Search PubMed⌕ Search

Biomedical subjects

R Keerl

Publications and source records attributed to R Keerl.

At least 19 recordsLinked to original sources
PubMed2004

[Dacryocystorhinostomy - state of the art, indications, results].

BACKGROUND: In the ophthalmological literature external dacryocystorhinostomy (DCR) is considered the gold standard for the treatment of lacrimal duct stenoses. Rhinologists, on the other hand, favour the endonasal approach. MATERIALS AND METHODS: On the basis of an extensive review of the literature and our own longstanding experience we present an overview of the causes, the necessary diagnostic procedures and the surgical management of lacrimal duct stenosis. The outcomes of the two operative approaches are compared and special operative techniques and aids such as the use of laser, endoscopic dacryoplasty, silicone stenting, silicone cones with lacrimal duct stenting and the use of mitomycin C are discussed. RESULTS: The results published for endonasal DCR are slightly worse than those for the external operation. The success rates are around 90 %. Laser-assisted DCR and endoscopic dacryoplasty do not currently appear to yield better results than the conventional methods. Silicone stenting is not necessary in conventional endonasal DCR except in the case of presaccal stenosis. There are no established indications or treatment regimens for mitomycin C to date. Postoperative care after endonasal DCR should consist in the removal of fibrin, crusts and granulations and the administration of eye drops (antibiotic + cortisone) and nasal steroids. DISCUSSION: With appropriate operative technique and in experienced hands, the success rates of endonasal DCR are practically equal to those of the classical external approach. Major advantages of the endonasal approach are shorter operation times, lower complication rates and reduced patient morbidity. Neither silicone stenting nor the application of mitomycin C are routinely indicated. Laser-assisted techniques do not currently appear to improve results. Appropriate postoperative care is essential to prevent endonasal synechiae and subsequent recurrences.

Dacryocystorhinostomy↗
PubMed2004

[Gastroesophageal reflux disease and chronic sinusitis].

BACKGROUND: It is increasingly suggested that there may be a connection between gastrooesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) and chronic sinusitis. We therefore wished to establish whether the literature contains sufficient evidence to support this assumption. MATERIAL AND METHODS: We performed a search in Medline (PubMed) and EMBASE with the key words "GERD, GER, reflux, sinusitis, chronic sinusitis". The literature obtained was assessed with regard to the reported results and their evidence levels. The level of evidence was classified according to the usual levels I - IV, only levels Ia or Ib being considered sufficient evidence for a knowledge gain confirmed by therapeutic trials. RESULTS: A total of 77 references were found in Medline and 142 in EMBASE. A large number of these were narrative review articles addressing the connection between GERD or sinusitis and asthma or GERD or sinusitis and chronic cough. Only 12 papers and one case report dealt more or less directly with the question of a connection between chronic sinusitis and reflux. None of the studies could be classed as evidence level I (randomised controlled trials), ten were classed as level III studies, one as level IIb and one as level IV. DISCUSSION AND CONCLUSIONS: The existing studies do not allow us to pinpoint LPR (and even less so GERD) as a clear-cut factor in the aetiopathogenesis of chronic sinusitis. However, despite all their deficiencies and limitations the studies nevertheless do show that reflux into the pharynx and nasopharynx is possible. This reflux (= LPR) can lead to chronic inflammation which can be successfully treated with antireflux therapy with proton pump inhibitors. Quantification of the association is not currently possible. An above-average proportion of the patients with chronic rhinosinusitis appear to have GERD/LPR. However the prevalence of GERD in the population is generally high. It has not yet been established with sufficient certainty whether the LPR must be regarded as a causative factor, whether it exacerbates or chronifies the disease or whether it is merely an epi-phenomenon which does not require specific treatment. To answer this important question we need prospective randomised controlled studies which will provide evidence of sufficient quality. These should be conducted with the help of standardised documentation.

Adolescent↗
PubMed2003

[First experiences in endonasal duraplasty without antibiotics].

BACKGROUND: Available evidence does not support the use of prophylactic antibiotics in patients with CSF fistulae. The question arises whether an antibiotic prophylaxis or therapy is mandatory planning an operative closure of frontobasal dural lesions. PATIENTS: In a retrospective survey a consecutive sample of 7 patients who had undergone endonasal ENT-department of two universities and an university teaching hospital was taken. The hospital course was evaluated and all patients were interviewed after a postoperative period between 6 and 36 months. Endonasal duraplasty by underlay or onlay technique without pre- or intraoperative application of antibiotics was performed. Hospital course, development of meningitis, need for antibiotic therapy later on, subjective complaints, history of meningitis, cerebrospinal fluid rhinorrhea, fluoresceine test (intrathecal administration of fluoresceine sodium and subsequent nasal endoscopy) were evaluated. RESULTS: 6 patients had an uneventful postoperative hospital course without any sign of inflammatory complications. In one patient with a larger resection of dura antibiotics were administered at the second postoperative day because of recurrent fever. There occurred no meningitis in any patient. All duraplasties were successfully closed. 5 patients showed a negative fluoresceine test, 2 patients denied it having no special problems. CONCLUSIONS: Duraplasty can be performed satisfactorily by endonasal approach. In small lesions and in the absence of special risk factors (diabetes, acute sinusitis, immunodeficient patients) endonasal duraplasty don't seem to inevitably need an antibiotic cover. A larger patient population is necessary to confirm these results.

Adult↗
PubMed2003

[Complications of lumbar administration of 5% sodium fluorescein solution for detection of cerebrospinal fluid fistula].

BACKGROUND: The detection of cerebrospinal fluid fistulas in the region of the anterior or lateral skull base can be difficult. The fluorescein test with lumbar administration of 5% sodium fluorescein solution can be used to detect cerebrospinal fluid leakage, identify weak points in the dura, achieve precise localisation of cerebrospinal fluid fistulas and to check intraoperatively that watertight dural closure has been achieved. However, use of the test is problematic as the fluorescein solution used is not licensed for this indication in Germany and severe neurological complications are described in the literature. In order to clarify the legal situation regarding use of the test, we therefore analysed the complications occurring in a sizeable patient sample. METHOD: The records of all patients in whom a fluorescein test had been performed between 1979 and June 2000 were analysed retrospectively for the occurrence of complications. RESULTS: The most frequent complication in the 368 fluorescein tests performed was headache, followed by nausea and vomiting, temperature elevation, dizziness and nuchal pain. These side-effects were no more frequent than described for lumbar puncture alone. Twenty-six patients experienced side-effects on the day of the operation, 65 on the first postoperative day, 36 on the second day, 34 on the third day and 13 patients after the third day. There were two cases of grand mal seizures following concomitant intrathecal contrast medium administration. None of the patients had side effects persisting longer than 4 weeks. CONCLUSIONS: Intrathecal administration of a 5 % fluorescein solution is a safe procedure provided that the maximum dosages are not exceeded and the solution is prepared and administered correctly and in accordance with the specified indications and contraindications. In view of its great diagnostic benefit and low risk when properly used, the dictates of therapeutic freedom allow use of this drug despite the fact that it is not licensed for this purpose in Germany. It is necessary to obtain written informed consent from the patient.

Adolescent↗
PubMed2002

Magnetic resonance imaging following fat obliteration of the frontal sinus.

The paper describes the evaluation of magnetic resonance imaging (MRI) following osteoplastic flap procedure with fat obliteration. MRI scans performed in patients after surgery between 1st January 1986 and 31st December 1997 were evaluated. Outcome parameters were time-dependent changes in the distribution of adipose or connective tissue, development of necroses or oil cysts, recurrences, inflammatory complications, or mucocoeles. Eighty-six postoperative MRI scans from 51 operations were evaluated. In 19 cases between two and five MRI scans were available. Time between surgery and the last MRI scan was 24.1 months on average. We found five mucocoeles. The amount of adipose tissue depictable on the last scan was less than 20% in the majority of cases (53%) and more than 60% in only 18% of cases. Statistical tests and modelling showed a significant decrease of adipose tissue with time, with a median half-life of 15.4 months in a subgroup with at least two MRIs. MRI is at times the most valuable diagnostic tool after frontal sinus obliteration using adipose tissue. The method has some limitations with regard to detection of small (recurrences of) mucocoeles and differentiation between vital adipose tissue and fat necroses in the form of oil cysts. In difficult cases long-term MRI follow-up is necessary for definitive evaluation.

Adipose Tissue↗
PubMed2001

Nasopharyngeal endoscopy adds to reliability of clinical diagnosis of infectious mononucleosis.

Frequently, the clinical picture in the oropharynx alone does not lend itself to a reliable differentiation between acute pharyngotonsillitis in infectious mononucleosis and a streptococcal inflammation. Such a differentiation, however, is essential for the indication of antibiotic therapy. Therefore, it was the aim of the present study to investigate whether or not endoscopic verification of larger-than-normal lymphatic tissue with fibrinous membranes in the nasopharynx would enhance the reliability of diagnosis. Fifty hospitalized patients exhibiting the clinical picture of acute pharyngotonsillitis were examined for the following parameters: nasopharyngeal endoscopy, determination of glutamine-oxaloacetic transaminase (GOT), glutamine-pyruvic transaminase (GPT), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), leucocytes and haemogram, antibodies to viral capsid antigen (VCA)-IgM, Epstein-Barr virus nuclear antigen (EBNA), and cytomegalovirus (CMV). In 24 patients with acute tonsillitis/peritonsillar abscess, and in 26 patients with infectious mononucleosis, the total leucocyte count in the blood and the blood/erythrocyte sedimentation rate were comparable. Atypical lymphocytes or absolute lymphocytosis were not seen in acute tonsillitis, but were found in 88.5 per cent of patients with infectious mononucleosis. Elevated transaminase levels were noted in 77 (GOT) and 88.5 per cent (GPT) of patients with infectious mononucleosis, and in acute tonsillitis in 4.2 (GOT) and 12.5 per cent (GPT) of patients. The CRP was higher than normal in 91.7 per cent of patients with acute tonsillitis, and in 57.7 of patients with infectious mononucleosis. In none of the patients with acute tonsillitis was lymphatic tissue with fibrinous membranes seen in the nasopharyngeal cavity. In contrast, nasopharyngeal endoscopy in infectious mononucleosis was positive in 24 out of 26 patients. Hence, the sensitivity was 92.3 per cent, the specificity 100 per cent, and the prediction value for a positive test turned out to be 1. Endoscopy of the nasopharngeal cavity employed as a simple and supplementary procedure adds to the reliability of diagnosis of infectious mononucleosis.

Adolescent↗
PubMed2000

[Transoral correction osteotomy in transdental fracture dislocation that healed in the wrong position].

Undislocated odontoid fractures may lead on the basis of conventional x-rays only to a wrong conclusion with regard to biomechanical aspect of stability. In this aspect the classification based on Anderson and D'Alonzo takes a high risk to misunderstand the fracture stability and can results in a secondary fracture dislocation. Therefore it is important to make the decision about operative versus nonoperative treatment on the base of the trauma mechanism. In this case report we elucidate this problem and the higher risk of anterior approach for correction. Furthermore a better classification of dens fractures will be recommended.

Adult↗
PubMed2000

[Endonasal endoscopic surgery of maxillary sinus mucoceles after Caldwell-Luc operation].

BACKGROUND: Mucoceles of the maxillary sinus after Caldwell-Luc procedure develop by entrapment of mucosa. Specially mucoceles far laterally were being revised by a second transoral approach. This procedure carries the risk of damaging the infraorbital nerve. In addition the problem of scarring at the bottle neck between the lateral recessus and the nasal cavity with reclosure remains. METHODS AND PATIENTS: In 3 patients with a mucocele of the maxillary sinus 4-25 years after Caldwell-Luc operation an endonasal endoscopic opening of the mucocele was performed. In addition a silicon spacer was placed for 6 months. RESULTS: Twelve to fifteen months postoperatively all 3 patients still had an uneventful maxillary sinus according to the data of endoscopy, computer-tomographic or MRI-examination. CONCLUSIONS: The endoscopic approach and the long standing placement of a splint seems to be a valuable alternative to a renewed somewhat risky Caldwell-Luc approach.

Adult↗
PubMed2000

[Value of multimedia educational software in training of the paranasal sinus surgeon].

BACKGROUND: When starting sinus surgery, every surgeon has to pass through an individual learning curve. To avoid complications, costly, time-consuming surveillance is necessary. We wanted to analyse the impact of multimedial teaching software on the learning curve. METHODS: A total of 1104 operations performed by four surgeons were evaluated. The first consecutive 200 operations by each surgeon were analyzed according to their complications. After revaluating the general phases of surgical development, we compared the first 90 operations by another group of four surgeons who had undergone training with the teaching program. RESULTS: Cauterization of the anterior ethmoidal anterior was nearly the same in both groups (10/8). Injuries of the dura dropped from 5 to 2, and periorbital lesions were reduced significantly from 20 to 5 (p < 0.001). CONCLUSIONS: Multimedial learning programs can reduce complications effectively and form a valuable part training.

Chronic Disease↗
PubMed2000

Osteoplastic frontal sinus surgery with fat obliteration: technique and long-term results using magnetic resonance imaging in 82 operations.

OBJECTIVE: To evaluate the intraoperative and late complications of osteoplastic sinus surgery with fat obliteration with long-term magnetic resonance imaging (MRI) follow-up. METHODS: The operative records of all patients who underwent osteoplastic frontal sinus surgery with fat obliteration between January 1, 1986 and December 31, 1997 were reviewed and the postoperative clinical course and magnetic resonance imaging (MRI) scans were analyzed if available. MRI analyses revealed that changes in the distribution of fatty and fibrous tissue, the development of necrosis or oil cysts, recurrences, inflammatory complications, and mucoceles were time-dependent occurrences. RESULTS: Eighty-two operative records were evaluated and 59 patients were followed 1 to 12 years after surgery. Eighty-six MRI scans in 51 patients were available for analysis. The most frequent intraoperative complications were exposure of orbital fat (19.5%), unintentional fracture of the anterior wall (19.5%), incorrect placement of the anterior wall (17%), and dural injury (9.8%). Persistent changes of the frontal contour (embossment, depression) occurred in 10.2% and the esthetic result was unfavorable in 5.1% of the cases. Mucoceles could be detected in 5 of 51 cases (9.8%). The amount of adipose tissue detectable in the last scan was less than 20% in the majority of cases (53%), and more than 60% in only 18% of the cases. The amount of adipose tissue decreased significantly with time (the median half-life was 15.4 mo). CONCLUSIONS: Osteoplastic frontal sinus surgery with fat obliteration is very useful and successful in patients in whom the frontal sinus is not accessible via an endonasal approach or the natural drainage cannot be reestablished. MRI is currently the most valuable diagnostic tool to evaluate the frontal sinus after obliteration with adipose tissue. The method has some limitations with regard to detection of small recurrent mucoceles and differentiating vital adipose tissue from fat necroses in the form of oil cysts. In these difficult cases, long-term MRI follow-up is necessary.

Adipose Tissue↗
PubMed1999

[Nuclear magnetic resonance tomography after fatty tissue obliteration of the frontal sinus].

BACKGROUND: The osteoplastic flap procedure with fat obliteration has been hailed as the gold standard of definitive frontal sinus procedures for chronic inflammatory disease. The value of magnetic resonance imaging (MRI) in postoperative follow-up has not yet been sufficiently examined. METHODS: All postoperative MRI scans performed in patients undergoing surgery between January 1, 1986, and December 31, 1996 were evaluated. The outcome parameters were time-dependent changes in the distribution of fatty or connective tissue and development of necroses or oil cysts, as well as recurrences, inflammatory complications, or mucoceles. RESULTS: Sixty-eight operations were performed in the specified period and a total of 73 postoperative MRI scans from 45 operations were available for evaluation. In 16 cases, between two and five MRI scans were available. The individual time between surgery and the last MRI scan ranged from two weeks to 130 months with an average of 30.1 months. We found four mucoceles 34, 49, 106, and 130 months, respectively. Three of the mucoceles were diagnosed on the first postoperative MRI scan. In the fourth case the mucocele had not been seen on the previous scan. The amount of adipose tissue depictable on the last scan was less than 20% in the majority of cases (58%) and more than 60% in only 18% of cases, although in the latter group the time between surgery and MRI was less than 7 months in half the cases. CONCLUSIONS: MRI is the most valuable diagnostic tool after frontal sinus obliteration using adipose tissue. Despite the good soft tissue differentiation, the method has some limitations with regard to detection of small recurrent mucoceles and differentiation between vital adipose tissue and fat necrosis in the form of oil cysts. In these difficult cases, long-term MRI follow-up is necessary for definitive evaluation. We therefore recommend MRI 1, 2, and 5 years after osteoplastic frontal sinus surgery with obliteration.

Adipose Tissue↗
PubMed1999

Surgical experience and complications during endonasal sinus surgery.

OBJECTIVE/HYPOTHESIS: The introduction of optical aids for endonasal sinus surgery has not produced the expected drop in the rate of serious intraoperative complications. STUDY DESIGN/METHODS: 1. Retrospectively, consecutive procedures of different surgeons were analyzed in regard to major complications (periorbital injury, orbital lesion, dural injury, endocranial lesion, damage to the internal carotid artery). The chronological distribution was transformed into a personal learning curve. 2. From our own experience and as surveyors, we analyzed the experiences of surgeons having encountered severe complications and compared them with the above-mentioned learning curve. RESULT: In total, 1,500 operations carried out by five surgeons with 16 serious complications were assessed. For the learning curve, the following stages were defined. stage I: greatest risk of complication, with dural injury (1st to 30th operation); stage II, slighter risk of complication, with frequent periorbital injuries (31st to 180th operation); and stage III, least risk, corresponding to an experienced surgeon. Serious complications occur most frequently among experienced surgeons. CONCLUSION: The beginner enjoys the most effective type of assistance, in the form of personal guidance of an experienced surgeon who is constantly present during the first 30 operations, and who should then be readily available during the next 70 operative procedures. The use of multimedia software appears to be helpful, though its actual value still remains to be determined. The experienced surgeon in particular must be willing to exercise repeated self-criticism to keep his or her rate of complications to a minimum.

Dura Mater↗
PubMed1999

Videoendoscopic analysis of nasal steroid distribution.

Topical corticosteroids are one of the main pillars in the treatment of nasal polyps. The exact topography of their intranasal deposition has not yet been adequately visualised. The intranasal distribution of a 1% sodium fluorescein solution applied with original Pulmicort Topinasal (budesonide) metered pump bottles was analysed by videoendoscopy. The study group included eight healthy subjects and ten patients who had undergone endonasal sinus surgery. Videoendoscopy was performed in the study group within the first minute after application of the fluorescein solution. Additionally the deposition pattern of Pulmicort Topinasal was analyzed using a nasal model. The examination showed that the majority of the substance is deposited on the anterior portion of the nasal septum and the head of the inferior turbinate. Only a small fraction actually reaches the middle meatus. The distribution is improved by application during the decongested phase of the nasal cycle, after use of vasoconstricting nasal drops and maintaining a spraying angle of 45 degrees upwards. The development of new delivery techniques and systems could improve the efficacy of intranasally administered corticosteroids and reduce the complication rate.

Administration, Intranasal↗
PubMed1998

[Tolerance, subjective complaints and mucociliary clearance in rhinitis sicca before and after nasal irrigation with Rhinomer Force 1].

BACKGROUND: Rhinitis sicca is a widespread disease, caused by a variety of factors. There are many different treatments, but none is more reliable than the other. METHODS: In a prospective study we examined 12 patients before and after a ten-day course of nasal irrigation with Rhinomer Force 1 regarding their symptoms, the mucociliary clearance measured with the saccharin test according to Andersen and tolerance of therapy. RESULTS: Improvement of nose breathing (57%), sensation of mucous running in the pharynx (42%), feeling of a dry nose (42%, significant p = 0.0313). The overall improvement was significant (67%, p = 0.054). Mucociliary transport analysed for each side of the nose (24 sides) resulted in 38% improvement (up 10 min in average), 12% same result, 50% worsening (down 12 min in average). The acceptance was reported as very good in 91% of the study group. CONCLUSIONS: Depending on the symptoms, a high to significant amount of improvement is documented after therapy with isotonic salt water solution. In our study the measurement of the mucociliary transport does not correlate with subjective symptoms. It does not appear to be an adequate tool for diagnosing rhinitis sicca or evaluating the success of treatment.

Adult↗
PubMed1998

[Complications with permanent damage in endonasal paranasal sinus operations--more frequent in experienced surgeons?].

BACKGROUND: The rate of serious complications in endonasal sinus surgery has not gone down although optical aids are widely used nowadays. Are serious complications caused more often by unexperienced or experienced surgeons using a microscope and/or endoscope? METHODS: We defined serious complications as follows: death, persistent neurological deficits or permanent loss of vision, and injury to the internal carotid artery. Two different studies were made: the first consecutive 300 interventions of 6 sinus surgeons were evaluated. Sixteen malpractice cases were analysed regarding the experience of the surgeon. RESULTS: In 9 out of 16 malpractice cases serious complications were attributable to experienced surgeons, five to moderately experienced surgeons, and only two to an inexperienced surgeon (although he had extensive experience in external sinus surgery). There were 6 deaths, 6 neurologic defects, 2 visual disorders, and 2 injuries to the internal carotid artery without any sequelae. In 9 cases the serious complications were related to injury of the internal carotid artery, in five cases to perforation of the skull base. Twice the orbital wall was penetrated. In 1800 procedures performed by 6 surgeons, no serious complications were encountered. There were only lesions of the periorbit (n = 33) or CSF leaks (n = 8) without any permanent damage to the patient. CONCLUSIONS: Even an experienced surgeon must always keep in mind that serious complications can occur in sinus surgery. One must constantly be alert to the possibility of anatomical variants or specific pathologic findings.

Cause of Death↗
PubMed1997

[Long-term follow-up of fronto-basal dura-plasty].

A safe closure of a dura lesion is necessary on account of the risk of potentially fatal (late) meningitis. 161 duraplasties of the frontal skull base carried out from 1979 to 1994 at the ENT-department Fulda were evaluated in a retrospective study in regard to etiology, operative techniques and results. Duraplasty of the rhinobasis was indicated in 70 cases of rhinobasal trauma, 47 cases after paranasal sinus surgery, 36 cases of tumors and 8 malformations. After an average follow-up time of 6 years the patients were interviewed for postoperative liquorrhea, sinusitis treated with antibiotics and meningitis. As an objective measure to verify the tight closure of the treated CSF-leaks a fluorescein test was performed in 50.9% 6 to 8 weeks after the operation. Duraplasty was successful in more than 96%. The approach and technique to perform a duraplasty have to be chosen individually considering size, location and etiology of the dural defect. In the majority of dural defects in the area of the frontal skull base reconstruction can be carried out now a days via an endonasal approach. By use of allogenic tissue, a mucosal flap from the surrounding area to cover the graft and fibrin clue good results were obtained.

Adolescent↗