Biomedical subjects
Publications and source records attributed to H Glanz.
Two cases of laryngeal cancer following gunshot injury are presented, and the relation of trauma to the development of cancer is discussed. A correlation between the two is accepted in medicolegal reports if a number of requirements are met. Histomorphological examination shows that these criteria are insufficient to provide conclusive proof.
Today an individualized proceeding is possible thanks to the progress in diagnostics. Different degrees of surgical procedures can be applied. The following methods are available: maxillectomy (partial transoral resection of the upper jaw, transfacial resection of the upper jaw, extended transfacial resection of the upper jaw) and lateral rhinotomy (lateral osteoplastic rhinotomy with resection of the ethmoid bone and evisceration of the inner nose, lateral osteoplastic rhinotomy with extended resection of the ethmoid bone, combined transfacial craniofrontal resection of the ethmoid bone).
The results in the management of 460 vocal cord carcinomas and 124 supraglottic carcinomas are reported. Of the vocal cord carcinomas, 63.3% were diagnosed in the early Tis and T1 stage. Seventy-six tumors were resected endoscopically, 128 by laryngofissure and chordectomy. Not one of these patients has lost his life, larynx or voice. In bilateral tumors of the T1b category, 2 patients developed local recurrences and lost their larynx. Sixty-two carcinomas of the Tis, T1a and T1b categories were irradiated primarily. Two of these patients died and 14 underwent laryngectomy for local recurrence. In T2 carcinomas a 5-year cure rate of 87.5% was achieved by vertical partial resection. The 5-year cure rate after laryngectomy or laryngectomy with neck dissection for T2N0 and T2N+ carcinoma was 86.2% and 75.0% respectively. Most treatment failures were due to late metastases which could not be controlled. In T3 carcinomas with a 5-year cure rate of 71.4% (N0) and 70.0% (N+) respectively, treatment failures were also mainly seen in patients with N0 necks where we did not carry out a prophylactic neck dissection. Five-year survival rates for primary surgery in supraglottic T1-T4 carcinomas were 100%, 82.4%, 84% and 58.3%. The widely hel opinion that laryngeal carcinoma should only be subjected to surgery for irradiation failure can no longer be sustained. More patients lose their larynx or their life after irradiation of small carcinomas than after primary surgery. Furthermore, too many patients have to undergo two major cancer treatments (irradiation and salvage surgery). In larger carcinomas radiotherapy produces a lower survival rate and too many patients require two stressful cancer therapies. The number of retained larynges is not substantially higher than with primary surgery. Primary irradiation for selected cases should be part of every therapy concept that aims at an adequate and individual treatment of every patient.
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Correlations between the manifestation of obstructive sleep apnoea syndrome (OSAS) and anatomical or functional changes in the upper respiratory tract remain controversial. The correlation between obstruction of the upper respiratory tract and the degree of sleep apnoea syndrome was investigated in 60 patients with obstructive sleep apnoea (diagnosed by polysomnography) and in 55 healthy controls. After clinical examination, rhinomanometry and determination of the size of the lower jaw and oropharynx, the motility of the pharyngeal walls during Mueller's manoeuvre was evaluated by flexible endoscopy. No significant anatomical or functional differences were observed between OSAS patients and healthy controls. There was no correlation between the degree of OSAS (expressed by the apnoea index) and pharyngeal size. Although no specific statement concerning diagnosis or degree of OSAS can be made on the basis of an otolaryngological examination, OSAS patients should always undergo otolaryngological examination to exclude pharyngeal disease.
Controversy began in the last century as to whether endoscopic surgery for vocal cord carcinoma carries an unnecessary risk for the patient. This controversy has been renewed since microlaryngoscopy offered the possibility of precise endoscopic resection of a vocal cord carcinoma. The most decisive prerequisites are careful assessment and adherence to strict indications. We only remove small carcinomas arising on freely mobile vocal cords by endoscopy, if the tumour is fully visible through a larger calibre operating laryngoscope. We prefer to use conventional microsurgical instruments rather than the laser. The specimen should be taken in one piece and be subjected to histological examination. Every patient must be closely followed up. A total of 76 patients with carcinomata in situ (Tis a, Tis b) and microinvasive carcinomas (T 1a, T 1b) have been followed for up to 8 years. So far not a single patient has lost his life, his larynx or his voice, or needed an additional external operation or irradiation. The results of endolaryngeal microsurgery for smaller vocal cord tumours are achieved with a minimum cost in time and money, and the least possible burden for the patient. They are scarcely inferior to primary irradiation with respect to the voice and are definitely better with respect to cure. However such results are only achieved in very carefully selected cases.
A serie of our observations of so-called "verrucous carcinomas" of the larynx show that these peculiar lesions do not develop true infiltrating growths or metastases, and do not fulfill the criteria of a true carcinoma. Our experiences indicate that these cases can be treated successfully by repeated endoscopic resections. We have found that no aggressive radical treatment - either by surgery or irradiation - is necessary in managing these lesions. Although the etiology of "Ackerman's tumor" of the larynx is still uncertain, we suggest that the lesions develop as the result of a virus infection and propose again the term "verrucous acanthosis" instead of verrucous carcinoma for this disease.
An attempt was made to assess the immunological importance of regional lymph node histology in relation to the survival of 107 patients with carcinoma of the larynx, operated on from 1973 to 1982 at the ENT-Clinic in Marburg. A total of 2765 sections of lymph nodes removed during neck dissections were examined microscopically to evaluate the morphological patterns of response. Microscopically, four distinct patterns were defined. Patients whose lymph nodes demonstrated immunological responses according to patterns I and II in the form of either expanded inner cortices or increased numbers of germinal centers had a greater 5-year survival rate than those patients whose lymph nodes showed an unstimulated pattern. Eight patients whose lymph nodes showed a depleted pattern, IV, did not survive more than 3 years. Morphological assessment of immunological activity in lymph nodes draining malignant tumors seems to be of value in predicting survival. The evaluation of the reaction pattern and difficulties in methodology, however, set definite limitations to our study.
During a period of 2 1/2 years palpation and high-resolution real-time sonography were carried out in 83 non-selected patients with head and neck carcinomas to diagnose metastatic involvement of cervical lymph nodes. The findings were compared with the results of the microscopic examination of the lymph nodes from the neck dissection specimen. Sonography is characterized by a high sensitivity in the detection of lymph node metastases. The relatively low specificity of this method proves that many enlarged but not metastatically involved lymph nodes are also displayed by ultrasound. Although there are no specific echomorphological criteria permitting a reliable identification of lymph node metastases, their sonographic visibility cannot be determined only by the size of the lymph node. Lymph node metastases less than 1.5 cm in diameter, in particular, can be detected more often by ultrasound than by palpation. Therefore, it can be presumed that pathological transformations besides the reactive hyperplasia occurring during metastatic involvement will also influence the echographic representation of lymph nodes. The accuracy data of other methods used for detecting lymph node metastases (computed tomography and lymphoscintigraphy) were compiled from the literature and compared with those of palpation in more than 5000 patients. Basing on our experiences with sonography in this field we tried to assess the chances and limitations of ultrasound in the pretherapeutic diagnosis of cervical lymph node metastases.
During a 3 year period 572 high-resolution sonograms were carried out in the follow-up examinations of 348 patients who had been treated for ENT malignancy. Our experiences in routine application of this diagnostic method are described and illustrated by typical sonograms. Ultrasound findings of complications (chylous cysts, seromas, granulomas, fistulae) are demonstrated and the value and limitations of sonography in detecting lymph node metastases and primary recurrences are pointed out. In spite of the high accuracy of this method, it is not possible to differentiate between lymph nodes which are invaded by tumour and those with non-specific lymph adenopathy by echographic criteria only. We used ultrasound for follow-up studies on patients treated by irradiation or chemotherapy. Finally, sonography provided additional information on the exact site and size of the tumor. Real-time sonography is not time-consuming and can be applied without any special preparation of the patient. It has therefore become a satisfactory diagnostic method in the follow-up of patients who have undergone treatment of malignant tumors.
Excellent imagination of anatomy and diagnostic procedures are the basis for the diagnosis and therapy of orbital lesions. They can divided into (1) periorbital, and (2) intraorbital diseases: (1.1) fractures of the orbital floor; (1.2) alterations of the orbital roof; (1.3) endonasal ethmoidal removal; (1.4) operations for orbital decompression; (2.1) arterial lesion with increase of tension after retrobulbar injection, vulneration of the ethmoidal arteries and resection of orbital fat; (2.2) retrobulbar tumors. Examples are demonstrated. The most frequent complications are disturbances of motility, but operative revisions of these should not be done before 6 months have passed. Additional therapeutic recommendations are made.
Long term results show that the behaviour of vocal cord cancer of the same size and undergoing the same therapy may vary widely. The biological behaviour of the tumour was assessed by well defined histopathological criteria of the malignancy evaluated by subserial sections on 49 previously untreated vocal cord carcinomas pT2-T4. Two parameters were related to the tumour cell population: differentiation and polymorphism, as well as the structure and margins of the tumour. Two parameters were related to the tumour-host relationship: vascular and perineural invasion and the cellular response of the host. Each parameter was given a three point score. The resulting malignancy index (total score = 10) gave a significant prediction of prognosis: patients with or without metastasis can be separated, high risk patients can be recognised early and decisions regarding treatment and follow up may be planned.
Recommendations are given on the preparation of biopsy and resection specimens to achieve the best histological investigation. The demands on clinical pathology have now reached the point where they can only be fulfilled by a specialised histologist.
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Two patients with squamous cell carcinoma of the middle ear appearing 8 years after a tympanoplasty for cholesteatoma are reported. The tumours presented as a recurrent cholesteatoma and a temporal lobe abscess. The pathogenesis of these tumours is discussed.
Ameloblastomas of the maxilla usually arise in persons in the middle of their lives and do not show any predominance in sex distribution. Six case reports and a review of the literature demonstrate that the tumor mostly causes unspecific symptoms and therefore is often only diagnosed very late. In the majority of cases the initial treatment was irradiation or limited surgery, assuming that the ameloblastoma is a benign, non-metastasizing tumor. In such cases the tumor tends to recur repeatedly and the disease becomes early incurable by local growth. Therefore ameloblastomas of the maxilla have to be treated by radical surgery, usually maxillectomy, from the very beginning like malignant tumors.
It is well known that certain kinds of fractures of the facial skull occur repeatedly. In attempting to classify our own patients we came to the conclusion that an easy categorizing into the known schemes is rarely possible. Therefore, we propose a new classification based on 353 facial skull fractures, treated in our clinic during the last eight years. In doing so, we take into account not only the localization of the fracture, but also the degree of the injury in the form of a grading. Both of the large groups, lateral and central facial skull fractures, are further divided into isolated fractures of particular localisations (zygomatic arc, orbital floor fracture etc.) and compound fractures of varying degrees (lateral or central impression fractures of the mid-face Grade I-III). This classification, based on practical experience, allows the majority of all existing injuries to be freely categorized.
Unilateral recurrent laryngeal nerve paralysis with atrophic vocal cord and persisting glottic insufficiency as well as hemiparesis of the larynx caused by lesions of the upper parts of the vagal nerve have to be managed surgically. Instead of the nowadays often applied Teflon-injection the authors prefer the following techniques of surgical medialization. 1. Medial shifting of the paralyzed vocal cord by subperiostal implantations of autogenous cartilage through a window in the thyroid ala. 2. "Wing door thyroplasty" with medialization of a door like part of the thyroid cartilage which is locked by a cartilage chip in the desired position. The results of the surgical treatment of 19 patients (13 paresis of the recurrent laryngeal nerve, 6 lesions of the upper part of the vagal nerve) showed an obvious improvement with regard to voice and aspiration. There have been no postoperative complications. These methods can be an alternative to Teflon-injections.