Die endonasale chirurgische Therapie der chronischen Sinusitis unter Benutzung moderner optischer Hilfsmittel gewann in den letzten Jahren zunehmend an Bedeutung. Die von uns entwickelte kombinierte endonasale mikro-endoskopische Operationstechnik wird detailliert erlÄutert. Die angegebene Indikationsliste ist als derzeit praktiziertes Konzept zu verstehen, Änderungen im Laufe der weiteren Entwicklung sind denkbar.

Nasal surgery is frequently performed. Predictors of surgical outcome in terms of chemosensory function are not clear. A total of 64 patients were included in this prospective study (41 men, 23 women; age range 22-67 years). Prior to surgery, patients received a detailed otorhinolaryngological examination including nasal endoscopy, and CT scans used to establish the Lund-Mackay score. Olfactory function was analyzed using a custom-built odor identification test which allowed separation of chemosensory function into "olfactory" and "trigeminal" portions. Retest was performed 6 months after surgery. In terms of the sense of smell, nasal surgery produced the highest success rates in women, high degree of polyposis, and aspirin-intolerance. Neither age, presence of asthma, nor the number of preoperative surgical interventions had a significant impact on the outcome of surgery in terms of chemosensory function. Although "trigeminal scores" changed to a lesser degree than "olfactory scores", the present results indicated that nasal surgery may also improve trigeminal function, although this needs further corroboration. Improvement of olfactory function following nasal surgery appears to last, on average, for at least 6 months. While the present results may be seen as an encouraging step towards the description of more detailed prognostic factors related to nasal surgery, results from the present investigation also point towards the idea that nasal polyposis is due to a multifactorial process that, so far, is not adequately addressed by current research. Future work is needed to identify further predictors of postoperative outcome in terms of olfactory function.

Hintergrund: Durch standardisierte Operationstechniken und die Verwendung von Ultraschalldissektion und Neuromonitoring ist die Morbidität in der Schilddrüsenchirurgie so gering geworden, dass für Patienten zunehmend auch ästhetische Aspekte im Vordergrund stehen. Methode: Wir berichten über minimal-invasive und endoskopische Verfahren mit zervikalen und extrazervikalen Zugängen aus der aktuellen Literatur und über unsere eigenen Ergebnisse. Ergebnisse: Die kritische Bewertung der eigenen und der bereits von anderen Autoren publizierten Verfahren zeigt, dass diese nicht in jedem Fall die geforderten Standards der endokrinen Chirurgie erfüllen. Schlussfolgerungen: Daher formulieren wir Mindestanforderungen an den optimalen endoskopischen Eingriff: Das Zugangstrauma muss minimal, das ästhetische Ergebnis optimal – ohne sichtbare Narben – sein. Das Resektionsausmaß sollte dem der offenen Chirurgie entsprechen. Das Präparat muss in toto entfernt werden können. Nur wenn die Ergebnisqualität des Eingriffes gewährleistet ist, darf der ästhetische Aspekt in den Vordergrund rücken. Sind all diese Forderungen erfüllt, liegen die Vorteile neben dem besseren kosmetischen Ergebnis möglicherweise auch in geringeren perioperativen Schmerzen und kürzerem stationärem Aufenthalt. Hierzu sind jedoch weitere Studien erforderlich.

CSF fistulas occur mainly after trauma, intracranial operations, or skull base procedures. In some cases they confront the surgeon with a therapeutic and operative problem that is often only solved by an interdisciplinary approach. However, localization and cause of the fistula is generally known, facilitating operative planning.

Liquorfisteln treten in erster Linie posttraumatisch oder nach intrakraniellen Eingriffen sowie Schädelbasiseingriffen auf. Sie stellen hier mitunter ein großes therapeutisches und operationstechnisches Problem dar, das in vielen Fällen ein interdisziplinäres Vorgehen erfordert. Die Lokalisation der Fistel und ihre Ursache sind aber meisten bekannt so dass die Op-Planungen konkret darauf abgestimmt werden können.

Reconstruction of the anterior skull base must be secure and watertight. Failure to achieve this places the patient at risk of the development of cerebral sepsis. We have developed the technique of endonasal duraplasty and have achieved a 90% long-term success rate. In this article we described the key elements of our technique starting with radiographic and fluorescein localization of a skull base defect. The main steps in reconstruction and materials used are detailed, together with modifications of our technique for certain difficult situations and tips for success. Attention is drawn to potential pitfalls that have been identified over 25 years of clinical practice.

BACKGROUND:The goal of this study was to assess the potentials and limitations of endonasal micro-endoscopic surgery in the treatment of sinonasal inverted papilloma (IP) and to demonstrate long-term results.PATIENTS AND METHODS:From 1989 to 2005, 64 patients underwent resection of IP via an endonasal approach using either the endoscope or microscope. Charts were reviewed retrospectively for presenting symptoms, radiological and intraoperative data. All patients were followed by endoscopic and MRI control during a period of up to 174 months, median follow-up was 78 months.RESULTS:Our study group consisted of 26 male and 38 female patients with an average age of 54.3 years. The majority of the patients (67 %) complained of unilateral nasal obstruction. 52 patients (81 %) were referred for primary surgery. In 12 cases (19 %) recurrent tumors were operated. According to the Krouse classification for IP the tumors were staged as T1 = 11 (17 %) cases, T2 = 37 (58 %) and T3 = 14 (22 %). In two patients a squamous cell carcinoma was associated with an IP ( = T4 stage). Most tumors were localized within the nasal cavity (72 %) or the anterior ethmoid (62 %). In 10 patients an infiltration of the bony skull base was present. During the follow-up period 6 patients developed recurrencies corresponding to an overall recurrence rate of 9.4 %.CONCLUSIONS:The advances in endonasal micro-endoscopic surgery allow both safe and effective removal of IP with low morbidity, and therefore it should be the approach of the first choice. The osteoplastic approach combined with endonasal surgery is suitable in far lateral located IP. Close follow-up is mandatory to ensure the surgical success.

BACKGROUND:Surgical therapy for paragangliomas (PG) of the head and neck is, due to the alternatives of radiation therapy and wait-and-scan strategy and because of postoperative morbidity, under ongoing discussion.MATERIAL AND METHODS:Between 1981 and 2004, 79 patients with 94 PG of the head and neck were treated at our department. These patients had follow-up examination within a clinical trial considering tumor control, functional results and for the first time neuropsychologically evaluated postoperative quality of life. Mean follow-up time was 65 months (1 to 228 months).RESULTS:Among the 94 PG there were 19 carotid body (GCP), 12 vagal nerve (GVP) and 63 jugular-tympanal paragangliomas (JTP). Of these, 87 tumors underwent surgery. In 68 patients (78.1 %), the tumor could be removed completely. In particular, complete resection of GCP was achieved in 100 %, of GVP in 90.9 %, of JTP type A in 100 %, of JTP type B in 83.3 %, of JTP type C in 66.6 % and of JTP type D in 61.5 %. During the follow-up period, residual or recurrent tumors were diagnosed in 17 patients (19.5 %). Six of the seven residual PG were observed by magnetic resonance tomography and did not show growth. One residual PG and 6 recurrencies were resected completely. One recurrent tumor was radiated and 3 others are under observation without showing growth tendencies. Two patients died postoperatively due to borderline operations of extended tumors. The quality of life after PG surgery showed a SIP of 4.8, which is comparably much better than after acoustic neuroma surgery (SIP 10.3).CONCLUSION:Whereas complete tumor resection of GCP and JTP types A and B is almost ever possible without cranial nerve palsies, surgery of GVP and advanced JTP causes often severe functional deficits. However, postoperative quality of life is mostly good. Nevertheless, advanced PG require an individualized therapeutic regime also including radiation and observation of tumor growth.

Background: The goal of this study was to assess the potentials and limitations of endonasal micro-endoscopic surgery in the treatment of sinonasal inverted papilloma (IP) and to demonstrate long-term results.Patients and Methods: From 1989 to 2005, 64 patients underwent resection of IP via an endonasal approach using either the endoscope or microscope. Charts were reviewed retrospectively for presenting symptoms, radiological and intraoperative data. All patients were followed by endoscopic and MRI control during a period of up to 174 months, median follow-up was 78 months.Results: Our study group consisted of 26 male and 38 female patients with an average age of 54.3 years. The majority of the patients (67%) complained of unilateral nasal obstruction. 52 patients (81%) were referred for primary surgery. In 12 cases (19%) recurrent tumors were operated. According to the Krouse classification for IP the tumors were staged as T1 = 11 (17%) cases, T2 = 37 (58%) and T3 = 14 (22%). In two patients a squamous cell carcinoma was associated with an IP (=T4 stage). Most tumors were localized within the nasal cavity (72%) or the anterior ethmoid (62%). In 10 patients an infiltration of the bony skull base was present. During the follow-up period 6 patients developed recurrencies corresponding to an overall recurrence rate of 9.4%.Conclusions: The advances in endonasal micro-endoscopic surgery allow both safe and effective removal of IP with low morbidity, and therefore it should be the approach of the first choice. The osteoplastic approach combined with endonasal surgery is suitable in far lateral located IP. Close follow-up is mandatory to ensure the surgical success.

BACKGROUND:The aim of the study was to evaluate postoperative hearing, facial nerve function, quality of life (QOL), affective status and neuropsychological performance after trans-temporal removal of acoustic neuromas (AN).PATIENTS AND METHODS:A retrospective analysis was carried out in 89 patients with AN who were operated at the ENT-Department of the Hospital Fulda between 1988 and 2004. Median follow up was 57 months. Of these 41 patients were additionally examined by a psychologist for evaluation of QOL, neuropsychological functions and affective disorders using several questionnaires.RESULTS:The AN were classified as follows: Type A = 53 %, type B = 35 % and type C = 12 %. One year postoperatively facial nerve function was excellent in 93.3 % of the patients (grade I and II). In 53 % of cases hearing could be preserved. The subjective QOL was expressed through depression and social withdrawal associated with deafness. However, facial nerve dysfunction did not lead to QOL effect. Objective QOL (functional level) was reduced because of verbal memory disturbances and symptoms like dizziness. In 47.5 % of the patients affective and/or neuropsychological dysfunctions were diagnosed. Subsequent MRI evaluation showed lesions of the temporal lobe in 40.5 % of the cases. Of these 80 % suffered from cognitive and/or affective disturbances.CONCLUSIONS:The cognitive and affective disturbances after trans-temporal removal of AN could be to a certain degree due to the elevation of the temporal lobe during surgery. Further research, especially pre- and postoperative examination of QOL and psychological state as well as the comparison between different approaches, particularly trans-temporal vs suboccipital have to clear up specific morbidity of the different approaches.

Background: Congenital nasal fistulas and cysts are uncommon craniofacial malformations. Mostly their symptoms appear already during childhood. In general, they are superficially located but they can reach the skull base or extend intracranially.Patients and Methods: Between 1979 and 2004 fifteen patients (11 children and 4 adults) with nasal fistulas and cysts were treated surgically at the ENT-Department of the Hospital Fulda gAG. In 7 patients (46.6%) the skull base was involved. An intracranial intradural extension was found in 1 child and therefore needed a combined ENT and neurosurgical procedure. In the other 6 cases the nasal fistulas or cysts were located extradurally. They were resected by removing the Christa galli and strenghten the dura. An additional septorhinoplasty was carried out in 4 of the 15 patients. Within the follow-up period of up to 25 years no recurrences were observed.Conclusions: The adequate therapy of nasal fistulas and cysts consists of complete resection. Magnetic resonance tomography (MRI) and computed tomography (CT) are essential to diagnose intracranial extension and to choose the proper surgical approach including a potential interdisciplinary procedure.

Background: There are many autogenous and allogenous grafts as well as alloplastic materials available for the reconstruction of craniofacial bony frame. We review our techniques and describe the advantages of using calvarial bone, especially split-thickness grafts for bone reconstruction in this area.Patients and Methods: Between 1996 and 2003 the orbitocranial bony frames of 15 patients were reconstructed using split calvarial bone grafts at the ENT-Department of the Hospital Fulda gAG. In 12 patients the anterior frontal sinus wall or the entire Os frontale were affected. In 1 patient each the lateral wall, roof and floor of the orbit had to be reconstructed. The causes of the bone defects were trauma (n = 6), recurrent frontal sinusitis partly with osteomyelitis (n = 4), benigne tumors (n = 2) and malignancies (n = 3). Twelve patients have had multiple previous operations. In 3 patients the bone reconstruction was performed in the same operation as the tumor removal. Within the follow-up period between 2 and 8 years the split calvarial bone grafts remained stable in size and shape. Graft rejection, osteomyelitis or bone resorption did not occur. Furthermore, we have not experienced significant complications in harvesting cranial bone and have not seen major donor site morbidity.Conclusions: Our results demonstrate that split-thickness calvarial bone is an excellent graft not only for facial and forehead contouring but also for orbital and complex craniofacial reconstruction.

BACKGROUND:The aim of this study was to determine the best surgical approach in the treatment of paranasal sinus mucoceles according to their localization. MATERIAL AND METHODS:A retrospective analysis was carried out in 255 patients with 290 sinus mucoceles who were treated surgically at the ENT-Department of the Hospital Fulda gAG between 1983 and 2001. This series include 125 frontal sinus, 23 frontoethmoid, 41 ethmoid, 72 maxillary sinus and 26 sphenoid mucoceles. The patients' history, presenting symptoms, radiological findings, and surgical management were reviewed. Of them, 185 patients were followed by endoscopic and CT or MRI control during a period of up to 19 years, median follow-up was 12 years. RESULTS:In 168 out of 255 patients (66 %) the mucoceles were arisen due to previous sinus surgery, in 37 cases (14 %) after traumatic lesions, in 5 patients (2 %) due to chronic sinusitis and in 2 cases (<1 %) according to tumors. In 43 cases (17 %) no causes were found. In 78.8 % the previous operation was performed via an external approach, either according to Jansen/Ritter or Caldwell-Luc, contrary to 1.5 % after endonasal surgery. The median period until mucocele appearance was 15 years for maxillary sinus, 13 years for frontoethmoid, 10 years for ethmoid, and 8 years for frontal and sphenoid sinus celes, respectively. 201 mucoceles (69.3 %) have been operated endonasal micro-endoscopically, 18.6 % via the osteoplastic approach, 10 % endoscopically combined with an osteoplastic procedure and only 2 % according to Jansen/Ritter. Thereafter, recurrence of mucoceles was found in 4 patients only ( = 2.2 %; related to the endonasal approach = 1.6 %). CONCLUSION:Frontoethmoidal, ethmoidal, sphenoidal and maxillary sinus mucoceles are excellent indication for exclusively endonasal micro-endoscopic surgery. The osteoplastic approach combined with endonasal surgery is suitable in far lateral located frontal or maxillary sinus mucoceles.

BACKGROUND There are many autogenous and allogenous grafts as well as alloplastic materials available for the reconstruction of craniofacial bony frame. We review our techniques and describe the advantages of using calvarial bone, especially split-thickness grafts for bone reconstruction in this area. PATIENTS AND METHODS Between 1996 and 2003 the orbitocranial bony frames of 15 patients were reconstructed using split calvarial bone grafts at the ENT-Department of the Hospital Fulda gAG. In 12 patients the anterior frontal sinus wall or the entire Os frontale were affected. In 1 patient each the lateral wall, roof and floor of the orbit had to be reconstructed. The causes of the bone defects were trauma (n = 6), recurrent frontal sinusitis partly with osteomyelitis (n = 4), benigne tumors (n = 2) and malignancies (n = 3). Twelve patients have had multiple previous operations. In 3 patients the bone reconstruction was performed in the same operation as the tumor removal. Within the follow-up period between 2 and 8 years the split calvarial bone grafts remained stable in size and shape. Graft rejection, osteomyelitis or bone resorption did not occur. Furthermore, we have not experienced significant complications in harvesting cranial bone and have not seen major donor site morbidity. CONCLUSIONS Our results demonstrate that split-thickness calvarial bone is an excellent graft not only for facial and forehead contouring but also for orbital and complex craniofacial reconstruction.

BACKGROUND:Congenital nasal fistulas and cysts are uncommon craniofacial malformations. Mostly their symptoms appear already during childhood. In general, they are superficially located but they can reach the skull base or extend intracranially. PATIENTS AND METHODS:Between 1979 and 2004 fifteen patients (11 children and 4 adults) with nasal fistulas and cysts were treated surgically at the ENT-Department of the Hospital Fulda gAG. In 7 patients (46.6 %) the skull base was involved. An intracranial intradural extension was found in 1 child and therefore needed a combined ENT and neurosurgical procedure. In the other 6 cases the nasal fistulas or cysts were located extradurally. They were resected by removing the Christa galli and strenghten the dura. An additional septorhinoplasty was carried out in 4 of the 15 patients. Within the follow-up period of up to 25 years no recurrences were observed. CONCLUSIONS:The adequate therapy of nasal fistulas and cysts consists of complete resection. Magnetic resonance tomography (MRI) and computed tomography (CT) are essential to diagnose intracranial extension and to choose the proper surgical approach including a potential interdisciplinary procedure.

Introduction: Under ongoing discussion is the subject of surgical therapy for paragangliomas (PG) of the head and neck region, including the alternatives of radiation therapy and the wait and scan strategy and the occurrence of postoperative morbidity.

Introduction: The aim of the study was to evaluate the postoperative hearing and facial nerve function and the quality of life (QL) after removal of vestibular schwannomas (VS).

Background: The aim of the study was to evaluate postoperative hearing, facial nerve function, quality of life (QOL), affective status and neuropsychological performance after transtemporal removal of acoustic neuromas (AN).Patients and Methods: A retrospective analysis was carried out in 89 patients with AN who were operated at the ENT-Department of the Hospital Fulda between 1988 and 2004. Median follow up was 57 months. Of these 41 patients were additionally examined by a psychologist for evaluation of QOL, mnestic functions and affective disorders using several questionaires.Results: The AN were classified as follows: Type A = 53 %, type B = 35 % and type C = 12 %. One year postoperatively facial nerve function was excellent in 93.3% of the patients (grade I and II). In 53 % of cases hearing could be preserved. The subjective QOL was expressed through depression and social withdrawal associated with deafness. However, facial nerve dysfunction did not lead to QOL effection. Objective QOL (functional level) was reduced because of verbal memory disturbances and symptoms like dizziness. In 47.5% of the patients affective and/or mnestic dysfunctions were diagnosed. Subsequent MRI evaluation showed lesions of the temporal lobe in 40.5% of the cases. Of these 80% suffered from cognitive and/or affective disturbances.Conclusions: The cognitive and affective disturbances after transtemporal removal of AN Could be to a certain degree due to the elevation of the temporal lobe during Surgery. Further research, especially pre- and postoperative examination of QOL and psychological state as well as the comparison between different approaches, particularly transtemporal vs suboccipital have to clear up specific morbidity of the different approaches.

Introduction: The aim of the present study was to establish the efficacy of endonasal microendoscopic surgery for removal of benign and malignant neoplastic lesions of the paranasal sinuses and the anterior skull base.