This is a case report on a middle grade differentiated keratinized squamous cell carcinoma of the larynx in a 12-year-old boy. Squamous cell carcinoma of the larynx is very rare in children and adolescents and in older literature studies less than 70 cases have been reported in children. Histologically the same variants are present as in adults. The way to the final diagnosis of laryngeal carcinoma often takes longer in children because dysphonia or dyspnoe are often caused by other pediatric diseases, risk factors such as those found in adults cannot be elucidated and many symptoms can be due to incomplete development of the laryngeal skeleton. Generally speaking, prior radiation therapy of the neck region and papillomatosis have been described as risk factors. In rare cases translocations or mutations can play a causative role.

Intracellular mucin-producing adenocarcinomas, so called signet ring cell adenocarcinomas (SRCAs), are most commonly found in the stomach or lower GI-tract. They occur far less frequently at other locations such as prostate, pancreas, mammarian gland or within the oropharyngeal cavity. We present the case of a patient who suffered from indolent cervical nodular tumour. Biopsy and histopathological workup showed parts of a poorly differentiated SRCA with p53 overexpression and mutations. Immunostaining gave no further hints for the origin of the malignancy. Thorough staging revealed an extended tumour of the oropharynx as primary origin. The definitive surgical therapy consisted of a transoral tumour resection with CO(2)-laser and bilateral neck dissection. Final classification was pN2c cM0 G3 R0 L1 V0. Adjuvant fractioned radiotherapy with 66 Gy was applied because of bilateral lymph node metastases and extracapsular spread. So far only few cases of oropharyngeal SRCAs have been published. These tumours turned out to be either metastases from gastric or lower gastrointestinal primaries, or had the small salivary glands as origin. In all published cases, as well as in our case, radical surgical resection was the first step of a curative therapy trial. Adjuvant targeted therapy with drugs like, e.g. herceptin or imatinib was not possible because of genetic and immunhistochemical findings. Because of the small numbers of published cases, an evaluation long-term outcomes and significance of different adjuvant therapy regimes is barely possible at this time.

Squamous cell carcinoma (SCC) in larynx is rare with children and adolescents. Usually larynx cancer is common with male smokers in the 7th decade. Among patients with no history of tobacco and/or alcohol consumption several factors have can play a role in the outbreak of laryngeal cancer: such as individual predisposition, radiation, gastroesophageal reflux, viral infection, dietary factors and environmental influences. In literature only few cases of laryngeal cancer with children are reported. Recent studies show that the most frequent laryngeal malignancy is the embryonal rhabdomyosarcoma. Besides the recurrent respiratory papillomatosis (RRP) based on an infection with human papilloma virus (HPV) types 6 and 11 (low risk) and types 16 and 18 (high risk) is known for a possible malignant transformation towards a SCC. HPV type 26 is only reported as low risk type HPV associated with cervical cancer. Final diagnosis often takes a long time. Initial symptoms such as hoarseness, cough or shortness of breath are often referred to more typical pediatric diseases or laryngeal development.

In a prospective, randomised, double-blinded controlled study, we compared the efficacy and safety of two different treatment options with the herbal medicines cineole and a combination of five different components for acute viral rhinosinusitis. One hundred and fifty patients with acute and viral rhinosinusitis (75 patients in each treatment group) were enrolled. The diagnosis rhinosinusitis was made according to a defined symptoms-sum-score which was based on rhinoscopic and clinical signs which are characteristic for rhinosinusitis. The primary endpoint was the amelioration of the symptoms-sum-score, which includes all relevant characteristics for rhinosinusitis as headache on bending, frontal headache, sensitivity of pressure points of trigeminal nerve, impairment of general condition, nasal obstruction, rhino-secretion, secretion quantity, secretion viscosity and fever in a treatment period of 7 days. The mean reduction of the symptoms-sum-score after 4 days was 6.7 (+/- 3.4) and after 7 days 11.0 (+/- 3.3) in the cineole group and 3.6 (+/- 2.8) after 4 days and 8.0 (+/- 3.0) after 7 days in the control group. The differences between both groups were clinically relevant and statistically significant after 4 and 7 days (P < 0.0001). This result is validated by the amelioration of the secondary endpoints headache on bending, frontal headache, sensitivity of pressure points of trigeminal nerve, impairment of general condition, nasal obstruction and rhino-secretion. These findings correlate with the statistically significant difference of the estimation of B-scan ultrasonography. It is safe to use both medications for 7 days in patients with acute viral rhinosinusitis. Treatment with cineole is clinically relevant and statistically significant, more effective in comparison to the alternative herbal preparation with five different components.

A common clinical presentation of WG involves the upper respiratory tract. Therefore ENT-specialists should be familiar with the disease. Especially in cases of persistent signs of bilateral "Mastoiditis" and neurological symptoms WG should be ruled out as differential diagnosis. A close interdisciplinary cooperation is essential for therapy and follow-up, because systemic involvement is the limiting prognostic factor.

Einleitung: Methodik: Schlussfolgerung: Introduction: Methods: Conclusion:

Dieser Artikel gibt einen evidenzgeleiteten Überblick über entzündungsszintigrafische Verfahren bei einigen seltenen Indikationen. Bei der Diagnostik und bei der Beurteilung der Aktivität einer chronisch-entzündlichen Darmerkrankung bleibt die Szintigrafie mit 99mTc-HMPAO-markierten autologen Leukozyten die nuklearmedizinische Standarduntersuchung. Eine Appendizitis kann sowohl mittels in vitro markierter Leukozyten als auch immunentzündungs-szintigrafisch mit hoher Sicherheit nachgewiesen und ausgeschlossen werden. Die späte SPECT (20-24 h p. i.) mit 99mTc-markierten monoklonalen Anti-CD-66-Antikörpern ist eine sinnvolle Zusatzuntersuchung zur transösophagealen Echokardiografie bei der Endokarditisdiagnostik. Infizierte Gefäßprothesen sollten mittels 99mTc-HMPAO-markierter autologer Leukozyten untersucht werden. Es muss diskutiert werden, ob die [18F]FDG-PET oder [18F]FDG-PET / CT bei dieser Fragestellung eine höhere diagnostische Genauigkeit aufweist.

INTRODUCTION Wegener's granulomatosis (WG) is a vasculitis that effects the upper and lower part of the respiratory tract and the kidneys. Untreated the disease results in death within weeks or months. The diagnosis is based on clinical criteria, level of antineutrophil cytoplasmatic antibodies (ANCA) and signs of granulomatous necrotizing vasculitis in histology. METHODS A case of an 18-year-old woman with initially symptoms of bilateral "mastoiditis" and weakness of her facial nerve is described. In this case ANCA levels remained normal for 3 months and persistent otological symptoms were predominant. The further clinical course was characterized by neurological problems (Palsy Nn. VII, IX, XII and thrombosis of the right sigmoid sinus). The initial therapy consisted of Prednisone 100 mg and Cyclophosphamide 100 mg daily. The patient has been treated successfully with Methotrexate 20 mg 1 x/week and Prednisone 15 mg/die for 4 months now. CONCLUSION A common clinical presentation of WG involves the upper respiratory tract. Therefore ENT-specialists should be familiar with the disease. Especially in cases of persistent signs of bilateral "Mastoiditis" and neurological symptoms WG should be ruled out as differential diagnosis. A close interdisciplinary cooperation is essential for therapy and follow-up, because systemic involvement is the limiting prognostic factor.

AIM:At time of diagnosis, up to 17 % of HNSCC present with distant metastasis or a second primary tumour. Distant metastases of these tumours most commonly occur in the lung, requiring a particularly precise evaluation of this organ within the staging process. It was the aim of this study to compare the radiological findings of plain chest X-rays with the results of CT-scans of the chest in regard to their sensitivity for metastasis detection. PATIENTS AND METHODS:The staging examinations of 47 patients (f: 13, m: 34, mean age: 61.6 y) with progressed (T3, T4, N+) or recurrent HNSCC were prospectively analysed and results of chest X-rays as well as CT-scans of the chest compared. RESULTS:Only one plain chest X-ray showed a possible metastasis, which was excluded by the following CT-scan. In none of the other 46 patients did X-ray reveal findings of metastatic disease or second primary tumours. CT-scans of the chest showed tumorous lesions in 8/47 (17 %) patients. Three of these tumours were confirmed as neoplastic by biopsy, in another case radiological signs and clinical symptoms permitted definite assumption of malignancy (4/47 : 8.5 %). Histologically, only one of the latter four tumours could be identified as metastatic. In the remaining three cases we found second primary tumours. A follow up CT-scan of one of the remaining four cases showed normal results. In 3 cases the aetiology of the CT-findings remained unclear. CONCLUSION:Cervical lymph node metastases, tumour-size and recurrence of HNSCC are known risk factors for metastatic disease in HNSCC. Chest X-ray as staging procedure in patients with progressed or recurrent HNSCC may not be able to identify metastases or a second primary tumour of the lung. We therefore recommend a CT-scan of the chest as a routine procedure in such patients to optimise the pre-operative staging.

The aims of follow-up of head and neck cancer patients are the detection of new tumour manifestations, management of impairments after tumour therapy, psychological care and the evaluation of therapeutic efficacy. The extent, success and cost-benefit ratio of follow-up are currently under discussion. We recommend interdisciplinary cooperation between the relevant specialists, such as oncology and radiotherapy, together with the otorhinolaryngologist for reasons of cost-efficacy and improvement of long-term results. We present a follow-up schedule for patients with head and neck squamous cell carcinomas, which are the by far most common manifestation. We recommend a standardized protocol, which should be individualized depending on tumour site, size, treatment and therapeutic options in the case of tumour recurrence. The most common salivary gland malignancies are also discussed. The objective is to increase the efficacy of follow-up in patients with head and neck cancer.

BACKGROUND:Postoperative nausea and vomiting (PONV) are among the most common complications in operative medicine. Especially patients undergoing middle ear surgery or stapedectomy are frequently suffering from PONV. On the other hand vertigo might be a symptom of an operative complication. For symptomatic therapy a various number of different drugs is available.PATIENT:We describe the clinical course of a 25-years-old female patient, who presented with massive orofacial tardive dsykinesia after therapy with metoclopramide (MCP). She had stapedectomy in general anaesthesia and suffered from PONV. The dyskinesia was treated successfully with Biperiden 5 mg i. v.DISCUSSION:Tardive dyskinesia is a potential and in rare cases irreversible complication of MCP-therapy. The efficiacy of MCP is in controversy. Studies with 5-HT3-antagonists like Ondansetron or neuroleptics like Droperidol show good results in PONV especially after middle ear surgery.CONCLUSION:Tardive dyskinesia is a rare but possible drug-related adverse effect of MCP. After review of the literature we can not recommend MCP as an antiemetic drug in PONV.

Patient: Diskussion: Schlussfolgerung: Patient: Discussion: Conclusion:

PATIENT:A case of a 54-year-old woman with a three month history of recurrent bilateral chondritis of the auricles, cochlear and vestibular inner ear damage and conjunctivitis is described. The diagnosis was based only on clinical criteria (auricular chondritis, conjunctivitis, inner ear damage). Antinuclear antibodies, ANCA and HLA-DR 4 antigen were negative. The only laboratory abnormality was an elevated erythrocyte sedimentation rate. The patient has been treated successfully with Methotrexate 20 mg 1 x /week and Prednisone 15 mg/die for 4 month now.DISCUSSION:The relapsing polychondritis (RP) is a rare, multisystemic and potentially fatal disease. The pathogenesis and optimal therapeutic approach is poorly understood. The disease is characterized by episodic inflammation of cartilage such as auricular, nasal and laryngotracheal. Many other proteoglycan-rich structures like inner ear, eye, kidney and blood vessels, may be involved as well. RP has an equal sex prevalence. The majority of cases appear between 40 and 60 years. Auricular inflammation is the most common feature. Effectiveness of non-steroidal anti-inflammatory drugs, dapsone, immunosuppressive drugs and prednisone has been described. The overall survival rates were 74 % at 5 years and 55 % at 10 in one 1986 series.CONCLUSION:The most common clinical presentation of RP regularly involves ENT-structures. Therefore ENT-specialists should be familiar with this disease. A close interdisciplinary cooperation is essential for therapy and follow-up, because pulmonary and cardiac involvement are limiting prognostic factors.

Einleitung: Die Xerostomie ist die haufigste und storendste Nebenwirkung bei der Bestrahlung maligner Tumoren des Kopf- Hals-Bereichs. Die Glandula submandibularis (GS) ist die wichtigste Speicheldruse, sie produziert 70% des unstimulierten Speichelflusses. In der Regel liegt die GS bei der Radiotherapie von Kopf-Hals-Tumoren im Bestrahlungsfeld, dies fuhrt zu einer Funktionsminderung der GS um 85–90%. Eine operative Verlagerung der Druse aus dem Strahlenfeld nach submental konnte dieses verhindern, da diese Region bei der Betrahlung ausgespart wird. Die Methode ist bereits von Seihaly et al. (2003) beschrieben worden. Kritiker dieser Methode bezweifeln jedoch, dass die parasympatische Innervation der Druse erhalten werden kann. Ziel dieser Arbeit war es zu untersuchen ob die Schonung des Ganglion submandibulare moglich ist und uber welche Strecke die Druse nach anterior verlagert werden kann. Methode: Die Praparation erfolgte an 6 Leichenschadeln. Dabei wurde die GS unter den Venter anterior des M. digastricus verlagert. Die Strecke wurde vermessen und die Anzahl der erhaltenen Ganglien pro Verlagerung bestimmt. Ergebnis: Im Mittel lies sich die Druse uber eine Strecke von 2,9cm±0.4cm verlagern. Die Ganglien konnten zu 100% erhalten werden. Conclusio: Bei einer chirurgischen Verlagerung der GS aus dem Bestrahlungsfeld kommt es u.a. auf den Erhalt der parasympatischen Innervation an. Anhand anatomischer Praparationen konnten wir belegen, dass dieses zu 100% moglich ist. Hierdurch kann eine Reduktion der Strahlendosis von 60 auf ca. 5Gy erreicht werden. Dieses sollte sich positiv auf Speichelflussraten und die subjektive Wahrnehmung der Xerostomie auswirken. Korrespondierender Autor: Dr. med. Robert Schonberg Universitats HNO-Klinik Hamburg Eppendorf, Martinistrase 52, 20246 Hamburg E-Mail: schoenberg@uke.uni-hamburg.de

Background: Radiotherapy of head and neck tumors often leads to acute reactions of the adjacent normal tissues resulting e.g. in mucositis and xerostomia. Therefore, radioprotective drugs have been developed to reduce these effects. Studies on a tumor model using amifostine and sodium selenite adjuvant to fractionated irradiation should show whether the radioprotective effect on normal tissue leads to an increase of radioresistance in the tumor and its metastatic potential. Methods: Rhabdomyosarcomas R1H of the rat growing subcutaneously in the right flank of male adult WAG/RijH rats were irradiated with 60Co-gamma rays (60 Gy/30 fractions/6 weeks). Amifostine (375 mg/m²), sodium selenite (15 µg/kg), and equivalent volumes of 0.9% saline were administered intraperitoneally 30 min before each irradiation. Tumor response was determined. Statistical analysis was performed using the post-hoc-test. Results: Irradiation alone inhibited R1H tumor growth (AUC 86.8±18.3). The efficacy of irradiation during radiotherapy was significantly improved by amifostine (AUC 63.1±15.8) in comparison to the irradiated controls. The radiosensitizing effect of sodium selenite (AUC 73.6±21.3) as well as irradiation and amifostine plus sodium selenite (AUC 68.3±7.8) was less compared to the irradiated controls and not statistically significant. However, tumor growth delay and metastasis rate were not changed by the radioprotective drugs. Further, the administration of amifostine and amifostine plus sodium selenite induced an enhanced decrease of animal body weight except for sodium selenite in comparison to the controls. Conclusion: The application of amifostine and sodium selenite to conventionally fractionated irradiation have no influence on the radiosensitivity of the rhabdomyosarcoma R1H. The systemic toxicity of amifostine might be of importance for the radiation treatment of a patient.

Einleitung: Das therapeutische Vorgehen bei Kopf-Hals-Malignomen wird entscheidend vom Nachweis einer Fernmetastasierung bzw. synchroner Zweitkarzinome beeinflusst. Die Wahrscheinlichkeit der Fernmetastasierung steigt abhängig vom T- und N-Stadium und vom Auftreten von lokoregionären Rezidiven. Von besonderer Bedeutung ist die Bildgebung des bronchopulmonalen Systems, da dort am häufigsten Fernmetastasen auftreten. Patienten und Methode: Es wurden die radiologischen Thoraxbefunde im Rahmen des Tumorstaging (konventionelles Thoraxröntgen versus Thorax-CT) prospektiv bei 47 Patienten (w: 13, m: 24, Durchschnittsalter: 61,6J.) untersucht. Ergebnisse: In 8 Fällen ergaben sich bei unauffälligem Röntgenthorax metastasenverdächtige Befunde im Thorax-CT. Ein entsprechender histologischer Nachweis konnte in 3 Fällen erbracht werden, in einem Fall ergab sich bei eindeutigem CT und seitengleicher Recurrensparese die Diagnose eines zentralen Bronchialkarzinoms (8,5%). 3 Fälle hochgradig metastasen-verdächtiger Befunde im CT blieben in ihrer Ätiologie unklar, da ein Patient verstarb und zwei sich der weiteren Abklärung entzogen. In einem Fall konnte der Fernmetastasenverdacht durch ein Verlaufs-CT des Thorax ausgeschlossen werden. Schlussfolgerung: Zur Optimierung der Therapieplanung von Kopf-Hals-Tumoren sollte bei Patienten mit erhöhtem Fernmetastasenrisiko (>T3, N+, Rezidiv) die CT des Thorax obligat in das präoperative Staging aufgenommen werden.