspergillus fumigatus is the most common airborne allergen of the Aspergillus family. However, allergies to Aspergillus spp. are increasing, and subsequently, allergies to Aspergillus species other than fumigatus are also on the rise. Commercial diagnostic tools are still limited to Aspergillus fumigatus. Hence, there is a need for improved tests. We decided to investigate the correlation between serological sensitization to A. fumigatus and other Aspergillus species. Methods: Hundred and seven patients with positive skin prick tests to A. fumigatus were included in this study. Immunoglobulin E (IgE) concentrations against A. fumigatus, A. terreus, A. niger, A. flavus, and A. versicolor were measured from specimens by fluorescent enzyme-linked immunoassays. Results: Patients showed considerably higher IgE concentrations against A. fumigatus (6.00 ± 15.05 kUA/L) than A. versicolor (0.30 ± 1.01 kUA/L), A. niger (0.62 ± 1.59 kUA/L), A. terreus (0.45 ± 1.12 kUA/L), or A. flavus (0.41 ± 0.97 kUA/L). Regression analysis yielded weak positive correlations for all Aspergillus spp., but low r2 values and heteroscedastic distribution indicate an overall poor fit of the calculated models. Conclusion: Serological sensitization against A. fumigatus does not correlate with sensitization against other Aspergillus spp. To detect sensitization against these, other diagnostic tools like a skin prick test solution of different Aspergillus spp. are needed.

BACKGROUND:Allergic rhinits is a prevalent condition, affecting a substantial proportion of the population. This study investigates the impact of ongoing biologic therapy, specifically with Dupilumab, on allergy diagnostics in patients with allergic rhinits. METHODS:Various tests, including the Skin Prick Test, serum IgE levels and Allergy Screening Panels, were examined for their effectiveness in detecting sensitizations during biologic treatment. RESULTS:The results indicate a significant decline in total IgE levels following biologic therapy initiation, aligning with previous findings on Dupilumab's inhibitory effects on IL-4 and IL-13. However, the specific IgE to total IgE ratio for major allergens was not significantly reduced. Comparing diagnostic tools, the Skin Prick Test demonstrates an impressive retention rate of sensitizations (98%) during Dupilumab treatment, outperforming the Allergy Screening Panel, which shows a 75% detection rate. Notably, the panel displays limitations in capturing lower sensitization levels. CONCLUSION:In summary, this study underscores that, despite the influence of biologic therapy on certain markers, standard allergy tests remain viable while emphasizing the importance of considering specific IgE levels rather than relying solely on CAP classes. The Skin Prick Test in particular proves to be a reliable tool for identifying sensitizations during Dupilumab treatment. The results offer valuable guidance for the diagnostic management of Allergic rhinits in individuals subjected to Dupilumab treatment.

BACKGROUND:Hyaluronidase is an ubiquitous enzyme, present, among others, in hymenoptera venom and in medical formulations. The latter include use as an emergency treatment or to correct undesired outcomes of medical and aesthetic procedures using hyaluronic acid fillers. OBJECTIVES:By performing detailed allergy work-ups including skin-prick tests (SPTs) we investigated whether patients with a history of allergic reaction to hymenoptera venom are also sensitized to medical grade hyaluronidase. METHODS:Ninety patients with a history of type-1 reaction to hymenoptera venom with and without a history of previous specific venom immunotherapy were included in the study. All underwent SPTs for medical hyaluronidase. All patients also underwent serological analysis for Api m2, the only commercially available IgE test for a hymenoptera hyaluronidase. RESULTS:Of the 90 patients with previous type-1 reactions to hymenoptera venom hyaluronidase included in the study, 60 had undergone previous venom immunotherapy; 30 did not. The majority (73 of 90) were allergic to wasps, followed by honeybees (14 of 90) and three were allergic to both. Neither patients having undergone previous immunotherapy nor those allergic to bees showed positive SPTs to medical hyaluronidase. Of those with a wasp allergy and naïve to immunotherapy, over 20% (5 of 23) showed positive SPTs to medical hyaluronidase. Healthy controls (0 of 30) without previous allergic reactions to hymenoptera did not show positive SPTs to medical hyaluronidase. CONCLUSIONS:Sensitization to hyaluronidase is most common in wasp-allergic patients who have not had previous specific immunotherapy. As allergic reactions to medical hyaluronidase are reported to be scarce, this group is probably at the highest risk to develop anaphylaxis to medical hyaluronidase. While all patients with untreated anaphylaxis to hymenoptera venom should consult an allergy specialist, it is particularly important that those with untreated wasp allergies seek specialist advice before treatment with medical hyaluronidase is initiated.

Die allergenspezifische Immuntherapie (AIT) ist die einzige kausale und krankheitsmodifizierende Therapie für eine Immunglobulin E (IgE)-vermittelte Allergie vom Typ I. Durch regelmäßige Exposition gegenüber dem Allergen kommt es zu einer immunmodulatorischen Wirkung, wobei sich die Gewichtung von Th2- zu Th1-Lymphozyten verschiebt und vermehrt allergenspezifisch blockierende Immunglobuline produziert werden. Die Zulassung der AIT ist über die Therapieallergene-Verordnung (TAV) geregelt. Es gibt subkutane und/oder sublinguale AITs für folgende Indikationen: Rhinitis allergica, Conjunctivitis allergica, allergisches Asthma und Insektengiftallergien. Im Folgenden soll insbesondere auf die Indikation der Conjunctivitis allergica eingegangen werden. Klinische Symptome und eine relevante Typ-1-Sensibilisierung sind die Voraussetzung zur Indikationsstellung einer AIT. Die Indikationsstellung und Durchführung einer AIT sollte nur durch allergologisch geschulte Ärzte gehandhabt werden.

Allergen-specific immunotherapy (AIT) is the only causal and disease-modifying treatment for immunoglobulin E (IgE)-mediated type I allergies. Regular exposure to the causative allergen results in an immunomodulatory effect by which the predominant T-helper (Th) 2 lymphocyte response is shifted to a Th1 lymphocyte response and more allergen-specific blocking immunoglobulins are produced. The approval of substances for AIT is regulated by the Therapy Allergens Ordinance (TAV). There are subcutaneous and/or sublingual AITs for the following indications: allergic rhinitis, allergic conjunctivitis, allergic asthma and insect venom allergy. In this article the indications for allergic conjunctivitis are discussed in particular. Clinical symptoms and a relevant type 1 sensitization are the prerequisites for the indications for AIT. The assessment of the indications and carrying out an AIT should only be carried out by physicians who have been trained in allergology.

Background Botulinumtoxin application in the face is amongst the most common aesthetic procedures in the head and neck region. It also has numerous medical uses. One of the main reasons for patients to refrain from it is the subjective discomfort that is experienced during injections. Objectives The study at hand aimed to determine whether needles with 33G and 34G offer an advantage in terms of individual pain perception during botulinumtoxin injections. Methods We conducted a prospective study where patients were asked to grade subjective discomfort on a visual analogue scale for each region (forehead, glabella, temple) that was treated directly after treatment and 15 minutes after. Patients were treated with 30G, 33G or 34G needles, respectively. Results Ninety-nine patients that underwent treatment of 189 regions were included in the study. Patients were evenly distributed amongst the different needle sizes and regions. Subjective discomfort was greatest in all regions for 30G needles (3.9 ± 1.6 forehead, 4.3 ± 1.7 glabella and 4.0 ± 1.6 temple) followed by 33G (2.7 ± 1.5 forehead, 2.7 ± 1.9 glabella and 2.2 ± 1.2 temple) and 34G (1.7 ± 1.2 forehead, 1.6 ± 1.4 glabella and 1.6 ± 1.4 temple). All differences between needle size were statistically significant ( p < 0.05) Conclusion 33G and 34G needles seem to offer smaller discomfort during BTX treatments of the head and neck, with 34G being superior to 33G. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266

INTRODUCTION:Systemic hypersensitivity to hymenoptera species venom is the most common cause for anaphylaxis in adults. Due to similarities between hornet (Vespa crabro) and wasp (Vespula spp.) venom, patients with hornet venom anaphylaxis are often treated similarly to wasp-allergic patients. However, comparative data are scarce. This study aimed to analyze differences and similarities between these two groups. METHODS:A retrospective analysis with 42 patients with certain anaphylaxis to hornet venom was conducted. These were matched for age, gender, and CAP class with 42 patients with wasp venom anaphylaxis. Clinical outcomes and treatment adherence were compared. RESULTS:Patients with hornet venom anaphylaxis showed a significantly higher degree of anaphylaxis (21 vs. 9 patients with grade III/IV anaphylaxis, p < 0.001), despite similar tryptase levels (6.3 ± 8.3 vs. 5.1 ± 4.2) or presence of mastocytosis (2 vs. 3). These patients also showed significantly lower therapy adherence, resulting in fewer patients undergoing specific immune therapy (29 vs. 37, p = 0.030) or sting challenges (14 vs. 27, p = 0.046). Both groups showed high efficacy of specific immunotherapy with wasp venom extract. CONCLUSION:Hornet stings induce more severe anaphylaxis, while patients with hornet venom allergies demonstrate lower treatment compliance, likely due to inadequate education. Specific immunotherapy with wasp venom extract remains effective for both.

Introduction Depending on the tumor size and localization treatment options for patients with growing acoustic neuroma (AN) comprise resection or radiation and are accompanied with impairment of the peripheral vestibular function. To date, little data exists on the central compensation, which was investigated in the present study.

Purpose Disturbance of cochlear microcirculation is discussed as final common pathway of various inner ear diseases. Hyperfibrinogenemia causing increased plasma viscosity is a possible factor for a critical reduction of cochlear blood flow that might lead to sudden sensorineural hearing loss (SSHL). The aim was to determine the efficacy and safety of drug-induced defibrinogenation by ancrod for SSHL. Methods Double-blind, randomized, placebo-controlled, multicenter, parallel group, phase II (proof-of-concept) study (planned enrollment: 99 patients). Patients received an infusion of ancrod or placebo (day 1) followed by subcutaneous administrations (day 2, 4, 6). Primary outcome was the change in pure tone audiogram air conduction average until day 8. Results The study was terminated early due to slow recruiting (31 enrolled patients: 22 ancrod, 9 placebo). A significant improvement of hearing loss was registered in both groups (ancrod: − 14.3 dB ± 20.4 dB, − 39.9% ± 50.4%; placebo: − 22.3 dB ± 13.7 dB, − 59.1% ± 38.0%). A statistically significant group-difference was not detected ( p = 0.374). Placebo response of 33.3% complete and 85.7% at least partial recovery was observed. Plasma fibrinogen levels were reduced significantly by ancrod (baseline: 325.2 mg/dL, day 2: 107.2 mg/dL). Ancrod was tolerated well, no adverse drug reaction was of severe intensity, no serious adverse events occurred. Conclusion Ancrod reduced fibrinogen levels that support its mechanism of action. The safety profile can be rated positively. Since the planned number of patients could not be enrolled, no efficacy conclusion can be drawn. The high rate of placebo response challenges clinical trials for SSHL and needs to be considered in future investigations. Trial registrations This study was registered in the EU Clinical Trials Register, EudraCT-No. 2012-000066-37 at 2012-07-02.