Biomedical subjects
Publications and source records attributed to K Jahnke.
Verrucous carcinomas (Ackerman tumors) are rare. The tumor is slow growing, locally invasive and is not supposed to metastasize. It is therefore thought to be unnecessary to perform a neck dissection. Two patients with local metastazing verrucous carcinomas (oral cavity and larynx) are presented. The possibilities of therapy are discussed with reference to the two cases presented and according to the literature.
A double-blind study was performed on nine pigmented guinea pigs which were unilaterally operated on in order to create an endolymphatic hydrops. After 12-18 months, both inner ears of the animals were removed and investigated by the freeze-fracture technique. The ultrastructure of the epithelial cells lining the endolymphatic compartment of the cochlea and the vestibular apparatus was analyzed. Special attention was directed to possible changes of the tight junctions (zonulae occludentes) in these sites. The number and depth of strands between the cells of sensory and non-sensory epithelia of both operated and unoperated sides were compared by an examiner unaware of the operated side. After the code of double-blind study was broken, it was found that there were no significant differences between the operated and the unoperated ears. These results are discussed in relation to the late DC-potential decrease in experimentally induced hydrops.
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A long-term review of 140 ears in 133 patients was carried out. All ears had first been operated on in 1971 and 1972 for cholesteatoma in the E.N.T. clinic. A closed technique was used in 110 ears and in the remaining 30 ears an open technique, depending on the pneumatisation of the mastoid, the extent of the cholesteatoma, tubal function and the age and social circumstances of the patient. At that time, second-look operations were carried out on relatively few patients after a closed operation. While the short-term results were favourable, recurrent cholesteatomas still developed 8 to 10 years later; 9 were discovered at this review alone. The long-term incidence of recurrence was 25%. Recurrent cholesteatomas were found in 57% of patients who were first operated on for a cholesteatoma before the age of 21, 24% of those between 21 and 40, and 11% of those between 41 and 60. These results reaffirm the necessity for a planned second-look operation in all young patients and also the importance of outpatient follow-up over many years.
The excellent tolerance of bio-inert aluminium oxide ceramic after being implanted into the middle ear has been shown by our electron microscopic studies and clinical experience over 4 years. Our implants developed for ossicular chain reconstruction were covered by a delicate middle ear mucosa within a few weeks. We have observed no foreign body reactions. The ceramic implants are distinguished by the almost unlimited number of forms or shapes into which they can be ground quickly and precisely during operation. We value Al2O3 ceramic implants because there is no bony fixation with the surrounding bone but rather a joint-like connection with the remaining parts of the ossicular chain.
The paper reports on the obliteration of mastoid cavities with resorbable tricalcium phosphate ceramic. As a model, we chose the pneumatic air cell system of the pig's hypotympanon, which resembles the human mastoid. At the time of surgery, the specimens were 10-12 weeks old. In a first group the cells of the hypotympanon were totally removed and the operation cavity was obliterated with adjacent layers of porous tricalcium phosphate ceramic. In a second group of specimens the air cell system was partly removed, leaving the apical part of the hypotympanon intact; the operation cavity was obliterated again with porous tricalcium phosphate ceramic. After 12 and 18 months survival the hypotympanons were removed and prepared for histological investigations. Those ceramic plates, lying close to the bony shell were strongly resolved and replaced by new bone. Other ceramic plates, however, especially those in the center of the implant, showed few signs of resorption and bony remodelling. Inside the ceramic implant there was hardly connective tissue. The space between the still unsolved ceramic plates was filled up with new bony tissue. This bone was partly structured and adjoined directly to the ceramic. The ceramic was integrated into the new bony tissue without any sign of an inflammation.
Our surgical techniques for the complete removal of large tumours of the anterior skull base are described. Neurosurgeon and otolaryngologist should perform this surgery together. However, only in few cases a combined transfrontal and subfrontal approach is indicated. In cases where the sinuses of both sides are involved the approach of Schloffer offers some advantages in combination with modern techniques of reconstruction. Special attention is directed to the reconstruction of large defects of the skull base with ceramics (e.g. highly pure aluminium-oxide-ceramic, porous tricalciumphosphate ceramic).
A survey is given concerning different techniques for the restoration of voice after total laryngectomy. Our experiences with tracheo-esophageal shunts without or with valve prostheses are compared and the advantages of specific surgical methods are reported. The threedimensional postoperative voice recording (fast Fourier-transformation) is demonstrated. Special attention is directed to case selection. For most of our patients (80%) who are receiving postoperative radiation therapy we recommend a two stage procedure.
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We studied the middle ear mucosal reaction to implanted plastic materials. The implants were removed from noninfected middle ears from 9 months to 20 years postoperatively. In most cases the mucosa was normal, and invariably the implant was covered by a thick fibrous capsule. Beneath the fibrous layer and within the pores epitheloid cells and giant cells, both with finger-like projections, were found. In addition, the pores of the prostheses contained vacuolated cells, macrophages and histiocytes in various developmental stages. These findings are typical of foreign body reaction and chronic resorptive processes.
A case report of a 60 year old female, who suffered from a perforation of the upper esophagus (broken dental prosthesis) and developed an acute candida albicans mediastinitis, is presented. There were no clinical indications for a mycosis (e.g. diabetes mellitus, esophagitis). The diagnostic criteria inclusively the role of computer-tomography as well as the surgical treatment (collar mediastinotomy) and antibiotic treatment are briefly discussed.
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Because of the slow lingering course of this disease, the diagnosis of hypothyroidism is generally made by chance particularly because the euthyroidism can change unobserved into manifest hypothyroidism. In old age the course of hypothyroidism may be oligosymptomatic: only adynamia and abnormal susceptibility to cold may be diagnosed. Because of the augmented oxygen requirement of tissues during therapy with thyroid hormones the medical treatment of hypothyroidism has to start - especially in old age - with a fractional part of the final dose. In old age bland struma more and more changes to nodular struma, where small autonomic areas are often developed. Conservative therapy with thyroid hormones predominates in this case. Radioiodotherapy is indicated when medical treatment has been without success and operation is contraindicated because of high risk. Cancer of the thyroid is important - with respect to differential diagnosis - especially in older patients. Cancer of the thyroid is most common in patients aged between 50-70 years, and the anaplastic carcinoma is the most frequently observed malignant growth of old age. Concerning therapy, a radical operation comes into consideration; if radical operation is combined with too high risks, remaining tissue may be treated by radioiodotherapy without danger.
The clinical signs of thyroid disease in older people may differ considerably from those in younger patients. The symptoms are often incorrectly interpreted and attributed to old age. The age is also important to the kind of therapy. The normal clinical hyperthyroidism-indices are not relevant in the diagnosis of hyperthyroidism in older patients. Organic symptoms predominate in old age (loss of weight, muscular asthenia, tremor, cardiac arrhythmia, stenocardia, congestive cardiomyopathy). Most of the time they are wrongly interpreted as additional symptoms of old age. Probably it is not the age that causes the difficulties in hyperthyroidism-diagnostics in old age, but the atypical symptoms of solitary or multilocular adenomas, which increase with advancing age. A special symptom of hyperthyroidism in old age, often misinterpreted, is "apathetic" hyperthyroidism. Radioiodotherapy is indicated in older patients with hyperthyroidism.
HLA antigens A, B, C, DR and BF were determined in 14 sibling pairs with type I diabetes and in 61 patients without familial risks. Significantly positive associations of the disease with HLA DR3 and DR4 and a negative association with DR2 were found. Positive and negative associations with the various HLA A, B and C antigens (A1, A2, B8, B15, B18, Cw3) are of a secondary nature due to strong genetic coupling with primarily associated DR alleles. Localisation of diabetes-associated genes in the HLA DR region could be demonstrated in two families with HLA recombinations. In both cases the hypothetic disease gene segregated with the HLA DR segment. Joint evaluation of these data in an international series involving 1200 type I diabetics showed furthermore that around 90% of all patients are DR3 and/or DR4 positive, that the highest morbidity risk exists in DR3/4 heterozygosity and that DR4 positive persons usually fall ill before their 20th year of life and frequently in the last 3 months of the year. Allotment of clinical, epidemiological, virological and immunological criteria of type I diabetes to only one of the both risk factors indicates heterogeneous immunopathogenesis of the disease. HLA DR3 predisposes particularly to endocrine autoimmune disease and DR4 to increased virus susceptibility.
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We have examined the suitability of ceramic materials for reconstruction in middle ear surgery. The excellent tolerance of bio-inert aluminum oxide ceramic implanted into the middle ear has been shown by our electron microscopic studies and clinical experience. Our implants developed for ossicular chain reconstruction were covered by a delicate middle ear mucous membrane within a few weeks. We have observed no foreign body reactions. The ceramic prostheses are distinguished by the almost unlimited number of forms or shapes into which they can be ground quickly and precisely during the operation. We value Al2O3 ceramic implants because there is no bony fixation with the surrounding bone, but rather a jointlike connection with the remaining parts of the ossicular chain. The composition of resorbable tricalcium phosphate, bio-active ceramic, corresponds to the inorganic component of bone. Because it exhibits the characteristic of being replaced by autogenous bone, we consider it for the obliteration of mastoid cavities. Based on our preliminary experience, dense tricalcium phosphate ceramic might play a valuable role in the reconstruction of the posterior auditory canal wall. In addition, we have used dense tricalcium phosphate ceramic to correct minor ossicular chain defects (for example, erosion of the long process of the incus). A survey is given concerning the indications and techniques for the use of these new materials in middle ear surgery, as well as our results covering a period of three years, which are very encouraging as far compatibility and function are concerned.