HNS - Head and Neck Surgery, Larynx and Others

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 DOI 10.1007/s00405-007-0344-7

HNS - Head and Neck Surgery, Larynx and Others

INSTRUCTIONAL COURSES HIC 1 Thyroid surgery and dealing with complications Jan Betka Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University, Faculty Hospital Motol, V U´valu 84, 150 06 Prague 5, Czech Republic The course provides overview of technique of thyroid surgery including both standard and up-to-date modern methods including not-cold instruments (harmonic knife), miniinvasive methods, endoscopic thyroid surgery. The extent of surgery (total thyroidectomy, hemithyroidectomy) is discussed. Various procedures for identiﬁcation of the recurrent nerve (including nerve monitoring) and parathyroid glands are shown. The question how to drain (if any) the wound is gone over. Finally special focus is aimed at dealing with complications—recurrent nerve palsy (unilateral, bilateral), parathyroid gland injury.

HIC 2 Electroporation therapy in head and neck cancer M. Burian, M. Formanek, B. Zeitlinger AKH Vienna, Vienna, Austria Electroporation therapy (EPT) is a new and promising method to treat solid tumors. The presence of an electrical ﬁeld increases the permeability of cell membranes. This mechanism allows for transmembraneous transport of a variety of compounds into the cell interior. Using bleomycin as a cytotoxic agent, this method can be used in the treatment of squamous cell cancer of the head and neck. The tumor is inﬁltrated with bleomycin and subsequently treated by means of a six needle applicator which delivers the electrical ﬁelds to the tumor and tumor surrounding tissue. Since EPT act very tumor speciﬁc, it is possible to spare healthy tissue in the surrounding of the tumor to a high extent. The device as well as the technique of Electroporation Therapy will be shown in detail during the course. EPT seems to serve as an interesting, tissue sparing treatment alternative in head and neck cancer. Future trials have to ﬁgure out the most appropriate

indication for EPT in patients with squamous cell cancer of the upper aerodigestive tract.

HIC 3 Digital volume tomography in oto-rhino-laryngology Carsten Dalchow Park-Klinik Weissensee, Scho¨nstr. 80, 13089 Berlin, Germany The digital volume tomography (DVT) is an extension of panoramic tomography. With this diagnostic technique, characterized by high resolution, minimal section thickness of 0.125 mm, and three-dimensional (3D) display, small pathological processes can be well visualized. The digital volume tomograph Accu-I-tomo (Morita, Kyoto, Japan) was routinely used to examine patients with a history of a disease in the ﬁeld of oto-rhino-lanyngology. A 3D dataset of a cylinder was obtained in one 360 rotation with 80 kV and 8 mA adjustments. The images of the temporal bone region are analysed with special 3D-software. The data were displayed after reconstruction on a PC monitor in three planes oriented vertically to each other with minimal intersection distance and a minimal section thickness of 0.125 mm. The section angle, section thickness, and intersectional distance were modiﬁed to selectively depict individual structures. The ﬁrst generation DVT with dimensions of a 3 · 4 cm cylinder and a grey scale of 256 was later replaced by the second generation DVT visualizing 6 · 6 cm with a grey scale of 4,096. Clinical investigations showed smallest bony modiﬁcations of the temporal bone and frontal skull base with the DVT. Small lesions like an erosion of the ossicles, semicircular canals, cochlea, internal auditory canal or apex of the temporal bone as well as pathologies of the frontal skull base can be routinely visualized. The 3D presentation allows good spatial orientation and a precise planning of surgical approaches. Digital Volume Tomography expands the application of diagnostic possibilities in the lateral and frontal skull base. Therefore we believe improved pre-op diagnosis can be achieved along with more accurate planning of the surgical procedure. In comparison with conventional CT and digital volume tomography, DVT delivers a smaller radiation dose and a higher resolution coupled with lower purchase price of the equipment.

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HIC 4 Challenges of professional voice Felix de Jong1, Willy Wellens2, Manuel Pais Clemente3, Bozena Woznica4, John Rubin5, Ekaterina Osipenko6, Antonio Schindler7, Willem Kersing8 1 Leuven, Belgium; Nijmegen, The Netherlands 2 Leuven, Belgium 3 Oporto, Portugal 4 Poznan, Poland 5 London, UK 6 Moskow, Russia 7 Milano, Italy 8 Enschede, The Netherlands The voice has been acknowledged to be the primary tool for communication, that in turn has been described as the most existential act of man. The voice is used to express emotions and meanings. Consequently, voice problems often have a signiﬁcant psychological, social, physical, occupational and communicational impact on an individual. Professional voice use can be characterized as a top sport, representing a great mental and physical effort. Professional voice disorders are often complex with a multifactor genesis and the professional voice has been found to be inﬂuenced by and exposed to various and different risk factors. These risks factors broadly may be classiﬁed for the sake of description into four domains: vocal load, physical factors, psycho-emotional factors and environmental factors. To develop occupational safety and health in voice professions it is essential to demonstrate the relationship between voice problems and the various risk factors, in order to create a risk proﬁle of the professional voice user. The impact of a voice problem depends also on how an individual perceives the problem. Therefore, it is extremely relevant to assess the degree of handicap and the risk factors that are perceived to exert a negative inﬂuence on the voice in subjects with voice complaints and those with a voice handicap. Remarkably, often insufﬁcient attention is paid to voice training in various educations for professions with high vocal demands. Obviously there is a need for adequate voice training and the prediction of voice problems in the concerning educations.

HIC 5 Current diagnostics of swallowing disorders: the ENT specialist´s and phoniatrician´s role Doris-Maria Denk-Linnert, Gudrun Mancusi ENT Department, Division of Phoniatrics and Speech Pathology, Medical University of Vienna, Wa¨hringer Gu¨rtel 18-20, 1090 Vienna, Austria Objective: Over the last years, diagnostics and therapy of oro-pharyngeal swallowing disorders have become a major task for the ENT specialist/phoniatrician within a multidisciplinary team. Statistics demonstrate the individual, social and economic relevance of an adequate dysphagia management. Up to 14% of patients in acute care hospitals and up to 60% in nursing hospitals suffer from swallowing disorders. Aspiration pneumonia is the fourth frequent death cause in patients over 65 years. Methods: To enable an appropriate treatment of the dysphagic patient, a thorough diagnostic procedure is indispensable. The main diagnostic focus is to ﬁnd out whether aspiration is present or not. In addition to this screening task, the etiology and pathophysiology of dysphagia have to be revealed in order to establish the therapy regimen and to recommend the type of feeding. Since the presence or absence of aspiration can only be visualized, the instrumental diagnostic methods of videoendoscopy (ﬁberoptic endoscopic evaluation of swallowing, FEES) and videoﬂuoroscopy are used complemen-

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 tarily.FEES plays an important key role in the diagnostic work-up because it allows a direct morphological and functional analysis of the upper aerodigestive tract.The target of this course is to present the current status of FEES and it´s position within the diagnostic armamentarium. Based upon history, the standardized, but individually tailored endoscopic procedure will be demonstrated, as well as beneﬁts and limitations. Case reports illustrate the theoretical background. Furthermore, new developments and trends are discussed. Conclusions: FEES is an important tool for the ENT specialist/ phoniatrician in the management of the dysphagic patient.

HIC 6 Mucosal melanomas B. Folz Germany Background: Malignant mucosal melanoma of the upper aerodigestive mucous membranes is a rare tumor. In comparison with cutaneous and ocular melanoma the prognosis is poor. Most studies have been case series and reports about larger series are rare. The aim of the course is to provide the participants with the key knowledge about mucosal melanoma with regard to natural history, diagnosis, therapy and prognosis. Methods: The data presented are based on 51 cases from three different centers and an extensive literature survey. Results: The nose and paranasal sinuses are the most commonly affected site in the head and neck with regard to mucosal melanoma. The basic symptoms are diffuse and not speciﬁc for the disease, they rather reﬂect the typical signs of nasal malignancies, like unilateral nasal obstruction, epistaxis, nasal discharge, headaches and in advanced cases—diplopia. If possible therapy should be surgical, but even with clear margins the recurrence rate is 80%. The explanation might lie in satellite tumors, micrometastasis and tumor cell migration within the mucosa at early stages of the disease. Rare sites for tumor manifestation are the pharynx, larynx and the middle ear. Repeated therapy achieves prolongued survival and combined therapies show a tendency towards better results. The overall prognosis however is bad, the 5-year-survival is below 40%. Conclusion: Mucosal melanoma is a rare tumor with a poor prognosis. The course tries to provide key knowledge about the disease, which could to establish diagnostic and therapeutic standards for this rare tumor. Pooling data from different centers might then help to gain more knowledge about the disease.

HIC 7 Clinical application of different laryngoplasty techniques G. Friedrich Ear, Nose and Throat Hospital, Department of Phoniatrics, Speech and Swallowing, Auenbruggerplatz 26/28, 8036 Graz, Austria Every surgery performed direct on the vocal folds in evitable carries the risk of damaging the delicate structure of the vocal folds thus leading to the risk of unfavourable postoperative result which can occur due to scaring and stiffening. The idea of inﬂuencing the endolaryngeal biomechanics and consequently improving the voice without touching the vocal folds by just changing shape and/or position of the laryngeal cartilages is an ingenious idea which adds a new dimension to the ﬁeld of phonosurgery. Based on Isshiki´s fundamental research four types of laryngeal framework surgery have been deﬁned which allow to approximate, expand, relax or tension the vocal folds. The various surgical procedures, their indications and KI for voice improvement and/or changes will be explained in detail.

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HIC 8 Applications of CO2 laser in phonosurgery Sachin Gandhi Voice Disorder Clinic, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India Objective: To evaluate the role of CO2 laser technology for phonosurgery and to assess the beneﬁts of its advanced accessories (acublade, ﬂashscanner). Methods: CO2 laser application includes setting up of laser instrument with microscope and archiving system along with speciﬁc microsurgical instruments and anaesthetic techniques. CO2 laser is used in surgery of benign laryngeal pathology which include protruding lesions like cord polyp, recessed lesions like sulcus vocalis and ﬂat lesions like leukoplakic patches, intradermal cysts. It is also used in surgical management of laryngeal malignancies, sex reassignment and compromised laryngotracheal airway especially in cases of bilateral immobile vocal cords. The presentation would describe the surgical methods which increase the efﬁcacy of CO2 laser surgery as well as the precautions to be taken to prevent the complications. Pre and post surgery voice therapy is applied to maximize the results of phonosurgical methods. Results: The surgical outcome in phonosurgery is measured with voice analysis (maximum phonation duration, fundamental frequency, jitter and shimmer) and digital videostroboscopy to observe the mucosal wave. Preservation of mucosal wave indicates lack of scarring following surgery, and makes usage of CO2 laser a viable proposition in phonosurgery. Conclusion: CO2 laser with its advanced accessories has distinct advantages over established phonosurgical methods. Its careful application with complete knowledge of laser tissue interaction and surgical set up is vital. Inadvertent use may result in surgical complications.

S7 It is feasible to perform continuous ﬂexible laryngoscopy concomitant with symptoms in most patients with breathing difﬁculties during exercise. By this novel procedure for laryngoscopy, laryngeal function during exercise can be precisely deﬁned. In this instructional course we will show how this test can be performed and practical advises will be given. A short summery of our results will be presented and there will be time for discussion at the end of the session.

HIC 10 The transnasal endoscopic analysis of the oesopharyngeal function Ingo F. Herrmann Rome, Italy During this course the technique of the transnasal endoscopy of the oeso-pharyngeal function is demonstrated life. No sedation or anesthesia is necessary for the passage through the upper oesophageal sphincter. The patient drinks the endoscope with clear water. No air-insufﬂation. The upright or recumbent position, sitting or running changes the relationship of the anatomical structures as well as the function while eating or drinking. This physiological approach is the basis for the understanding of the function and dysfunction of the oeso-pharyngeal unit as, e.g., the different manifestations of reﬂux and their treatment and the different dysphagia problems. It allows to see the gas in the gas-pressure chamber of the stomach and oesophagus as well. Gasreﬂux is the main reason for the extra-oesophageal complications of reﬂux. The endoscopy of the function is easy to perform. For the right interpretation of the well-known measurement techniques as pHmetry, impedanzometry, ergometry and polysomnography the combination with the endoscopy of the function will be a must in the near future.

HIC 9 A method for visualising laryngeal stridor during exercise

HIC 11 Computer-assisted quantitative upper airway analysis and calibrated cephalometry

John-Helge Heimdal1, Robert C. Maat1,2 1 Department of Oto-rhino-laryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway 2 Department of Pediatrics, Haukeland University Hospital, Bergen, Norway

Dr. Hsu Pon Poh Changi General Hospital, Singapore

Breathing difﬁculties during exercise due to airway obstruction at the laryngeal level is surprisingly often misdiagnosed as exercise induced asthma. This misdiagnosis should be avoided to prevent unnecessary medication. The larynx normally opens widely at both the supraglottic and glottic level during exercise in non-symptomatic individuals. The pathophysiological mechanisms explaining the exercise induced reduction of the internal area at either one or both of these laryngeal levels in symptomatic subjects, are still under discussion. Exercise induced airﬂow constraint in an otherwise normal larynx becomes visible only at high airﬂow level. Since airﬂow rapidly decreases after exercise, both pre- and post exercise laryngeal examinations are not optimal. Respiratory symptoms should therefore be recorded and larynx continuously visualised during exercise if laryngeal dysfunction is to be studied in detail. A diagnostic set up has been developed for continuous laryngeal inspection as well as recording of gas exchange parameters, exercise ﬂow volume loops and breath sounds during exercise. This test has been entitled Continuous Laryngoscopy Exercise (CLE)-test.

Objective: This course introduces the various techniques of upper airway assessment in obstructive sleep apnea syndrome. This will enable the accurate identiﬁcation of speciﬁc sites of upper airway collapse and the precise quantiﬁcation of the airway at various levels. Method: There will be a detailed step-by-step demonstration on how to perform computer assisted videoendoscopic quantitative upper airway measurement. The presentation format with be didactic lecture with digital slides and videos to demonstrate the various techniques discussed. Result and Conclusion: Participants will be able to perform and appreciate the various techniques of upper airway assessment discussed. In particular, they will be able to perform computerassisted videoendoscopic quantitative airway measurements in their own ofﬁce practice. This simple, cost-effective technique will allow them to obtain precise airway measurements and identify the anatomical sites of the upper airway in need of correction and assist in the selection of surgical procedures to improve the upper airway. This technique also enables comparison of airway dimensions before and after surgery. Efﬁcacy of various surgical procedures can also be compared with this technique.

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HIC 12 Diagnosis of sleep disordered breathing using portable devices: how to improve the quality of an out-patient recording K. Ho¨rmann, J. T. Maurer Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Germany Introduction: Portable devices are regularly used to diagnose sleep disordered breathing in an outpatient setting as they are cheap and easy to use. However, the recording cannot be attended while the patient sleeps at home, which may lead to a deterioration of the recording quality and misinterpretation of the results. Editing of the raw data is necessary but time consuming during the tight daily schedule. Course content: The participants will learn how to improve the quality of an outpatient recording. They will learn to evaluate outpatient recordings properly and to recognise misinterpretations of the registrations obtained. Original raw data as well as numeric and graphic report data will be used.

HIC 13 Management of patients after corrosive substance ingestion Ljiljana Jovancevic, Dragan Dankuc Clinical Center, Novi Sad, ENT Clinic, Novi Sad, Serbia Management of patients after corrosive substance ingestion at ﬁrst must mean ﬁrst aid measures, reanimation of the patient and substance dilution. The dilution can be done within 60 min, with water or milk. After the stabilisation of all vital parameters, further treatment should start by meaning of diagnostics and therapeutic measures. The best diagnostic procedure to determine the presence and severity of corrosive oesophageal lesions is oesophagoscopy. Basic therapeutic principles in the management of patients after corrosive substance ingestion are accepted worldwide and must be applied. It is contraindicated to induce vomiting, diarrhoea and do corrosive substance neutralisation. Charcoal has no effect. The kind and quantity of ingested substance must be determined, oral feedings stopped, ﬂuid and electrolyte balance carefully assessed and development of complications followed. We have treated a total number of 107 patients during 10 years, mostly adults (age average 50 years). There was 32.7% male and 67.3% female patients. Ingestions of corrosives were suicidal in 67.3% patients and accidental in 32.7%. In 55.1% of patients there was acid ingestion, and in 25.2% alkali. Oesophagoscopy was done in 86 (80.4%) patients, out of which 59 (68.6%) were with and 27 (31.4%) without corrosive oesophageal lesions. Stenosis of the oesophagus developed in 10 (9.4%)patients. Out of all 107 treated patients, 13 (12.2%) died. This instructional course will present the complete treatment protocol of ENT Clinic, Clinical Center, Novi Sad, Serbia. This protocol has been in use for 6 years now (since 2000) and the results are excellent.

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HIC 14 Management of sialorrhoea (drooling) in children Haytham Kubba, Jane Leonard Departments of Otolaryngology and Community Paediatrics, Royal Hospital for Sick Children, Yorkhill, Glasgow, Scotland, UK Drooling of saliva (sialorrhoea) can be a major problem in children with neurodisability (for example, cerebral palsy). Although it may sound trivial, sialorrhoea can have a signiﬁcant impact on the quality of life for the carers and it impacts upon the child physically (excoriation of the skin), socially (less physical display of affection from family, reduced contact with peers) and psychologically (embarrassment). In this instructional course we aim to share the experience gained in our multi-disciplinary saliva control clinic. We will present the results of our studies on the local prevalence of sialorrhoea, together with information from our studies on quality of life. We will discuss the various management options that we offer in our clinic, including oral motor skills training by the speech and language therapist, anticholinergic medications, botulium toxin injections, saliva diversion surgery and saliva reduction surgery. The indications, techniques and outcomes will be discussed. We hope to show that it can be very rewarding to treat these children and that otolaryngologists have much to offer in their management.

HIC 15 The subcranial approach to the anterior skull base Dan M. Fliss, Sergei Spektor, Avraham Abergel, Ziv Gil Skull Base Surgery Unit, Department of Otolaryngology-Head and Neck Surgery, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel Introduction: The purpose of this study is to present the technique of the extended subcranial approach to the anterior skull base, and to review the results of 100 cases operated for extirpation tumors in this anatomical region. Methods: A retrospective review was conducted on the records of patients who underwent excision of tumors originating in the nasal cavity, paranasal sinuses, orbit or meninges. The evaluation procedures, surgical technique and complications were reviewed. Results: Forty-four cases involved malignant tumors and 56 involved benign tumors. The most common benign pathology was meningioma and the most common malignant tumor was squamous cell carcinoma. The principal skull base reconstruction procedure was performed using a multi-layered fascia lata. Postoperative follow-up (26 months in average) revealed that 80% of the patients are without evidence of disease, 12% are alive with disease, 2% died of their diseases and 6% died of unrelated causes. The rate of severe complications was 4.4%, and included meningitis (n = 2), cerebrospinal ﬂuid rhinorrhea (n = 1) and tension pneumocephalus (n = 1). Conclusions: We conclude that the extirpation of anterior skull base tumors via the subcranial approach is simple, reproducible and reliable, and is associated with reasonable complication rate. Keywords: Subcranial approach, Craniofacial surgery, Skull base, Paranasal sinuses, Anterior fossa tumors

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HIC 16 Microvascular reconstructive surgery in head and neck cancer: practical approach towards better quality of life C. Rene´ Leemans, Remco de Bree The Netherlands To reconstruct oral and pharyngeal defects after surgery several techniques have been developed for restoring functional and cosmetic features. These are primary closure, skin grafts, local transpositions of skin, mucosa or muscle, regional ﬂaps and free vascularised ﬂaps. Because of the ‘bulky’ and pedicled structure of the locoregional ﬂaps, with consequent frequently unsatisfactory functional results, free vascularised ﬂaps have gained almost uniform popularity during the last decade. Vascularised ﬂaps encompasses soft tissue free ﬂaps and bony free ﬂaps. For reconstruction of oral cavity and pharyngeal defects, fasciocutaneous (e.g., radial forearm ﬂap and anterolateral thigh ﬂap) and myocutaneous free ﬂaps (e.g., rectus abdominis and latissimus dorsi) have proven to be very reliable. In the reconstruction of bony defects of the mandible or maxilla free vascularised osteocutaneous ﬂaps (e.g., ﬁbula ﬂap and iliac crest) allows an adaptable approach to be used for each type of defect. Depending on the site, size and involved tissues of the defect and properties of the patient different reconstructive options are available. For both soft tissue and bony defects of the upper aerodigestive tract, microvascular free ﬂaps provide good functional outcomes, resulting in acceptable quality of life.

HIC 17 Application of F-18-FDG PET/CT in head and neck cancer Peter Lind1, Susanne Kohlfu¨rst1, Ewald Kresnik1, Michael Markitz2, Hans Edmund Eckel2, Martin Lobnig3, Klaus Armin Hausegger3 1 Department of Nuclear Medicine and Endocrinology, PET/CT Center, Klagenfurt, Austria 2 Department of Oto-Rhino-Laryngology, Head and Neck Surgery, LKH Klagenfurt, Austria 3 Departnment of Radiology, LKH Klagenfurt, Austria The incidence of head and neck cancer is increasing world-wide. In addition to clinical investigation including palpation and endoscopy with biopsy, conventional morphological imaging methods, i.e., ultrasonography, radiography, computed tomography and magnetic resonance imaging (MRI), have a routine role in the diagnosis of malignant head and neck cancer. However, the primary tumour often cannot be found despite extensive examination of the head and neck by means of several techniques (CUP). Furthermore, for staging purposes as well as for the detection of tumour recurrences after chemotherapy and/or external radiotherapy, morphological examination techniques such as CT and MRI are of limited accuracy. In recent years F-18 FDG PET is playing an increasing role in the assessment of malignant head and neck cancer. This is not only true for staging and restaging of head and neck cancer but also for the detection of CUP in case of histologically proven lymph node metastases. In recent years combined PET/CT maschines are availabe with the possibility to overlay the metabolic (FDG PET) and morphologic (CT) information resulting in fusion images of the head

S9 and neck area but also of the whole body for localizing distant metastases. For head and neck cancer where anatomy is often difﬁcult, especially after treatment, the fused PET/CT images give a much better accuracy in staging and restaging head and neck cancer but also for detecting CUP. This instructional course will provide pertinent and timely information on current guidelines, indications, and interpretation of PET-CT scanning in the initial diagnostic work-up and in treatment monitoring of head and neck cancer patients.

HIC 18 Bipolar radiofrequency induced thermotherapy (RFITT) for snoring and OSA Josef Lindenberger Kopfklinik Frankfurt Main, Germany This course is designed to help and improve ORL specialists to ﬁnd an approach for R-F surgery. Final outcomes are shown for different treatment modalities of an internationally well accepted minimally invasive procedure. Sleep related breathing disorders (SDB), such as habitual snoring or obstructive sleep apnea (OSA), often originate from obstructions at different levels in the naso- and oro-pharynx. Those obstructions are often caused by a combination of various indications, such as turbinate hypertrophy, an enlarged or slackened soft palate, an enlarged and/or weak tongue base muscle, as well as hypertrophy of the tonsils. Limiting the treatment to only one of these indications can lead to unsatisfactory results. However, conventional multi level methods, like turbinectomy, UPPP, tongue base wedge excision, tonsillectomy or corrections of the jaw, are invasive and often painful procedures. Bipolar radiofrequency induced thermotherapy (RFITT) can be applied to patients with different extent of SDB, in order to increase the effectiveness. Video clips for this surgery procedures will be shown: turbinate reduction, tightening of the soft palate, shortening of the uvula and removal of webbing with bipolar cutting unit, volume reduction of the palatine tonsils, tongue base volume reduction. A signiﬁcant therapeutic effect, rated by reduction of the snoring sound and AHI, can be achieved in a well selected group of patients. Furthermore, morbidity in multi level RFITT is not signiﬁcantly higher than in single level RFITT and considerably lower compared to conventional surgery. Therapy for a surgeon only can be successful using one system in the beginning. A decision must be made which device ﬁts best. We are showing our long term results with the Celon R-F device which is (a) widely used in Germany and (b) for a very long period of years. That’s why a comparison with different medical groups and procedures can be shown in this course. There is a discussion of the world wide literature, evaluation of short and long term efﬁcacy of a ‘‘multi level’’ therapy shown with a wide range of video clips. Step by step development of different approaches and surgical procedures with the R-F system. Different R-F lesions treatment modalities for the soft palate and tongue base are demonstrated as well as the long term outcomes of our treatment in a private ORL medical center. Our subjective data, shown in the course, (evidence based data are still very rare !) demonstrate a safe procedure which is well accepted by patients.

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HIC 19 Cricotracheal resection: the surgical solution for subglottic stenosis in children? P. Monnier Switzerland Despite constant improvements and reﬁnements in surgical techniques, the management of pediatric laryngotracheal stenosis (LTS) remains challenging for the otolaryngologist. The laryngotracheal reconstruction (LTR) has proved very successful in the treatment of pediatric LTS, but has shown some limitations when dealing with the most severe grades of LTS (grade III and IV = subtotal or total obstruction of the airway). In an attempt to improve the surgical outcome of severe (grades III and IV) LTS, the concept of removing the diseased segment of the airway has emerged as an attractive alternative to LTR to allow decannulation. Partial cricotracheal resection (PCTR) with primary thyrotracheal anastomosis spares the glottis and reconstructs a rounded, more ‘‘normal’’ mucosalized subglottic airway. It minimizes the problems of wound-healing seen with costal cartilage graft and with stenting in LTR. Extended partial cricotracheal resection (extended PCTR) is used to describe a PCTR combined with an additional open airway procedure. The indication is typically that of LTS with glottic involvement, either posterior glottic stenosis with possible crico-arytenoid joint ﬁxation, fusion of the vocal cords or laryngeal distorsion resulting from previous failed LTR. In this situation, PCTR cannot be done as a single-stage procedure, and a tracheostomy must be left inside until the airway is fully healed and stable after a period of stenting with a laryngeal mold. This course will address in detail all the problems related to the appropriate indications, the technique of the surgery, the postoperative management and the results of this type of surgery.

HIC 20 Selective neck dissection Eugene N. Myers Distinguished Professor and Emeritus Chair, Department of Otolaryngology, University of Pittsburgh School of Medicine and Medical Center, USA Cancer of the head and neck is an uncommon disease. The most important indicator of survival in cancer of the head and neck is the extent of metastases to the neck; therefore management of the neck remains an important part of cancer control. Treatment by surgery, radiotherapy or both depends upon the site and state of the primary as well as the clinical and pathological staging of the neck. The selective neck dissection (SND) which removes lymph nodes vulnerable to metastases from various primary sites spares adjacent structures and has low morbidity. The SND originally applied for diagnostic purposes in the N0 neck may also be used successfully in the treatment of the N+ neck. Indications for surgery, surgical technique, postoperative management complications and outcomes will be discussed.

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HIC 21 Evidence based voice assessment Mette Pedersen Denmark Introduction: In the clinical work, diagnoses in laryngology can often be secured with supplementary acoustical measurements. Material: Laryngological disorders are diagnosed in hospitals and private clinics. As a routine ﬁberscopy and at the same time an evaluation of the upper airways/mucosa is commonly made. Especially the mucosal function is evaluated. Often allergy and functional deviation of the nose and pharynx is taken into account. This is to some extent also the case for lower airways and esophagus/stomach problems with for example reﬂux, Helicobacter pylori and food intolerance. Method: The overall functions of the mucosa of the upper airways are diagnosed, based on the patients complaints. It is suggested that Jitter, Shimmer, Fundamental Frequency and Glottis closure is measured with a sustained tone and standard text as well. In singers and speakers it is also suggested that phonetograms and overtone measurement is made as a routine. Results and conclusion: We have used the above-mentioned program for several years now and systematic studies have been made.

HIC 22 Crico-tracheal resection and anastomosis (CTRA) forcintrsinsic and extrinsic tumors of the laryngotrahealjunction (LTJ): indications, techniques, oncologic, and functional outcome G. Peretti, C. Piazza Department of Otolaryngology, University of Brescia, Spedali Civili, Piazza Spedali Civili 1, 25123 Brescia, Italy Objective: CTRA is mostly applied to benign subglottic stenoses. Aim of this course is to describe our experience in approaching by CTRA selected cases of LTJ tumors, with particular emphasis given to indications, surgical techniques, management of perioperative complications, and oncologic outcomes. Methods: Between September 1996 and January 2007, we performed CTRAs in 92 patients, 31 of them (34%) affected by LTJ tumors. Eleven were primary tumors (1 pleomorphic adenoma, 6 low-grade chondrosarcomas, 2 low-grade mucoepidermoid, 1 adenoid cystic, and 1 squamous cell carcinomas), 20 were tumors from adjacent sites involving the airway (11 welldifferentiated and 3 dedifferentiated thyroid cancers, 3 thyroid metastasis from non-head and neck malignancies, and 3 metastatic recurrential lymph nodes from cancer of the UADT). All of them were submitted to CTRA involving only tracheal rings in 9 cases, the trachea and the cricoid arch in 12, the trachea, the arch and part of the cricoid plate in 10. At last consultation, all patients with primary LTJ tumors were free of disease (mean follow-up, 62 months; range 12–126). Among patients with tumors arising from adjacent sites, 10 (50%) were free of disease (mean follow-up, 20 months; range 2–51), 7 (35%) were alive with distant metastases (mean follow-up, 34 months; range 6–91), 2 died for local-regional disease 12 and 2 months after surgery, and 1 died for distant metastases 32 months after CTRA. Complications occurred in 9 patients (29%) and required permanent tracheotomy in 1 patient and total laryngectomy in another. Conclusions: CTRA is an organ preservation technique to be considered oncologically safe in selected LTJ tumors in which the endoscopic approach either failed or was thought unfeasible.

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HIC 23 Instrumentation for endolaryngeal surgery H. E. Eckel, Marc Remacle ENT-Department, LKH Klagenfurt, Austria; Cliniques Universitaires U.C.L. de Mont Godinne, Belgium The use of endoscopic surgery for benign and malignant lesions of the larynx has modiﬁed numerous operative procedures in laryngology and has given way to a wide variety of innovative and sophisticated procedures. The speciﬁc instrumentation required for these interventions will be discussed in detail during this instructional course. The essential problem in microlaryngoscopic surgery is to obtain an adequate view of the operative ﬁeld and to have the ability to use the necessary instruments at the surgical site. In laryngeal surgery, operating laryngoscopes are employed for this purpose. Since no laryngoscope can satisfy all requirements, the laryngeal surgeon should have an assortment of different models on hand. The most important are Kleinsasser laryngoscopes (sizes A–C, DN, J, JL), bivalved laryngoscopes in various sizes (Rudert, Steiner, Weerda), Lindholm laryngoscopes (when they are inserted into the vallecula they provide an excellent view of supraglottic structures ore even of the whole larynx), diverticuloscopes for endoscopic cricopharyngeal myotomy, and pediatric laryngoscopes (various models). For tissue ablation, the CO2 laser meets the criteria for use for most benign and malignant laryngeal lesions, particularly in phonosurgery, stenosis surgery, swallowing rehabilitation, and for the resection of laryngeal tumours. Implants are needed to replace anatomical structures an to restore function. Endolaryngeal approaches can now solve most clinical challenges in operative laryngology. Adequate instrumentation, however, is indispensable to accomplish the goals of this minimally invasive approach.

HIC 24 Vocal fold augmentation with Bioplastique material by indirect phonosurgical treatment under topical anesthesia Josef Schlo¨micher-Thier, Matthias Weikert HNO- Ofﬁce and Austrian Voice Institute, Salzburgerstrasse 34, 5202 Neumarkt, Salzburg, Austria Vocal cord paralysis is a complex and multifactorial condition. In this study we present 23 patient with vagus nerve lesions that affect only the recurrent laryngeal nerve and two patient with a vagus nerve lesions above the level of the pharyngeal nerve branch.The unilateral abductor paralysis of these patients occurs as a result of lesions caused by following reasons. 2x intrathoracic malignant neoplasms, 1x trauma to the neck, 14x thyroidectomy, 2x idiopathic disorders, 5x intrathoracic surgery and 2x vagus nerve lesions caused by malignant neoplasms of the skull base. Twenty-four patients has had the vagus nerve lesion more then 1 year, only two patient with intrathoracic malignant neoplasms where treated within 2 month after the paralysis occurs. All the patient where treated with intracordal Bioplastique injection by indirect transoral technique in topical anesthesia under a direct laryngoscope. Bioplastique is a biologically stable and suitable material without allergic reaction and without resorption of the material. It had been used since more then 30 years for medical products without complications. The authors have developed a special equipment to inject the bioplastique material by a ‘‘one hand technique‘‘ to place the material for a successful augmentation to treat the glottic incompetence and to reinstall the glottic vibration.

S11 The pre-and postoperative result has been documentated by videostroboscopic examination and accustically by Multispeech of Kay Elemetrics and the Phonetogramm of Hacki/Homoth and Lingcom/Lingwaves. The author will demonstrate in these workshop the pretherapeutic documentation, the technic of the vocal fold augmentation by the indirect transoral technic and the posttherapeutic management. This method is a simple and low morbiditic procedure that can be performed at an outpatient ofﬁce under topical anesthesia.

HIC 25 Foreign bodies localized in larynx, trachea, bronchus and esophagus in children: diagnostic and treatment Fernando Silva Chaco`n Children Hospital Francisco De Icaza Bustamante, Ecuador The author present 1,211 cases of foreign bodies located in the digestive, airway system, being a frequent pathology in the seen hospital emergency treated by the author from January of 1986 until August of the 2006. Realizing the diagnostic by the clinical history, (aphonia, cough, wheezing, distress in airway, dysphagia, swallowing, ingest only liquids, lost of weight in esophagus) completing it with radiological study, in some cases one doesn’t observe the foreign body for what was requested C.T., in a study carried out by the author with T.C. to diagnose foreign bodies in 12 cases. In 10 they reported that the foreign body was not seen. For rigid endoscopy (esophagoscopy, laryngoscopy and bronchoscopy) the foreign bodies were extracted corresponding in their majority coins, seeds, toys, chicken bone, etc. Of these 1,211 cases, bigger incidence in the masculine sex from 1 to 3 years of age followed by 4 years old, 143 were in to the airway (Larynx 35, traquea15, bronchus’s 93) and in esophagus 1,068 cases (cervical Esophagus 923, middle third of esophagus 107 and lower third 38) 5 cases presented complications: two deaths for foreign body in the airway and three esophagus perforations post extraction and they evolution favorably to their surgery treatment(thoracic surgeon closed the perforations diagnostic the ﬁrst hours) and intravenous antibiotics.

HIC 26 Advanced techniques of radiofrequency surgery in otorhinolaryngology Klaus Vogt Medic. Faculty, University of Latvia, Riga; Tagesklinik im Provianthaus, Rendsburg, Germany Objective: The interstitial applications of RF-surgery or widely known as principles of modern somnosurgery. The minimal lateral heat and the versatility of RF-Techniques by changing energy, waveform and different tools allow precise dissections and coagulation in anatomically difﬁcult regions as in the nose and in the middle ear. These techniques are demonstrated in videospots and in some model experiments. Methods to be demonstrated: The differences between classic electrosurgery and RF-surgery are outlined by some model and cadaver head demonstrations. The following surgical details will be shown by using 4 MHz-technology and new application instruments: Radiofrequencytonsillotomy, dissection techniques in neck and parotid surgery, endoscopic and microscopic endonasal surgery, in particular by using microﬁber technique, RF-Myringotomy and applications in the middle ear, modiﬁcations of pharyngoplasties in snoring and OSAS, techniques of cartilage modelling in intranasal surgery and otoplasty, new techniques in endolaryngeal RFsurgery.

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HIC 27 Skin cancer with emphasis on plastic surgical procedures Alexander Weber1, Angelika May2 1 HNO-Klinik, kath. Hospital St. Josef, Kliniken Essen Su¨d, Germany 2 J.W.-Goethe Universita¨tsklinik, Frankfurt am Main, Germany Basal cell and squamous cell carcinoma are the most common types of skin cancer found among the Caucasian population. It is estimated that 2.8 million cases of nonmelanoma skin cancer will be diagnosed each year worldwide. Environmental and individual factors predispose to tumor formation. If conservative strategies fail histologic controlled surgery is the most effective way to cure skin cancer. The correct interpretation of macroscopic appearance of skin malignancies is important, because solid well-differentiated basaliomas behave different from wide spreading morphea-like basaliomas. In addition histologic diagnosis will inﬂuence the treatment to achieve local control. Thorough understanding of the esthetic units and functional anatomy of the face are necessary to plan successful reconstruction with a favourable outcome. Therefore, this course will familiarize the participants with causes, symptoms and types of skin cancer. The main focus is laid on operative strategies to cure skin cancer. In a step by step demonstration of reconstruction techniques the participant will learn how to reconstruct most defects seen in normal practise as well as challenging cases. The algorisms include primary closure, advancement ﬂaps, pedical ﬂaps, or grafts. On a simple model the participants can get practical experience with ﬂap techniques. Alternative treatment options such as radiation therapy or immune modulation will be discussed.

HIC 28 Surgical treatment of residual/recurrent nasopharyngeal cancer William I. Wei FRCS FRCSE FRACS (Hon.) FACS, W. Mong Chair in Otorhinolaryngology, The University of Hong Kong In current practice, the primary treatment modality for nasopharyngeal cancer is concomitant chemotherapy and radiotherapy. To manage those patients who develop a small residual or recurrent tumour in the nasopharynx after the chemoradiation, the logical strategy is salvage nasopharyngectomy. Anatomically, the nasopharynx is located in the center of the head; it is difﬁcult to expose the region adequately for an oncological procedure. We have employed the anterolateral approach to the nasopharynx to carry out the salvage nasopharyngectomy. This procedure essentially swings the maxillary antrum laterally while it remains attached to the anterior cheek ﬂap. The tumour in the nasopharynx and its vicinity is adequately exposed and all pathologies can be resected under direct vision. After tumour extirpation, this osteocutaneous complex is returned to its original position and ﬁxed to the rest of the facial skeleton. Over the years, this has been carried out for 189 selected patients and a 5-year actuarial local tumor control rate of 63% with a 5-year disease free survival rate of 54% could be achieved. The surgical procedure is not difﬁcult and there was no hospital mortality. With the modiﬁcation of surgical techniques, the palatal ﬁstula which previously occurred in 20% of patients has been eliminated. The associated morbidity with the procedure was

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 minimal. This approach also allows the control of the internal carotid artery and removal of other lesions located in the central skull base. During the course, surgical procedure to expose the nasopharynx and central skull base with the maxillary swing approach will be illustrated step by step through slides and video. Practical hints to avoid complications will be stressed.

HIC 29 Neoplasms of the parotid gland Peter Zba¨ren Bern, Switzerland Educational objectives: (1) Know the occurrence of the different histiotypes of parotid neoplasms. (2) Know the histologic characteristics of the capsule of pleomorphic adenoma and understand their impact on surgical treatment. (3) Understand the indication and value of different diagnostic modalities, such as MR imaging, ﬁne-needle aspiration cytology and frozen section analysis, in the diagnosis of malignant primary parotid carcinomas. Course abstract: First, an overview of the different histiotypes and the frequency of benign and malignant parotid neoplasms is presented on the basis of our own 900 parotid neoplasms, treated during the last two decades.The second part deals with benign tumors. The histologic characteristics of the capsule of pleomorphic adenoma is demonstrated. In this context, our experience with 40 recurrent pleomorphic adenomas is presented and discussed and compared with the literature. The controversial debated extent of pleomorphic adenoma surgery is discussed on the basis of studies in the literature. The last part deals with primary parotid carcinomas. The value of diagnostic modalities, such as MR imaging, ﬁne-needle aspiration cytology and frozen section analysis in the diagnostic work-up for primary parotid carcinomas is presented. The outcome of the different histiotypes is covered. Finally, the indication for elective neck dissection in cNO neck and postoperative irradiation for small carcinomas are discussed.

HIC 30 B-Mode- and colour-coded-sonography of the head and neck Heinrich Iro, Alessandro Bozatto, Johannes Zenk Germany Ultrasound in its different applications (B-Mode, Color coded ultrasound, Power Mode, Harmonic imaging, contrast enhanced ultrasound) is in our hands a very powerful diagnostic tool in the head and neck area. During the last 10 years the quality of the images has been signiﬁcantly improved so that ultrasound is as sensitive and speciﬁc as MRI concerning diagnosis of neck and parotid gland masses. Within our course we describe the different techniques currently used and provide also the possibility to follow through normal sonographic anatomy as well as the multiple variety of pathologies of the head and neck. A main focus will be the sonography of the salivary gland disorders as well as the possibilities of prediction of malignancies in sonographic ﬁndings. Moreover we will discuss the meaning and indication of colour coded sonography and contrast enhanced sonography. Participants of the course will also have the possibility to be trained live on site.

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HIC 31 Sialendoscopy course Francis Marchal Director of the European Sialendoscopy Training Center, Switzerland Sialendoscopy is one of the most fascinating innovations introduced in the last few years in the ﬁeld of oto-laryngology, head and neck surgery. Sialolithiasis and sialadenitis is one of the most frequently presenting disorders of the salivary glands. It’s classical treatment ranges from the use of surgery—intra-oral extraction or external lithotripsy, to the more frequent performance of external excision of the gland. Diagnostic sialendoscopy allows for optical exploration of the salivary ductal system and its diseases, while interventional sialendoscopy enables extraction of the stones by a basket under endoscopic view, laser-fragmentation, or stenosis dilatation under endoscopic control. In Geneva, a speciﬁc training and demonstration model for Sialendoscopy has been validated in the European Sialendoscopy Training Center, where an International Faculty reports their clinical, radiological, medical and surgical approaches to salivary gland pathologies twice a year for training courses. This present course aims to give a complete overview on the sialendoscopic techniques, for the treatment of all ductal pathologies, including salivary stones, recurrent parotitis of children, single or multiple stenotic processes of the ducts, and more rarely ductal tumors. In difﬁcult cases, where the results of sialendoscopy are poor, we have developed other surgical techniques, combining sialendoscopy and external surgery which will be presented: These techniques allow the extraction of large stones, or the treatment of ductal stenosis by a veinous patch interposition. The author, who has developed the instrumentation and the technique, presents his personal experience over the last 12 years, on more than 1,000 sialendoscopies. Participants will have during this course a complete and detailed overview on all available methods to treat ductal diseases.

LECTURES Basic Science HL 1 The relapse-free survival in oro- and hypopharyngeal squamous cell carcinoma correlates signiﬁcantly with the genotype of the T393C polymorphism of the Gas gene G. Lehnerdt1, P. Franz1, A. Zaqoul1, A. Bankfalvi3, K. Schmitz3, S. Lang1, K. W. Schmid3, W. Siffert2, K. Jahnke1, U. Frey2 1 Department of Otorhinolaryngology, University of DuisburgEssen, Hufelandstraße 55, 45122 Essen, Germany 2 Institute of Pharmacogenetics, University of Duisburg-Essen, Hufelandstraße 55, 45122 Essen, Germany 3 Institute of Pathology and Neuropathology, University of Duisburg-Essen, Hufelandstraße 55, 45122 Essen, Germany Introduction: In preliminary studies we could demonstrate that the T-allele of a speciﬁc Single Nucleotide Polymorphism (SNP) in the Gas gene (T393C) correlates with increased Gas expression and hence apoptosis and therefore represents a potential factor with regard to carcinogenesis, progression, and therapeutical response. Method: Objective of the study was the evaluation of the prognostic value of the T393C SNP in an unselected series of oro- and

S13 hypopharyngeal SCC including all tumour stages and therapeutical regimens. After pyrosequencing the genotypes were correlated with the clinical data. Results: The median follow-up of the 219 patients (178#:41$) was 33, the average 43 months. The allele frequencies [TT = 54 (25%), CT = 95 (43%) and CC = 70 (32%)] were not signiﬁcantly different from those of healthy blood donors, which makes an association between the T393C SNP and a predisposition for the analysed tumours unlikely. The analysis of disease progression revealed that the relapse-free survival (RFS) was signiﬁcantly correlated with the genotype (P = 0.02 log-rank test). This effect was pronounced in males (average relapse free survival TT = 86, TC = 72, CC = 52 months; P = 0.003 log-rank test). In multivariate Cox proportional hazard analysis AJCC tumour stage, gender, and tumour localization, but also the T393C SNP were independent prognostic factors for RFS. In comparison to homozygous T-allele patients, homozygous C-allele patients had a 2.0 fold (95%-CI 1.03–3.97) higher risk for a recurrence of disease (P = 0.034). Conclusion: The T393C polymorphism turns out to be a reliable genetic tumour marker to predict the clinical course of patients suffering from oro- and hypopharyngeal cancer.

HL2 Human papillomavirus frequency in head and neck squamous cell carcinoma Mircea Romanitan1, Tina Dalianis2, Torbjorn Ramqvist2, Corneliu Romanitan3, Romeo Calarasu1, Eva Munck-Wikland4 1 IFACF – ORL ‘‘Prof.Dr.D.Hociota’’, str. Mihail Cioranu 21, sector 5, Bucharest, Romania 2 Cancer Centrum Karolinska, Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden 3 Central Military Hospital, str. Mircea Vulcanescu 88, sector 1, Bucharest, Romania 4 Department of Oto-Rhino-Laringology, Head and Neck Surgery, Karolinska University Hospital, Stockholm, Sweden Objective: The aim of this study was to examine the presence of Human Papillomavirus (HPV) in head and neck cancer in a Greek material collected between the years 1986–2005 and to compare it with our previous studies in Sweden. Methods: DNA was extracted from 93 parafﬁn embedded pretreatment biopsies. For the detection of HPV, PCR with HPV consensus primers GP5+/6+ and CPI/IIG were used. For detection of HPV 16, a PCR with HPV 16 type speciﬁc primers was used. Results: In total 9/93 tumours were HPV positive. Eight of the 18 tonsillar cancer samples (44%) were HPV positive and notably, within the same material, 7/12 (58%) of the tonsillar cancer samples obtained between years 2000–2005 were HPV positive. Seven (88%) out of the eight HPV positive tonsillar tumours were HPV 16 positive. Of the tongue cancer samples 1/31 (3%) were HPV positive, while none of the 44 oral cavity cancer samples were HPV positive. Conclusions: In summary, almost half of all the Greek tonsillar cancer patients had presence of HPV in their tumours, and HPV-16 was the dominant type. In Sweden, we have demonstrated a highly signiﬁcant and parallel increase both in the increase of tonsillar cancer and the proportion of HPV-positive tumors. We concluded that the incidence of Greek HPV positive tonsillar cancer was almost as high as in Sweden conﬁrming our previous reports regarding HPV as an important risk factor for tonsillar cancer.

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HL 3 The comparison of the presence of Epstein-Barr Virus derived latent membrane Protein-1 gene in cervical metastatic lymph nodes of patients with head and neck carcinoma Bijan Khademi1, Jalal Mahmoudi1, Ahmad Monabati2, Mohammad J. Ashraf2 1 Department of Otolaryngology, Head and Neck surgery, Khalili Hospital,Shiraz, Iran 2 Department of Pathology, Shiraz University of Medical Sciences, Shiraz, Iran Background: Cervical lymphadenopathy is occasionally of unknown origin & Nasopharyngeal carcinoma (NPC) closely associated with Epstein-Barr Virus which is frequently related with malignant cell transformation through the action of the oncoprotein latent membrane protein -1 (LMP -1). Objective: In this retrospective study the presence of EBV-derived LMP-1 gene in nasopharynx and metastatic nodes of nasopharyngeal, oral cavity, laryngeal and skin cancers and nonmalignant tonsil of patients were compared. Methods: Eighty-four parafﬁn-embedded tissues of various head and neck specimens including nasopharynx, oral cavity, larynx and skin were examined for the presence of LMP-1 gene, using polymerase chain reaction. Results: Ten of 12 nasopharyngeal biopsies and 8 of 10 specimens from metastatic lymph nodes of the same NPC were positive for LMP-1 gene. The LMP-1 gene was detected in metastatic lymph nodes of NPC with a sensitivity of 80%, speciﬁcity of 100%, positive predictive value of 100% and negative predictive value of 91%. On the contrary after application of PCR, the LMP-1 gene was not detected in any samples of other head and neck carcinomas,their metastatic nodes and tonsillar specimens. There was a signiﬁcant association between the presence of LMP-1 gene and tumor location in nasopharynx (P < 0.0001). Conclusion: The study demonstrated that the presence ofLMP-1 gene detected by PCR in metastatic tumor cells is only significantly associated with tumor location in nasopharynx and EBV has no essential role in the tumorigenesis of carcinomas arising from other head and neck sites. The polymerase chain reaction method is a potential tool for localizing primary site of a cervical metastatic cacinoma.

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HL 4 Ultrastructural aspects of olfactive mucosa of laryngectomees Barbara Cutrera1, Maurizio Marchini2, Fulvia Ortolani2, Cesare Miani2, Giancarlo Tirelli1, Lucia Petrelli2 1 University of Trieste, ENT Clinic 2 University of Udine, Human Morphology Department Objective: Patients who have undergone total laryngectomy experience a decrease of odor perception. The aim of the study is understanding if this lack of olfaction is simply the result of the disconnection between upper and lower airways due to surgery or if there are citopathological ﬁndings at the base of this, through an ultrastructural analysis of olfactory mucosa specimens of laryngectomees and rhinologically normal patients. Methods: Olfactory mucosa specimens were endoscopically collected from seven laryngectomees and from three rhinologically normal subjects (as controls) and then examined with a CM-12 Philips transmission electron microscope. Results: There have been observed deep ultrastructural changes in the morphology of olfactory neuroepithelium that appeared widely disrupted and degenerated. Conclusions: The citopathological damage observed in the olfactory mucosa of laryngectomees is a direct cause of decreased neurosensorial performance in this group of patients.

HL 5 HPV as prognostic factor in oral/oropharyngeal squamous cell cancer Jan Klozar, Ruth Tachezy, Vı´ t Kratochvı´ l, Eva Vesela, Roman Kodet, Eva Hamsikova Department of Otorhinolaryngology Head and Neck Surgery, Motol Faculty Hospital, Prague Objective: To compare the survival between patients with HPV positive and HPV negative tumours. To compare the presence and type of regional metastases in the patient population with HPV positive and negative tumours. To ﬁnd out about the prognostic factors of survival and to ﬁnd out whether HPV status is an independent prognostic factor. Methods: Investigations were carried on 81 patients treated by surgery including neck dissection for oral or oropharyngeal squamous cell cancer. A computerized medical report was completed for each patient. Analysis of the tumour specimen was performed on parafﬁn ﬁxed tissue. HPV DNA detection and typing was done by by GP5+/GP6+BIO reverse line blot hybridization. Results: In the whole group 64% (52/81) of the tumours were HPV positive, in tonsilar location it was 80% (41/51). HPV positive patients had signiﬁcantly better survival than HPV negative patients both overall (73 vs. 35%) and disease speciﬁc (78 vs. 45%). No signiﬁcant differences were found in the prevalence of regional metastases and in the nature of the involved nodes between HPV positive and HPV negative tumours. The signiﬁcant prognostic factors of survival found were the presence of HPV in the tumour, gender, extracapsular spread and the T classiﬁcation. HPV presence, female gender and no extracapsular spread were still signiﬁcantly associated with better survival after the Cox multivariate analysis. Conclusion: As the HPV status seems to be the strongest prognostic factor, we should possibly consider it in clinical treatment decisions.

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HL 6 Correlation between p53 and PCNA in lymph nodes metastases of oral/oropharynx cancer Giancarlo Tirelli1, Ledia Papanikolla1, Mauro Melato2, Elena De Nardi1 1 ENT Clinic, University of Trieste 2 Flow Cytometry Center, University of Trieste Objective: To characterize p53 and PCNA expression in primary tumors and lymph nodes metastases of oral/oropharynx carcinomas by ﬂow cytometry and to evaluate the relationship between these parameters in primary tumors and locoregional metastases, clinical-hystopathological parameters and survival time. Methods: Twenty-eight patients were retrospectively studied: 13 with metastases and 15 without metastases. The parameters considered were the degree of keratinization, Broder’s grading of histological differentiation, invasive cell grading, thickness and tumor size. Nuclei were stained using anti-p53 and antiPCNA FITC conjugated monoclonal antibodies. Was used a Coulter Epics Elite ﬂow cytometer. Results: A close relationship between p53 and PCNA in primary tumors; no correlation with clinical-histopathological parameters; no correlation between p53 and PCNA expression in primary tumors and in lymph nodes metastases; no correlation between p53 and PCNA values in primary tumors and survival. Conclusions: The different expression of p53 and PCNA in primary tumors and lymph nodes metastases is a questionable prognostic parameter.

HL 7 Analysis of the wingless pathway in oral squamous cell carcinomas Dietmar Thurnher1, Patricia Pintor dos Reis2, Boban Erovic1, Phillip Kloimstein1, Ralph Gilbert2, Patrick Gullane2, Jonathan Irish2, Suzanne Kamel-Reid2,3 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of Vienna, Austria 2 Applied Molecular Oncology, Ontario Cancer Institute and Otolaryngology and Surgical Oncology University Health Network, Toronto, ON, Canada 3 Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada Background: Reduction in cell–cell adhesion and vascular invasion are essential steps in the progression from localized malignancy to metastatic disease. Proteins involved in intercellular adhesion, such as E-cadherin and Beta-catenin play an important role in metastatic processes and cellular differentiation. Less is known about the role of the Wingless (Wnt) pathway in head and neck cancer. Our objectives are thus to examine the expression of these genes in oral squamous cell carcinomas (OSCCs). Patients and methods: OSCC tissue samples were obtained at the time of surgery from the Toronto General Hospital and snap frozen in liquid nitrogen. RNA was isolated from 20 OSCC specimens. Quantitative real-time RT-PCR (QRT-PCR) was used for relative quantiﬁcation of gene expression. Data analysis was performed using the Delta Delta Ct method. Protein expression was determined using tissue micro arrays. Results: QRT-PCR analysis showed that the Wnt pathway genes Beta-Catenin1, TCF4 and Wisp2 were 100-fold, 40-fold and sixfold overexpressed, respectively, whereas Wisp-1 was not overexpressed when compared to reference DNA. Protein expression

S15 analysis of the respective genes showed that Beta-Catenin1 was expressed in 60–70% of tumor cells, TCF-4 in 20% and Wisp-1 and Wisp-2 in 10–20% of tumor cells. Conclusion: Genes of the Wnt pathway are regulated in OSCCs.

HL 8 Response from upper airway epithelial cells to X-irradiation R. Reiter1, T. Deutschle1,D. Bartkowiak2, T. Wiegel2,H. Riechelmann1 1 University of Ulm, ENT Department, Ulm, Chair: Prof. Dr. G. Rettinger 2 University of Ulm, Department of radio-oncology, Ulm, Chair: Prof. Dr. T. Wiegel Objective: Radiotherapy of head and neck tumours may also affect normal epithelial cells, which contribute to adverse tissue reactions. Mechanisms involved in dose and time dependent effects on airway epithelial cells of X-irradiation should be investigated. Methods: Cultures of BEAS-2B-cells (n = 27)were X-irradiated in triplicate experiments with single doses of 2, 5 and 8 Gy with a Philips MG 320 (300 kV X-rays, 1 Gy/min). After 2, 6 and 24 h differential gene transcription (1,232 genes) was analyzed and grouped by biological themes according to the ‘‘Gene Ontology Consortium‘‘. Enrichment factors (ef) of upregulated gene clusters were determined with GoTREE (http://bioinfo.vanderbilt.edu/ gotm). Additionally ten cytokines were measured in cell culture supernatants. Early cell cycle response and apoptosis induction were determined by ﬂow cytometry 0, 24, 48 and 96 h after irradiation.

HL 9 Elevated levels of circulating endothelial progenitor cells in patients with head and neck squamous cell cancer Markus Brunner, Dietmar Thurnher, Mattha¨us C. Grasl, Christoph Arnoldner, Boban M. Erovic Department of Otorhinolaryngology, Head and Neck Surgery Medical University of Vienna, Vienna, Austria Objecives: Measurement of circulating endothelial cells (CECs) and progenitor cells (CEPs) has potential as a surrogate marker for monitoring antiangiogenetic treatment and both cells might be the target of new therapeutic strategies. This study evaluated the signiﬁcance of CECs and CEPs in the blood of patients with headand neck squamous cell cancer (HNSCC). Methods: In a multicentered prospective study, fresh blood samples from 21 patients with HNSCC and from 17 age/sex matched controls were tested using multiparametric ﬂow-cytometry. 1 · 106 cells were analyzed per sample. CECs were deﬁned as being positive for CD31 and CD146 and negative for CD45, CD3 and 7AAD. CEPs were deﬁned as being positive for CD133 and KDR and negative for CD3, CD19, CD33 and 7AAD. Results: Median levels (Min/Max) of CECs were 4 (0/9) in the tumor and 5 (1/13) in the control cohort (P = 0.33). Median levels of CEPs were 8 (2/37) in the tumor and 3 (1/13) in the control cohort (P = 0.001). CEC and CEP levels were not found to correlate with tumor size and did not predict response to radiation-therapy after 6 months of observation (n = 12). Conclusions: CD133 positive circulating endothelial progenitor cells were signiﬁcantly elevated in the blood of patients with HNSCC. These results warrent an extension of our study to determine whether CEP levels are surrogate markers for the response to antiangiogentic therapies.

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HL 10 Carbonic anhydrase IX in head and neck malignant tumours: a meta-analysis Stamatios Th. Peridis1, Dimitrios Iosif1, Michail Chatzimichalis2, Georgios Kostas1, Charalambos Nikolou1, Basilios Roditis1. 1 Department of Oto-Rhino-Laryngology Head and Neck Surgery, General Hospital of Rhodes, Greece 2 Department of Oto-Rhino-Laryngology Head and Neck Surgery, Anticancer Hospital of Piraeus ‘‘Metaxa’’, Greece Objective: Carbonic anhydrases (CA) are proteins involved in the catalytic hydration of carbon dioxide (CO2) to carbonic acid (HCO3–). The protein CA IX is an endogenous marker up-regulated by tumour hypoxia. The present study uses meta-analytical techniques to compare CA IX (–) versus CA IX (+) and CA IX low versus high expression at different cut-offs for resected specimens in patients with any head and neck malignant tumours with regards to long-term outcomes. Methods: The literature was searched using Medline, Embase, Ovid, and Cohrane databases for all studies published. Comparative studies between 2001 and 2006 of CA IX (–) versus CA IX (+) and CA IX low versus high for head and neck cancer were included in the analysis. The end points evaluated were: CA IX expression of the resected specimens, and long-term outcomes (overall survival at maximal follow-up and recurrence free survival at maximal follow-up). Random-effect meta-analytical techniques were used for analysis. Results: Seven studies matched the selection criteria, reporting on 758 patients, of whom 159 (41.84%) were CA IX (–), 221 (58.16%) were CA IX (+), 102 (36.88%) were CA IX low and 178 (63.12%) were CA IX high for any head & neck cancer. CA IX (+) was signiﬁcantly expressed (P < 0.00001) on the resected specimens. Overall survival (P = 0.02) and recurrence free survival (P < 0.005), were all signiﬁcantly reduced when CA IX was positive. Conclusion: CA IX (+) results in a reduced overall survival and recurrence free survival at maximal follow-up when compared to CA IX (–) patients, i.e., CA IX is an indicator for poor survival rate when positive.

HL 11 Immunohistochemical detection of E-cadherin and beta-catenin in salivary gland tumors Theodoros Papadas1, Nicholas S. Mastronikolis1, Panagiota Ravazoula2, Maria Gkermpesi2, Gabriel Tsiropoulos1, Panos D. Goumas1 1 Department of Otorhinolaryngology, University Hospital of Patras, Patras, Greece 2 Department of Pathology, University Hospital of Patras, Patras, Greece Objective: E-cadherin links to the cytoskeleton via catenins and mediates cell-cell homophilic adhesion. Beta-catenin not only regulates cell–cell adhesion, as a protein interacting with cadherin, but also functions as an important component of the Wnt signaling pathway which has been found to be closely associated with tumor formation. This study was performed to examine the

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 expression of E-cadherin and beta-catenin in salivary gland tumors in order to evaluate their possible roles in the formation of salivary gland tumors. Methods: Archival formalin-ﬁxed, parafﬁn-embedded sections of 46 mixed tumors (pleomorphic adenomas), 18 Warthin tumors, 3 mucoepidermoid carcinomas, 1 adenoid cystic, 1 acinic cell and 1 squamous cell carcinoma, total 70 tumors, were studied immunohistochemically using an Envision/horseradish peroxidase (HRP) technique. Healthy salivary glands were used as controls. Results: Membrane and cytoplasmic associated E-cadherin and beta-catenin expression was present in 54/69 and 68/69 of the tumor types studied, respectively. E-cadherin and beta-catenin showed a similar distribution; however E-cadherin was less frequently expressed than beta-cadenin. Expression of both proteins was stronger in Warthin tumors and in mucoepidermoid, adenoid cystic, acinic cell and squamous cell carcinomas. Reduction and/ or absence of E-cadherin was only observed in mixed tumors. Conclusions: This study suggests a direct association of E-caderhin and beta-catenin expression with neoplastic histology phenotype of salivary gland tumors.

HL 12 Genotoxicology studies with human laryngeal miniorgan cultures Norbert Kleinsasser, Christian Ginzkey, Katja Kampﬁnger, Rudolf Hagen Otolaryngology, Head and Neck Surgery, Julius-MaximilianUniversity, Josef-Schneider-Str. 11, 97080 Wu¨rzburg, Germany Miniorgan cultures (MOC) of upper aerodigestive tract epithelia, as ﬁrst described by Steinsvag and Olofsson, have been shown to be a relevant tool in genotoxicology studies. MOC allow repetitive or chronic exposure of cells to xenobiotics and monitoring of possible adverse effects. The present report focuses on initial experiences with MOC from supraglottic laryngeal epithelia. Culture of mini organs was performed by cutting pieces of 1 mm3 from fresh specimens of human laryngeal epithelium. MOC were incubated on multi-well plates with Bronchial Epithelial Basal Medium and on days 7, 9, and 11 aliquots were exposed to xenobiotics, e.g., nicotine. Cytotoxic effects were monitored by the trypan blue exclusion test, genotoxic effects by the aid of the single cell microgel electrophoresis assay, structure of MOC by repetitive histology. MOC showed a good viability over the experimental period. First observations demonstrated an elevated DNA-migration after triple exposure to nicotine at 4 mM whereas after single exposures migration enhancement was not signiﬁcant. MOC were coated by epithelium after one week. However, in some MOC with a too big diameter, centrally located cells appeared to be ill-nourished. This type of organ culture of laryngeal epithelia provides an in vitro model suitable for the assessment of genotoxic effects of environmental pollutants mimicking the in vivo situation with target cells of carcinogens in their functional organ speciﬁc intercellular architecture. However, further reﬁnements of the protocol are necessary and studies to demonstrate the metabolic competence of laryngeal MOC.

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HL 13 Peptidomic study of saliva from subjects affected by precancerous and cancerous lesions of the oral cavity and larynx Scarano Emanuele1, Inzitari Rosanna2, Agostino Stefania1, Fanali Chiara2, Fiorita Antonella1, Cabras Tiziana3, Passali Giulio Cesare1, Mario Rigante 1, Castagnola Massimo2, Paludetti Gaetano1, Messana Irene3 1 Institute of Otolaryngology, Catholic University, Rome 2 Institute of Biochemistry and Clinical Biochemistry, Catholic University, Rome 3 Department of Sciences Applied to Biosystems, Cagliari University, Italy Objective:The object of this study is to investigate and quantify speciﬁc salivary peptides (statherin, histatin 1-3-5, PB peptide and a-defensin 1–3) in patients affected by precancerous and cancerous lesions of the oral cavity and larynx, in order to evaluate the use of salivary samples as test of screening for cancer risk. Methods: We investigated 34 patients divided in three groups: (1) 14 patients with precancerous and cancerous lesions of the oral cavity; (2) 20 patients with laryngeal neoplasm, (3) 15 healthy volunteers. Saliva specimens were diluted with acidic solution (0.2% TFA) and analyzed by HPLC-mass spectrometry. Nonparametric test (Mann–Whitney) was used. Results: Statherin and PB peptide levels were found signiﬁcantly lower in both patients groups with respect to control group (P = 0.001 for both peptides in group II; P = 0.006 and 0.02, for statherin and PB, respectively, in group I). Also levels of histatin 1 and 5 were signiﬁcantly reduced in both groups (P £ 0.009 for histatin 1; P £ 0.004 for histatin 5). No signiﬁcant differences were found for a-defensin 1–3 levels in groups I and II with respect to control group. Conclusions: This study evidences the reduction of levels of speciﬁc salivary peptides in oral and laryngeal cancer. The role of human salivary proteins in oral cancerogenesis is actually not yet understood. On the bases of our results we suggest an evaluation of salivary proteins as biomarkers for malignant lesions of larynx and oral cavity and as possible test of screening for cancer risk.

HL 14 Hypermethylation of secreted frizzled related protein genes in head and neck sqaumous cell carcinoma Miguel Angelo, Hyppolito, Ricardo C. Demarco Faculty of Pharmaceutics Sciences of Riberao Hypothesis: We postulate hypermethylation of sFRP1 gene is a frequently occurs in head and neck cancers. Background: The molecular pathology of head and neck squamous cell carcinoma (HNSCC) is poorly understood. Regions of the short arm of chromosome 8(8p11.2) are deleted frequently in a range of solid tumours, indicating that tumour suppressor genes reside in these loci. The sFRP1 gene was proposed to lie at 8p11.2.

S17 Our previous data indicates that sFRP1 protein/mRNA expression is substantially suppressed in advanced head and neck cancers. The aim of this study is to identify the role of sFRP1 gene methylation in the HNSCC. Method: The study population was recruited from the Head and Neck oncology clinic. Informed consent was obtained from each patient for molecular analysis of the resected specimen. We performed methylation speciﬁc PCR in a cohort of 18 HNSCC samples and compared these with expression levels in normal upper aero digestive mucosa samples from the same patient. Results: Hypermethylation of sFRP1 was detected in 10 out of 18 patients. The expression of sFRP1 proteins was lower in 14 patients. Conclusion: Above study indicates the hypermethylation of sFRP1 gene is a common event in HNSCC. Aberrant promoter methylation appears to functionally silence sFRP1 gene expression in HNSCC. These pathways may be useful targets for chemoprevention strategies in this common solid tumour.

HL 15 Expression of VEGF-A/C, VEGF-R2, PDGF-a/b, c-kit, EGFR, Her-2/Neu, Mcl-1 and Bmi-1 in Merkel cell carcinoma: is targeted anticancer therapy a feasible option? Boban M. Erovic1, Markus Brunner1, Johannes Pammer2, Sylvana Geleff2, Gregor Heiduschka1, Christoph Arnoldner1, Dietmar Thurnher1 1 Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria 2 Department of Clinical Pathology, Medical University of Vienna, Vienna, Austria Objecitves: The aim of the study was to evaluate, whether targeted anticancer and anti-angiogenic therapies such as receptor tyrosine kinase inhibitors and antisense oligonucleotides are feasible treatment options in Merkel Cell Carcinoma (MCC). We determined the expression of the target molecules VEGF-A and -C, VEGF-R2, PDGFa/b, EGFR, c-kit, Her-2/Neu, Bmi-1 and Mcl-1 in 15 samples of patients with MCC. C-kit positive samples were analyzed for clinically relevant mutations. Methods: Formalin ﬁxed, parafﬁn embedded sections were stained immunohistochemically with antibodies directed against the above mentioned proteins and the percentage of staining was categorized into low, moderate and intense expression. Mutational analysis of c-kit (Exons 9 and 11) was performed on the two samples that showed c-kit expression in immunohistochemistry. Results: We found that c-kit (13%), Mcl-1 (87%), Bmi-1 (100%) VEGF-A (73%) and VEGF-R2 (33%) were expressed in MCC. No DNA-mutations were found in samples expressing c-kit. Discussion: Since VEGF-A, VEGF-R2 and c-kit are targets of new cytostatic agents used in the treatment of other cancers, inhibition by a multi-targeted chemotherapy could be a very promising treatment option. High expression of Bmi-1 and Mcl-1 validates further studies on the use of antisense oligonucleotides in Merkel cell carcinoma.

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HL 16 GPI-15427, a PARP-1 inhibitor, radiosensitizes in head and neck cancer Khurram Khan, Guayan Li, Xin Li, Jie Zhang, Weizheng Xu, David Calvin, Lisa Morgan, Zhaocheng Tang, Krystyna Wozniak, Christina Alemu, Randall Hoover, Bert O’Malley Jr, Rena Lapidus, Daqing Li Department of Otolaryngology-Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA [KK, GL, XL, BO, DL] and MGI Pharma, Baltimore, MD, USA [JZ, WX, DC, LM, ZT, KW, CA, RH, RL] Objective: Inhibition of poly(ADP-ribose) polymerase-1 (PARP1), an enzyme involved in DNA repair, has been reported to enhance the tumourical effect of radiotherapy. In this study we tested a novel PARP-1 inhibitor GPI-15427 (MGI Pharma, Baltimore, MD) with radiotherapy in human head and neck squamous cell cancer (HNSCC). Methods: Pharmokinetic analysis was determined using oral and intravenous bioavailability assays in rats. Human xenograft HNSCC tumours were established in nude mice. Animals were treated with GPI-15427 (at 4, 10, 40 mg/kg) intravenously, administered 30 min before tumour irradiation (2 Gy for 2 consecutive days). The model was repeated using orally administered GPI-15427 (at 10, 30, 100 mg/kg) given 1 h prior to tumour irradiation. Three-dimensional tumour volumes were measured pre and post-treatment. Neutral comet assay was employed to analyze DNA double strand break damage and the ‘‘tail moment’’ (product of the amount of DNA in the tail and distance of tail migration) calculated. Results: GPI-15427 competitively inhibits PARP-1, and reached a Cmax of 4,189 + 327 ng/ml in plasma after a single iv dose of 40 mg/kg. Combined GPI-15427 and radiation signiﬁcantly reduced tumor volume compared to controls, radiation alone, and GPI-15427 alone treatment groups (P < 0.01). No drug-related toxicities or deaths were observed. Neutral comet analysis revealed the mean tail moment, indicative of DNA damage, to be signiﬁcantly elevated in cells treated with combined GPI-15427 and radiation compared to radiation alone (P < 0.001). Conclusions: The PARP-1 inhibitor GPI-15427 signiﬁcantly enhances the effect of radiotherapy by impairing DNA repair: this represents a promising new treatment in HNSCC.

HL 17 Transplantation of epithelial laryngeal cell culture in experiment Chekan Valery Departament of Otorhinolaryngology Belarusian, Medical Academy of Post Graduate Education, I`insk, Republic of Belarus Objective: The main and the most difﬁcult problem in treating chronicscarred laryngeal stenoses is preventing restenosis of respiratory tract. The aim of this research was to study the possibility of transplantationof laryngeal mucosal epithelial cells for reconstructing the mucosal defects after the scar excision.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Methods: The primary and saturated epithelial cell culture of dog laryngeal mucosa was obtained as a result of conducted study. The scarring in subglottic laryngeal area was modeled in animals. The scar tissue from previously deepithelized parts of laryngeal mucosa was excised following the laryngeal ﬁssure. The saturated suspension of epithelial cells with medium was applied to the ﬁrst wound. Then this defect was closed by autoﬁbrine membrane ﬁxed supra- and submucosally on the wound. The reconstruction of the second laryngeal wound was performed using monolayer epithelial cell culture located on the nitrocellulose ﬁlter. Results: Twenty experiments aimed at the reconstruction of the mucosal laryngeal epithelium were carried, the results of 18 being positive. Regardless the type of the transplant the epithelial cells were revealed in the center of the wound, and they were not associated with the lateral zone. The lateral zone represented monolayer multiline epithelium of laryngeal mucosa per se. This phenomenon suggests the possibility for the scar defect epithelization due to the transplantation of epithelial cell culture. Conclusions: The possibility of transplantation and engraftment of obtained saturated epithelial cell culture of laryngeal mucosa was conﬁrmed experimentally.

HL 18 Matrixmetalloproteinases in patients with larynx cancer and benign glottic lesions Ilknur Haberal Can1, Kursad Ceylan1, Muzaffer Caydere2, Ethem Erdal Samim1, Huseyin Ustun2, Hatice Emir1, Zeynep Kizilkaya1 1 Ministry of Health Ankara Research and Training Hospital Ear Nose and Throat Department, Ulucanlar Cad. No: 1Mamak Ankara, Turkey 2 Ministry of Health Ankara Research and Training Hospital Pathology Department, Ulucanlar Cad. No: 1 Mamak Ankara, Turkey Objective: To investigate MMPs (Matrix metalloproteinase) levels in patients with larynx cancer and benign glottic lesions comparing to control group with a retrospective, clinical trial in a tertiary care centre. Methods: The excisional biopsy specimens from rigid suspension direct laryngoscopy performed on patients with laryngeal cancer and benign glottic lesions were examined immunohistochemically. MMp levels including MMP 7, MMP9 and MMP 1 tissue inhibitor levels were investigated in each specimens. There were 20 patients selected in each group. All results were compared with the results of the control group which included patients with chonca bullosa. Results: Over expression MMP 9 was observed in laryngeal cancer specimens when compared to benign glottic lesions and control groups (P < 0.001 for both). MMp 1 and MMP 7 levels did not differ signiﬁcantly in comparison of the three groups. Conclusion: The physiopathologic mechanisms causing laryngeal cancer is still unclear. This study is one of the studies related to the etiopathogenesis of this disease. Our study indicates that the expression of MMP-9 is up-regulated in invasive laryngeal carcinoma.

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HL 19 Osteopontin expression predicts the clinical outcome of laryngeal intraepithelial neoplasia D. Testa1,G. Motta1, A. Celetti2, S. Staibano3,R. Iovine1, M. Mascolo3,G. De Rosa3, M. Santoro2 1 Institute of Otorhinolaryngology, Second University of Naples 2 Institute of Endocrinology and Experimental Oncology of CNR c/o Biology and Cellular and Molecular Pathology Department ‘‘L.Califano’’- University of Naples ‘‘Federico II’’ 3 Department of Functional and Biomorphological Sciences-University of Naples ‘‘Federico II Factors related to malignant transformation of laryngeal precancerous lesions is largely unknown. Laryngeal carcinogenesis is a multistep process with premalignant lesions progressing to invasive carcinoma over a period of years. The aim of the study was to examine the potential utility of osteopontin and CD44v6 as candidate biomarkers for detecting laryngeal intraepithelial neoplasia (LIN) of different degree.Osteopontin (OPN) is a glycosilated phosphoprotein found in all body ﬂuids and in the proteinaceous matrix of mineralized tissues. We studied 82 cases of laryngeal precancerous lesions, compared to hyperplastic and normal tissue, to evaluate the immunoreactivity and histological ﬁndings. Osteopontin expression was higher in all severe LIN than in patient matched normal mucosa. Its expression levels were signiﬁcantly correlated with degree of displasia (P = 0.0094), the recurrence of dysplasia after intervention and the development of laryngeal squamous cell carcinoma (P < 0.0001). Osteopontin expression was paralleled by progressive cell surface reactivity for CD44v6. CD44v6 intense positivity correlated negatively with disease free survival, too (P = 0.007). Our ﬁndings identify osteopontin and Cd44v6 as predictive markers of recurrence or aggressiveness in Laryngeal Intraepithelial Neoplasia.

HL 20 Age-related aspects of the course of RRP induced by HPV-6 and 11 Natalia Babkina1, Iouri L. Soldatski2,3, Nadzeya Barysik1, Sergei Backanov4, Polina Lukashenko1, Herbert Pﬁster5, Valentin Gerein1,6 1 Department of Pediatric Pathology, Institute of Pathology, University of Mainz, Langenbeckstrasse 1, 55101 Mainz, Germany 2 Department of Otorhinolaryngology, IM Sechenov Medical Academy, Moscow, Russia 3 Department of Otorhinolaringology, St. Vladimir Moscow Children’s Hospital, Rubtsovsko-Dvorcovaya Street, 1/3, Moscow 107014, Russia 4 Snegiri Clinic, Regional Children’s Clinical Hospital, Medgorodok, 454076 Chelyabinsk, Russia 5 Institute of Virology, University of Cologne, Fu¨rst-Pu¨ckler-Straße 56, 50935 Cologne, Germany 6 Pediatric Clinic of Johann Wolfgang Goethe University, Frankfurt am Main, Germany Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany Objective: The aim of our study was to analyze the course of recurrent respiratory papillomatosis (RRP) associated with HPV

S19 type 6 and HPV type 11 in relation to the age of patients from our bank of data. Patients and methods: A multicenter study was conducted in 1983–2006 in Germany and in 1988–2006 in Russia. The data of 90 patients matched our criteria and were taken from our bank of data for analysis. Patients had active histologically conﬁrmed papillomas with identiﬁed HPV type and the followup period not less than 5 years. Eighty-two patients had juvenile-onset RRP, mean age of onset was 3.5 ± 3.0 years and eight patients had adult-onset RRP, mean age of onset was 30.7 ± 10.8 years. Mean follow-up duration of patients in German group was 15.3 ± 1.8 years after of a-IFN therapy. The virus type was identiﬁed by Soutern blot and PCR. Results: Patients with juvenile-onset RRP induced by HPV type 11 and HPV type 6 had onset of symptoms at mean age of 3.3 ± 3.0 and 4.1 ± 3.2 years, respectively. Patients younger 2 years were more likely to be affected by HPV type 11 than by HPV type 6 (P = 0.007). All patients with adult-onset RRP had HPV type 6 except one patient with type 11 and two more patients with type 6/11. All patients with pulmonary spread and squamous cell carcinoma of the lung had HPV type 11. Patients with RRP associated with HPV type 11 demonstrated more severe course than patients with RRP associated with HPV type 6 (P = 0.029). Conclusions: HPV type 11 is more likely to cause severe course of RRP with high recurrence rate, pulmonary spread, malignant transformation, requiring more aggressive surgical treatment and it is more common in children of younger age. HPV type 6 is more likely to induce less severe disease and primarily affects older children.

Dysphagia + Reﬂux HL 21 dysphagia and chorea Huntington disease: report on a blinded follow-up study W. Habermann, A. Pilhatsch, A. K. Hodl, M. K. Magnet, R. M. Bonelli Department of General ENT Head and Neck Surgery (Head Prof. Dr. H. Stammberger), Department of Radialogy, Department of Psychiatry, Medical University Graz, Auenbruggerplatz, 8036 Graz, Austria Objective: Dysphagia with aspiration pneumonia is the mean cause of death in patients with Chorea Huntington disease. The purpose of this study was to analyse the course of dysphagia in relation to the course of disease. Methods: Prospective blinded cohort study, classiﬁcation of Huntington disease, classiﬁcation of pathologies of videocinematography by two blinded investigators according to predeﬁned criteria, statistical analysis (SPSS 14.0, Spearman´s correlation) Results: Seventy-six patients were included, signiﬁcant correlations were found between: stage of disease and: drooling, control of oral bolus, pathological swallowing reﬂex, leaking, and bolus passage. Duration of the disease and: control of oral bolus, pathological swallowing reﬂex, leaking, and penetration. Conclusions: In patients with Huntington disease the oral part of swallowing is much earlier affected then the pharyngeal and laryngeal part.

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HL 22 Bile acids and total bilirubin detection in saliva of patients submitted to gastric surgery E. De Corso, S. Baroni, G. Cammarota, M. R. Marchese, J. Galli Instituto di Otorinolaringoiatria, Universita` Cattolica del Sacro Cuore, Policlinico A.Gemelli, L.go F. Vito 00168, Roma Objective: Recently it has been hypothesized that biliary-reﬂux may reach the upper aero-digestive tract and enhance the development of laryngeal malignancies, even though, the presence of duodeno-gastric contents in this region has never been revealed. The aim of this study is to detect bile acids and total bilirubin in saliva of gastrectomized patients, in order to conﬁrm objectively presence of biliary laryngo-pharyngeal reﬂux and its relationship with laryngeal mucosa damage. Methods: We carried out a prospective observational case-control study on 52 patients (cases) previously submitted to gastric surgery and on 51 healthy volunteers (controls). Patients were submitted to clinical interview, esofago-gastro-duodenal endoscopy, endoscopic laryngeal evaluation and saliva collection. In all saliva samples bile acids, total bilirubin and Pepsinogen II were assayed. Results: In cases bile acids levels were recorded in 17/52 (32.6%) patients, while in 35/52 (67.4%) they were undetectable. All controls were negative for bile acids. A signiﬁcant (P < 0.05) correlation between bile acids, total bilirubin and Pepsinogen II values was found in cases positive for bile acids, and a signiﬁcant (P < 0.05) higher prevalence of symptoms and ﬁndings of laryngeal damage and of previous aryngeal neoplastic lesions was observed in positive cases if compared to negative one. Conclusions: We found detectable levels of bile acids and total bilirubin in saliva of patients submitted to previous gastric surgery, prospecting an intriguing diagnostic role of this dosage in the study of biliary laryngo-pharyngeal reﬂux. We revealed ﬁnally a high incidence of laryngeal disorders in patients with positive bile acids in saliva.

HL 23 Milk nasendoscopy v/s videoﬂuoroscopy in investigation of aspiration V. Singh1, S. Berry1, M. J. Brocbbank2,R. A. Frost2, S. E. Tyler2,D. Owens1 1 Department of Otolaryngology, Royal Glamorgan Hospital, Llantrisant, UK 2 Department of Otolaryngology, Radiology and Speech therapy, Salisbury district hospital, Salisbury, UK Objective: Videoﬂuoroscopy has become the gold standard investigation for assessment of aspiration in patients with clinically diagnosed dysphagia due to neurological causes. Modiﬁed nasendoscopy has been described for detection of aspiration with varying ﬁndings. Milk Nasendoscopy is a simple clinic based technique to evaluate swallow dysfunction, requiring no radiological input. This paper aims to review the correlation of Milk Nasendoscopy and Videoﬂuoroscopy in the detection of aspira-

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 tion among patients with clinically diagnosed neurological dysphagia. Design: A retrospective notes review of 100 patients attending combined swallow clinic for clinically diagnosed aspiration. All patients were subjected to both Milk Nasendoscopy and Videoﬂuoroscopy. Correlation of investigation results was reviewed by Kappa testing, and difference statistically examined with Chi squared testing. Results: Assessment of aspiration in pre-swallow, swallow and post-swallow phases was reviewed using Milk Nasendoscopy and Videoﬂuoroscopy. The signiﬁcance of difference was measured using Chi squared testing. Milk Nasendoscopy detected post swallow phase aspiration signiﬁcantly more than videoﬂuoroscopy with no signiﬁcant difference in pre swallow phase. Conclusion: In the investigation of clinically diagnosed neurological dysphagia, substantial correlation was seen in detection between Videoﬂuoroscopy and Milk Nasendoscopy. We suggest that Milk Nasendoscopy could be used as a preliminary clinic based test thereby reducing the need for investigations requiring radiation doses.

HL 24 Instrumental and logopaedic approach in adult neurological dysphagia Bruno Fattori, Andrea Nacci, Valentina Mancini, Fabio Matteucci, Roberta La Vela, Francesco Ursino 3rd Otorhinolaringology Unit, Department of Neurosciences, University of Pisa, Italy Objective: Dysphagia can be secondary to numerous neurological diseases, whether acute or chronic-degenerative. Methods: With this study we compared two groups of patients: the ﬁrst group (22 cases) included patients affected with Amyotrophic Lateral Sclerosis (ALS) and the patients in the second (13 cases) had suffered ictus cerebri. All patients underwent phoniatric examination, analysis of their swallowing function by means of morphological and functional examination of the oropharyngeal structures, and with instrumental tests such as ﬁberoptic endoscopic evaluation of swallow (FEES) and oropharyngo-esophageal scintigraphy (OPES). Results and conclusions: FEES revealed altered motility of the phono-articulation organs in both groups of patients whereas the greatest sensorial deﬁcits were seen in the ictus patients. The study on swallowing demonstrated that the bolus most easily managed by both groups of patients was a semi-solid one. The data produced by OPES conﬁrmed an increase in oro-pharyngeal retention index in both groups studied, the most evident alterations with liquid bolus being those in the subjects with the neurodegenerative disease (81% of patients). Logopaedic therapy was carried out in both groups and the results obtained were clinically assessed by FEES. The semiquantitative evaluation performed with OPES showed improvement in the oro-pharyngeal retention index in the post-ictus patients both with a liquid bolus and with a semi-solid one (pre- and postlogotherapy with the liquid bolus: 14.8 and 20.3%, respectively; preand post-logotherapy with the semi-solid bolus: 16.2 and 21.9%, respectively).

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HL 25 Using scoring system and empiric treatment in the diagnosis of reﬂux A. Batioglu, M. Kulekci, O. Develioglu, Taksim Egitim Arastirma Hospital, Istanbul, Turkey Objective: There is no optimal method for evaluation of laryngopharyngeal reﬂux (LFR). Although pH monitoring is a gold standard for diagnosis, the difﬁculty of application and the insufﬁciency in detecting non-acid reﬂux patients, make the test impractical for screening and diagnosing the disease. This study aims to evaluate success of medical treatment in patients suffering LFR disease by scoring ﬁndings and symptoms with empiric treatment with a follow up period of 1 and 3 months, respectively. Methods: Our study included 122 patients with complaints of globus, coughing and soreness that were examined. Patients with a score of 13 or higher in reﬂux symptom index (RSI) and 7 or higher in reﬂux ﬁnding score (RFS) were considered to have reﬂux. Patients were treated with 30 mg lansoprozol twice a day. All patients were evaluated before and during the treatment period at 1 and 3 months. Student’s t test and Pearson’s correlation were used to detect signiﬁcance for RSI, RFS records at 1 and 3 months. Results: A signiﬁcant improvement is determined in ﬁndings and symptoms due to treatment modality (P < 0.001). These improvements in RFS and RSI were correlated, thus conﬁrming the diagnosis. This ﬁnding also strengthens the reliability of the score indices that we have used in the study. Conclusions: This study (1) conﬁrms reﬂux diagnosis in patients improving with empiric antireﬂux treatment with scores higher than 7 in RBS and higher than 13 in RSI. (2) strengthens the reliability of RBS and RSI. We suggest that this scoring system is a useful diagnostic tool that can be used easily in outpatients as a ﬁrst choice instead of ph monitoring. It will also prevent patients from over treatment. Keywords: Scoring system, Empiric treatment, Reﬂux

HL 26 Changes in the ﬁndings of laryngopharyngeal reﬂux with treatment M. Kulekci, A. Batioglu, O. Develioglu, Taksim Egitim Arastirma Hospital, Istanbul, Turkey Objective: Until recently, no deﬁnite test for the diagnosis of laryngopharyngeal reﬂux (LFR) is present, except for the healing of laringitis with acid suppression. Although compatibility between ﬁndings and LFR or response to treatment are controversy, value of improvement of endoscopic ﬁndings is deﬁnite in diagnosis. Our aim was to compare the endoscopic ﬁndings that constitude reﬂux ﬁnding scores before treatment with ﬁrst and third months of treatment and indicate improvements of treatment quantitatively. Methods: One hundred and twenty-two patients with complaints of reﬂux symptoms and patients with a score of 13 or higher in reﬂux symptom index (RSI) and 7 or higher in reﬂux ﬁnding score (RFS) have been studied between January 2005 and 2006. The

S21 endoscopic records of all the patients who were given 30 mg of lansoprozol twice a day before and in ﬁrst and third months of treatment were evaluated by two physicians having different experiences without knowing periods of diagnosis and treatment. T test was used to compare the scores of all the ﬁndings. Results: Except granulation a signiﬁcant decrease in scores and ratios of all ﬁnding which constituted RFS with treatment. (P < 0.001). Though some ﬁndings soluterly were not spesiﬁc for LFR, acceptance of a 7 and higher score as reﬂux according to RFS made the presence of at least a few ﬁndings together overcome this negativity. Resolution of ﬁndings with treatment proved that these ﬁndings were due to reﬂux. Conclusions: This study shows that the improvement of endoscopic ﬁndings is an appropriate way to follow the response to the treatment. Keywords: Endoscopic ﬁndings, Antireﬂux treatment, Improvement

HL 27 Reevaluation of surgical treatment by external approach for Zenker’s diverticulum M. D. Cobzeanu1, V. Costinescu1, Carmen Daniela Rusu1, Monica Voineag1, V. Drug2, Camelia Cobzeanu3 1 ENT Clinic, ’’Sf. Spiridon’’ Hospital, Iasi, Romania 2 Gastroenterology and Hepatology Institute, Iasi, Romania 3 Radiological Ambulatory Department of ‘‘Sf. Spiridon’’ Hospital, Iasi, Romania Objective: Surgical options for treating symptomatic Zenker’s diverticulum include both traditional external procedures as well as endoscopic and minimally invasive techniques. The authors make a retrospective evaluation of the treatment for Zenker diverticulum by classic external approach. Methods: The study included seven cases (mean age 69 years) with different sizes Zenker’s diverticulum, treated by external surgery in our department between 2000 and 2005. The presenting symptoms were dysphagia, halitosis, regurgitation, aspiration, hoarseness, weight loss. In ﬁve cases, Zenker diverticulum was associated with gastroesophageal reﬂux. Paraclinical assessment included barium esophagography, esophageal manometry, ﬂexible endoscopy, CT scan. In the selected cases, different surgical procedures by external approach were performed. One of these cases is reported: a 61-year-old patient with large Zenker’s diverticulum who underwent cricopharyngeal myotomy and diverticulectomy by laterocervical approach. Results: Cricopharyngeal myotomy associated with diverticulectomy or diverticulopexy was the preferred treatment in the selected cases with large Zenker diverticulum and allowed a complete excision, without recurrences. Medical treatment for gastroesophageal reﬂux was associated. No major complications occurred and more than 90% of patients reported complete resolution of symptoms. Conclusions: The surgical treatment should be performed according to the clinical and paraclinical characteristics of diverticulum and the patient. In certain selected cases, the external surgery remains a good option with favorable long term functional results.

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HL 28 Swallowing outcomes in oropharyngeal squamous cell carcinoma Ligy Thomas, Derek Lowe, Sankalp Tandon, Terry Jones, Simon Rogers University Hospital Aintree, Longmoor Lane, Liverpool, UK Management of cancer tends to focus on maximising survival, with less regard for functional outcome. A cross-sectional survey was carried out to assess post treatment swallowing disability. Aim: To assess swallowing outcome for patients who had curative treatment for orpharyngeal carcinoma (soft palate, oropharynx, tonsil and base of tongue). Objective: (1) To compare the swallowing domain of The University of Washington Quality of Life scale (UW-QOLv4) with MD Anderson Dysphagia Inventory (MDADI) and Swallowing Quality of Life measure (SWAL QOL). (2) To compare subjective rating with clinician-rated FEES (using penetration aspiration score). Method: All patients treated between 01/01/1999 and 31/05/05 for oropharyngeal Ca from the Liverpool Head and Neck oncology database were identiﬁed. Among the 110 patients eligible, 77 were willing to participate, 29 unwilling and 4 were untraceable. Patients completed three validated questionnaires and FEES assessment. Findings: Median follow-up was 21 months (range 2– 60 months). Swallow was normal in 19, 52% could swallow certain solid foods, 18% were restricted to liquids and 11% could not swallow. A third were dependant on feeding tubes for nutrition. There were differences in swallowing scores with treatment modality. The Spearman correlation co-efﬁcient between UW-QOL swallowing domain and MDADI & SWALQOL was 0.6 (P < 0.001). Correlation between FEES score and swallowing status was –0.46, P < 0.001. Conclusions: The swallowing domain in UW-QOL correlates well with detailed dysphagia assessment tools and clinician rated assessment. Further prospective study required to elucidate the differences between treatment groups.

HL 29 Spatial measurements of the pharynx in the swallows of patients with small head and neck cancers S. H. Vyas, S. Ford, S. W. Gollins, P. Hobson, H. Zeitoun Glan Clwyd Hospital, Sarn Lane, Rhyl, N. Wales, UK Objective: To assess the swallowing in T1 laryngeal carcinoma patients, using video-ﬂuroscopy (VF), prior to radiotherapy. In particular the effects of age, gender, body mass index (BMI) and cancer site are evaluated. Methods: Forty-eight consecutive patients (34 males and 14 females) diagnosed with T1 laryngeal carcinoma were included in the study, prior to radiotherapy treatment. Their demographic details along with BMI, past medical history, as well as smoking and alcohol consumption were recorded. To evaluate

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 the pharyngeal anatomy, naso-endoscopy was carried out, followed by VF. The swallow assessments were carried out with three consecutive 10 ml of Baritop liquid and were digitally recorded using the Kay’s Swallowing Workstation. Results: The posterior pharyngeal wall moved further, relative to the tongue base, for all patients. Signiﬁcant gender and age differences were found which were in-keeping with previous studies of normal swallows. BMI was found to have a signiﬁcant effect on the width of the pharyngo-eosophageal (PES) opening. It was found that whilst the diameter of the PES in the lateral view showed no signiﬁcant differences for gender, from the anterior-posterior view there was a signiﬁcant difference, with PES diameter being larger in males than in females (P = 0.026/0.022). Conclusions: The spatial measurements of the pharynx in the swallows of patients with small head and neck cancers (T1 larynx) were in-line with those of normal swallows.

HL 30 A randomised prospective assessement of lidocaine spray during ﬂexible nasoendoscopy in normal volunteers S. H. Vyas, S. Gollins, S. Ford Wales Cancer Treatment Centre, Glan Clwyd Hospital, Rhyl, UK Objective: To assess and compare patient discomfort during ﬂexible nasoendoscopy (FN), with or without the use of lidocaine nasal spray. Also to see if it made any difference to swallowing. Method: One hundred and ten healthy volunteers were recruited for the study and randomised into two groups: Group A (58), prior to FN had 2.5 ml of lidocaine hydrochloride 5% w/v intranasal spray (which also contained phenylephrine hydrochloride 0.5% w/v). Group B (52) had no spray prior to FN. The volunteers underwent examination of their nasal cavity, post-nasal space, base of tongue, and larynx. As part of a further ’normal’ swallowing study they underwent a series of swallow tests with 20 ml of natural blue dye, 1, 10, and 20 ml of water. The patient discomfort was assessed using a Visual Analogue Scale (VAS 0-5). A further questionnaire was ﬁlled to assess any other symptoms such as rhinorrhea, nausea, vomiting, headache and altered sensation of swallowing. Results: VAS (0-5): Group A (58): 1(28/58,48.3%), 2(25/ 58,43.1%), 3(5/58,8.6%). Group B (52): 1(12/52,23.1%), 2(24/ 52,46.2%), 3(14/52,26.9%), 4(2/52,3.8%).Rhinorrhea: 13/58 (22.4%) in group A. 8/52 (15.4%) in group B. Difﬁculty in swallowing: 13/58 (22.4%) in group A and 6/52 (11.5%). Nausea: 8/58 (13.8%) in group A and none in group B. Conclusions: In group A, 53/58 (91.3%) and in group B 36/52 (69.2%) reported VAS up to 2. Therefore using lidocaine appears to be slightly better at preventing discomfort, however perception of other symptoms such as rhinorrhea, nausea and altered sensation of swallowing are higher.

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HL 31 Dysphagia due to chemoradiotherapy of head and neck cancer E´. Remena´r, K. Me´sza´ros, M. G} ode´ny, A. Boe´r, J. Lo¨vey, Z. Taka´csi-Nagy, E. To´th, M. Ka´sler National Institute of Oncology, Budapest, Hungary Objective: To evaluate the swallowing function of head and neck cancer patients before and after chemoradiotherapy. Methods: Physical and endoscopic examination, swallowing X-ray with water-soluble contrast material of different viscosity, quality of life questionnaires, type and quantity of food, weight measures performed before, during and after chemoradiotherapy in 35 patients. Results: Impaired oropharyngeal motility, reduced elevation of the larynx, silent aspiration, ﬂuid only or parenteral nutrition and weight loss were the most common ﬁndings during or within one week after chemoradiotherapy. These parameters slightly improved 1 month after the end of therapy, but even at the 12-week control of the therapy response most of the patients had at least one of the above mentioned symptoms. Conclusions: Despite of the promising results of chemoradiotherapy with respect to organ sparing and overall survival in advanced head and neck cancer, functional disabilities especially swallowing disorders due to this therapy are severe and require more activities from the speech and swallowing therapist, until less toxic treatments will be introduced.

HL 32 Swallowing and speech dysfunction in post-laryngectomy patients. Does radiotherapy make a difference? Carmen de Casso, Jarrod Homer Department of Otolaryngology, Manchester Royal Inﬁrmary, Oxford Road, Manchester, M13 9WL Treatment of carcinoma of the larynx by total laryngectomy, alters signiﬁcantly speech and swallowing, resulting in marked impact in the patients quality of life. Objective: (a) To determine the incidence and severity of dysphagia in patients treated for carcinoma of the larynx with total laryngectomy as a single modality treatment or with surgery and radiotherapy. (b) To determine the ability to communicate and the preferred method. Methods: Multi-centre retrospective cross-sectional study. Participants: One hundred and twenty-one post-laryngectomy patients all of which had completed deﬁnitive treatment at least 6 months before this study. Twenty-six patients had total laryngectomy as a single modality treatment and 95 had total laryngectomy and radiotherapy. Main outcome measures: Swallowing (solid food, soft diet or ﬂuid/ PEG) and voice development (valve, oesophageal speech or no surgical speech). Results: Data was analysed using SPSS, Chi square and Fisher’s exact test. Ninety-eight (81%) communicated verbally. However, only 82 (67.76%) patients developed a surgically restored voice, with 16 (13.22%) needing an electro-larynx. Fifty-nine (48.76%) could swallow solids, 23 (19%) soft food, 25 (20.66%) ﬂuids and 17 (14%) required a PEG as supplementary or only feed. Speech in patients who had radiotherapy (69.47%) or no radiotherapy

S23 (57.69%) was not signiﬁcantly different. Swallowing was signiﬁcantly better in the group who had no radiotherapy (P = 0.0008), 80.76% managed solids, compared to 38.95% in the surgery with radiotherapy group. Conclusions: The impact of radiotherapy on total laryngectomy patients results in further impairment of swallowing. Interestingly, voice seemed only minimally inﬂuenced by radiotherapy.

HL 33 Complete recanalization of a completely obstructed cervical esophagus with an endoscopic-radiologic rendez-vous and self-expanding stent De Vincentiis Marco1, Fiocca Fausto2, Salvatori Filippo Maria3, Ceci Vincenzo2, Donatelli Gianfranco2, Corona Mario3, Boatta Emanuele3, A. Gallo1 1 Department of ENT, ‘‘G. Ferreri’’, University ‘‘La Sapienza’’, Rome, Italy. Policlinico ‘‘Umberto I’’, Viale del Policlinico, 155- Rome, Italy 2 Department of Emergency Endoscopic Surgery, University ‘‘La Sapienza’’, Rome, Italy. Policlinico ‘‘Umberto I’’, Viale del Policlinico, 155- Rome, Italy 3 Department of Radiology, University ‘‘La Sapienza’’, Rome, Italy. Policlinico ‘‘Umberto I’’, Viale del Policlinico, 155- Rome, Italy Objective: Radiotherapy for head and neck cancer frequently causes injury to the cervical esophagus with strictures that need frequently endoscopic dilatation. Mini-invasive treatment of a long complete obliteration of the cervical esophagus after radiotherapy for cancer of the rinopharinx is reported. A 37 years old woman with advanced (T3 N1 M0) cancer of the rinopharinx underwent chemo-radiotherapy for intractable cancer. A PEG and tracheostomy were placed before therapy. After 60 Gy and 5-FU radio-chemotherapy the patient, free of disease, after 6 months developed complete obstruction of the esophagus. An upper endoscopy found a complete obliteration at the level of the crico-pharinx muscle not allowing the transit of a small guide wire or contrast medium. Methods: With a bronchoscope through the PEG the cardias was incannulated and a cannula inserted in the distal esophagus: a complete stricture 3 cm long was evidentiated. Controlling the exact alignment under ﬂuoroscopy a needle was advanced from the distal esophagus toward the above where the needle was catched with a snare. When the continuity was reestablished with a guide wire after a balloon dilatation up to 10 mm a feeding tube was left in place. After two days a full covered removable self- expanding stent 16 mm in diameter was inserted and mantained in place for 1 month. The patient tolerated well all procedures under general anesthesia and tolerated well the stent. Results: After the stent was removed a good patency of the esophagus was found without dilatation. The patient is doing well after 6 months and she can swallow after a period of reeducation. Conclusions: Complete obstruction of the esophagus after chemo-radiotherapy for head and neck cancer may occur in as great 23% of patients and is condition that is badly tolerated especially by young patients. Surgery is difﬁcult and often at risk. Efforts should be done to improve the quality of life of these patients. The combination of endoscopical and radiological expertise with the aid of new technologies can solve many problems.

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HL 34 Videoﬂuoroscopy in neopharyngeal dysfunction post laryngectomy Samit Ghosh1, Jeffrey Lancaster1, Sankalap Tandon1, Eileen Gilmartin2, Huw Lewis Jones3, Terry Jones1 1 Department of ENT-Head and Neck Surgery, University Hospital Aintree, Liverpool, UK 2 Department of Speech and Language Therapy, University Hospital Aintree, Liverpool, UK 3 Department of Radiology, University Hospital Aintree, Liverpool, UK Objective: We assessed the videoﬂuoroscopic appearances of neopharynx in patients with with either/and/or dysphagia, poor valve voice, central valve leakage to see if any part of the surgical procedure, or modiﬁcation thereof, can alter outcome. Methods: Fourteen patients presented 11 months (median, range 2–59) after laryngectomy. Videoﬂuoroscopy was performed and surgical factors assessed. Results: No patients suffered poor valve voice or dysphagia alone. One patient had all three problem, one had dysphagia and leakage, two patients had central leakage, two had leakage + poor voice. Six patients had poor valve voice and dysphagia. Three patients had partial pharyngectomies, 12 patients had constrictors closed, 9 patients had pharyngeal myotomy. Nine patients had speech valve placed primarily and three secondarily. One patient did not have a valve. In the swallowing series six patients demonstrated cricopharyngeal spasm, three were normal, six had persistent spasm from C3 to C7 delaying barium transit which typically disappeared on relaxation. In voicing, six patients had cricopharyngeal spasm and ﬁve had long segment spasm reducing air passage through the valve reducing volume, duration and quality of phonation. In two cases where constrictors were not closed, one patient had dysphagia and poor voice,and the other dysphagia alone. Conclusion: In dysphagia the most common ﬁnding is cricopharyngeal spasm and neopharyngeal spasm appears to be the main issue in valve voice problems. As a result a change in practice has been adopted to not close the constrictor muscles in our patients thus also leaving it easier to treat cricopharyngeal spasm with single site botulinum toxin injection.

Larynx HL 35 Autoﬂuorescence endoscopy imaging in diagnosis of laryngeal neoplasia Maciej Dariusz Zatonski, Tomasz Krecicki, Maria Zalesska-Krecicka Medical University of Wroclaw, Department of Otolaryngology, Head and Neck surgery Objective: Autoﬂuorescence endoscopy imaging is a new diagnostic method in otolaryngology, and seems to have many important advantages. The objective of this study was to assess

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 speciﬁcity and sensitivity of autoﬂuorescence endoscopy imaging in comparison to white-light endoscopy. Methods: One hundred and twenty-nine patients with various laryngeal epithelial pathologies entered the study. All patients underwent white-light endoscopy (and stroboscopic examination when possible) followed by autoﬂuorescence (blue-light) endoscopy. Biopsy samples were obtained as reference. Speciﬁcity and sensitivity were calculated. Chi-square test was used for statistical analysis. Results: AF-endoscopy proved to be a sensitive (95.6%) method with high speciﬁcity (81.6%) in diagnosing laryngeal lesions. It shows signiﬁcant advantage over white-light examination (P < 0.01), especially when diagnosing early pre-cancerous lesions or early stages of laryngeal cancer. Conclusions: AF-endoscopy is an excellent addition to classic white-light endoscopy and stroboscopic examination. It is highly sensitive and speciﬁc in diagnosing early stages of carcinogenesis, starting from LIN II. It allows to precisely deﬁne borders of lesions. Unlike stroboscopic examination, AF-endoscopy can be used in diagnosing and monitoring changes located in supraglottic area of the larynx.

HL 36 Current state of robotic scanning applications with the CO2 laser Marc Remacle, Georges Lawson, Monique Delos Department of ORL, Head and Neck Surgery, Department of Pathology, University Hospital of Louvain at Mont-Godinne Introduction: The development of the automatic scanning system has considerably enhanced CO2 laser energy delivery, improving cutting and ablation modes. Objective: In order to know if there are any differences in phonosurgery between SuperPulse and UltraPulse lasing applications (both compatible with the scanning system) with regard to thermal diffusion into the surrounding tissues, healing time and clinical results, 13 patients with bilateral and similar vocal fold lesions have been operated, one side in SuperPulse mode and the other side in UltraPulse mode. Methods: The UltraPulse mode allows for higher pulse energies as compared to SuperPulse mode at the same average power. This impacts the amount of thermal damage positively. The automatic parameters for phonosurgery have been: depth of 0.2 mm, 10 W, single pulse, 0.10 s for SuperPulse; two passes, 10 W, single pulse, 0.10 s for UltraPulse. Results: Incisions are sharper with UltraPulse, making the surgery easier but at the ﬁrst postoperative control after 8–10 days no differences were observed in the presentation, the healing and the vibration of the two vocal cords. Coagulation along the incision line is 40 lm for SuperPulse and 25 lm for UltraPulse. Conclusions: In comparison with SuperPulse, the UltraPulse CO2 laser makes a procedure easier, but did not improve the clinical outcome.

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HL 37 Chronic hyperplastic laryngitis (a clinical follow-up study) Dejan Radaljac1, Zeljko Petrovic2, Ivan Boricic3 1 ORL Department, Hospital ‘‘Dr. M.Marin’’, Loznica, Serbia 2 Institute of ORL and Maxillofacial Surgery, Belgrade 3 Institute of Pathology, School of Medicine, Belgrade University Objective: Chronic hyperplastic laringopathies are considered precancerous lesions because of their possible transformation in time into malignant epithelial neoplasia. The aim of this study was to evaluate in the long-term the risk of malignancy occurring in the larynx of patients with chronic hyperplastic laryngitis. Methods: A series of 138 cases of hyperplastic chronic laryngitis was studied from 1998 to 2003. All patients entered the study after microlaryngoscopy and biopsy, 11 patients with initial biopsy before 1998. Histological diagnosis were graded according to Ljubljana classiﬁcation into simple, abnormal and atypical hyperplasia and Ca in situ. The mean follow-up period was 40 months. Results: Malignancy developed in 37% (10/27) of the cases with atypical hyperplasia, and in 5% (6/111) with simple and abnormal hyperplasia (P < 0.001). The groups were correlated with epidemiological factors. Conclusions: There is a positive connection between age, gender, tobacco smoking, alcohol consumption, degree of epithelial hyperplasia and cellular atypia in bioptic material and the risk of developing larynx carcinoma. Patients affected by chronic hyperplastic laryngitis need regular follow-up and immediate surgery in cases of relapse.

HL 38 Clinical study of laryngeal cancer screening in human dry dock Shun-Ichi Sasaki, Toshikazu Maeda, Yoshihiro Watanabe Department of Oto-Rhino-Laryngology Head and Neck Surgery, Ashikaga Red Cross Hospital, Japan Objecitves and methods: Since 1998 laryngeal cancer check with ﬁberscope and stroboscope as optional subject have been performed in persons who underwent human dry dock in our hospital. From 1998 to 2006 these checks were examined total 1,084 persons (males 916, females 168). This study was reported background, diagnosis, and improvement of life style in these cases. Results: The most diseases were as follows, in 1998 chronic corditis (M 26.2%, F 4.8%), atrophy (M 6.2%), GERD (M 7.7%), nodule (M 3.1%), in 2001 chronic corditis (M 23.3%, F 12.5%), GERD (M 7.7%), atrophy (M 5.4%), polypoid degeneration (M 4.5%), in 2006 chronic corditis (M 30.1%, F 13.5%), GERD (M 8.1%), polypoid degeneration (M 6.2%, F 10.0%). The rate of repeat was 70.8 (1999), 66.4 (2001), and67.0% (2006) (range 66.2–73.8%). The rate of smoker was 1998—M: 58.3%, F: 19.0%, 2001—M: 50.9%, F: 12.5%, 2006—M: 42.2%, F: 6.7%. In all period two cases of laryngeal cancer (T1aN0) and one case of hypopharyngeal cancer (T1N0) were detected. Conclusions: These examinations motivated them to improve voice habits, because they could know how to use vocal fold and how smoking and vocal abuse are bad for their phonation.

S25 Not detect malignant tumor in larynx alone but also their combination with laryngeal hygiene lecture and individual guidance is important. Keywords: Human dry dock, Laryngeal cancer, Hygiene lecture

HL 39 Bilateral vocal cord palsy associated with myxedema Vikto´ria Kova´cs, A´kos Reme´nyi, Gyo¨rgy Lichtenberger Szent Ro´kus Hosp. and Inst., Department of ORL-HNS, 1085 Budapest, Gyulai Pa´l u. 2., Hungary Objective: Bilateral vocal cord palsy and laryngeal myxedema are sever complications of thyreoidectomy. Management of dyspnoea caused by association of these factors means a great therapeutic challenge. Methods: In the acute post-operative period of thyreoidectomy for managing dyspnoea caused by bilateral vocal cord palsy we perform reversible vocal cord lateralisation. However later when there is no chance for the recovery of the recurrent laryngeal nerves irreversible procedure is done. Applying these techniques we can achieve satisfactory breathing in about 95% of cases avoiding tracheostomy. In 5% of cases there are other factors in the background of unsuccessful results. From these we emphasize the role of myxedema. Between 01.01.1989 and 30.09.2006 we did 154 reversible and 125 irreversible vocal cord lateralisations. From these cases three men had further obstruction due to myxedema. We demonstrate our experience achived by managing these patients. Results: Applying endoscopic glottis dilating operations and levothyroxine replacement therapy sufﬁciently wide glottic chink has been achieved in all the cases. Conclusion: According to our experience dyspnoea caused by bilateral vocal cord palsy after thyreoidectomy needs interdisciplinar therapeutic approach beside glottis dilating operations.

HL 40 Videocontact endoscopy associated with microsurgical ‘‘cold’’ techniques and CO2 LASER techniques in the surgery of the glottic plan Viorel Zainea, Romeo Calarasu, Razvan Hainarosie, Novac Popescu, Anca Iliescu Institute of Phono-audiology and Functional ENT Surgery from Bucharest; No. 21 Mihai Cioranu Street, District 5, Bucharest, Romania Introduction: Videocontact endoscopy of the vocal fold represents an interesting opportunity to study the lesions of the vocal fold ‘‘in vivo’’ and ‘‘in situ’’. The aim of this study was to verify if this method can contribute to the decision of approaching the lesion with ‘‘cold’’ instruments or/and CO2 Laser techniques. Method: The patients underwent videocontact endoscopy during endoscopic surgery of the larynx. Videocontact endoscopy showed the aspects concerning the uniformity of the epithelial ﬁeld, ratio between nucleus and cytoplasm, the shape and the size of the epithelial superﬁcial cells ‘‘in vivo’’ and ‘‘in situ’’. The surgical decision concerning the approach using ‘‘cold’’ instruments or CO2 Laser techniques took into account the images offered by videocontact endoscopy. Some representative cases illustrate the main results in different pathologic situations. Results: Videocontact endoscopy represents an interesting method to be used before taking the decision of approaching the lesion with ‘‘cold’’ instruments or with Laser techniques at the level of the glottic plan.

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HL 41 Towards an automatic categorization of images of laryngeal diseases Antanas Verikas1,2,3,4, Adas Gelzinis2, Marija Bacauskiene3, Virgilijus Uloza4 1 Intelligent Systems Laboratory, Halmstad University, Halmstad, Sweden 2 Department of Applied Electronics, Kaunas University of Technology, Kaunas, Lithuania 3 Department of Applied Electronics, Kaunas University of Technology, Kaunas, Lithuania 4 Department of Otolaryngology, Kaunas University of Medicine, Kaunas, Lithuania Objective: To elaborate an approach integrating the global and local kernel-based automated analysis of vocal fold images aiming to categorize laryngeal diseases. Methods: This study used a set of 785 digital laryngeal images. The images were acquired during routine direct microlaryngoscopy employing the Moller-Wedel Universa 300 surgical microscope. The 3-CCD Elmo color video camera of 768 · 576 pixels was used to record the images. The problem was treated as an image analysis and recognition task. A committee of support vector machines was employed for performing the categorization of vocal fold images into healthy, diffuse, and nodular classes. In this study, the main task was to differentiate between the healthy class and pathological classes and then differentiate among the classes of vocal fold mass lesions. Two groups of mass lesions of vocal folds were distinguished i.e. nodular lesions (localized thickenings): nodules, polyps, and cysts, and diffuse lesions: papillomata, hyperplastic laryngitis with keratosis, and carcinoma. Analysis of image color distribution, Gabor ﬁltering, co-occurrence matrices, analysis of color edges, image segmentation into homogeneous regions from the image colour, texture and geometry view point, analysis of the soft membership of the regions in the decision classes, the kernel principal components based feature extraction were the techniques employed for the global and local analysis of laryngeal images. Results: The correct classiﬁcation rate of over 94% was obtained. Conclusion: Bearing in mind the high similarity of the decision classes, the results of automatic correct classiﬁcation of laryngeal images are rather encouraging.

HL 42 Endoscopic laser management of bilateral vocal fold immobility Vasant Oswal1, Sachin Gandhi2 1 James Cook University Hospital, Middlesbrough, England, UK 2 Deenanth Mangeshkar Hospital, Pune, India Patients with bilateral vocal fold immobility require life long tracheostomy. Endoscopic laser arytenoidectomy is the method of choice for a successful decannulation Out of 66 patients, 33 had iatrogenic aetiology. Twenty-seven of these had intubation trauma whereas six were post-thyroidectomy. Other aetiology was idiopathic bilateral abductor paralysis, neck trauma, chemical burns, infection and congenital. All but one had undergone tracheostomy. Patient without tracheostomy decided to come back later for a more deﬁnitive surgery of arytenoidectomy. Sadly, this patient developed acute stridor and was dead on arrival. In

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 tracheostomised patients, endoscopic arytenoidectomy was undertaken with CO2 laser. The vocal ligament was severed from vocal process. The vocal folds retracted anteriorly. The submucosal muscular and ﬁbrous bands were vaporised and the body was extracted submucosally. Soft tissue and any tags were vaporised until a posterior airway of between 5 and 7 mm, depending upon the size of the patient, was achieved. Postoperatively the patients were given steroid sprays and inhalations. Six week postoperatively staged decannulation was successfully achieved as inpatient. In the absence of a contributing pathology such as subglottic stenosis, the endoscopic laser method offers an elegant method for restoration of airway and decannulation without signiﬁcant patient morbidity. An expectant management is possible by cord suture lateralisation made technically easier by Lichtenberger dedicated needle holder. If restoration of movement is not observed in nine to twelve months, then suture lateralisation is made permanent by burying it under the skin. Open neck surgery management is now considered obsolete.

HL 43 Optimizing the results of Type 1 thyroplasty: our experience Handa, Kumud Kumar All India Instittue Of Medical Sciences, New Delhi, India Objective: The authors present their work of Type 1 Thyroplasty alone or with arytenoids adduction in their institution All India Institute of Medical Sciences, New Delhi from 1998 to date. The commonest indication was Unilateral Vocal cord paralysis. The objective was to determine the factors which would help in achieving the best possible results after Type 1 Thyroplasty. Methods: The data included patients who underwent Type 1 Thyroplasty alone or with arytenoids adduction. The parameters studied included Role of pre-operative stroboscopy, Type of prosthesis, Shape of prosthesis, Combination of thyroplasties and whether cartilage was removed or not. Combination of thyroplasty with arytenoids adduction and presence of any co-existing lesions on the vocal cords. The outcome measures were Objective voice analysis and perceptual analysis. Siliastic block was used in 67 out of 72 patients while in 5 patients Netterville prosthesis was used. In four patients Type 1 Thyroplasty had to be combined with Type 4 Thyroplasty. Results: The results showed that Type 1 Thyroplasty sufﬁces for glottic defects which are elliptical but for glottic defects which are because of higher lesions and due to combined superior laryngeal and recurrent laryngeal paralysis arytenoid adduction is required along with Type 1 Thyroplasty. Proper patient selection and preoperative stroboscopy is essential. Preoperative stroboscopy helps identify certain subtle lesions which may be the cause of non improvement of voice post operatively. The quality of siliastic in preformed prosthesis may be better than that in siliastic blocks where due to repeat sterilization the quality may be affected. Removing the cartilage window gives better results than retaining it. The free cartilage is likely to under go resorption. Conclusion: Type 1 Thyroplasty alone or in combination with Type 4 Thyroplasty or in combination with arytenoids adduction is the standard treatment for Unilateral paralysed cord. However the best results can be obtained by keeping the above mentioned variables in mind.

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HL 44 Bilateral vocal cord paralysis: aerodynamic measures and quality of life W. Harnisch1, S. Brosch1, R. Hagen1 1 Univ.-ENT-Clinic Wuerzburg, Germany Objective: The aim of this study was to evaluate the long-term effect of surgical treatment on airﬂow dynamics and quality of life in patients with bilateral vocal cord paralysis. Methods: Ten patients underwent ﬂow-volume spirometry and body-plethysmography at least 6 months after glottal surgery. The chronic respiratory questionnaire (CRQ-SAS) and the EORTC QLQ-C30, H&N35 were used to assess breathing difﬁculties and health related quality of life. The size of the glottal area, residual vocal fold movement and mucosal wave were determined during microlaryngostroboscopy. Results: Residual recurrent nerve activity was seen in ﬁve patients. Pulmonary data varied widely and were not closely related to the size of the glottal area. Patient’s subjective dyspnoea, quality of life and physical functioning were found to be correlated with expiratory airﬂow. Conclusions: Surgical success in terms of an enlarged glottal area might not lead to sufﬁcient respiratory improvement and patient’s satisfaction. Reduction in inspiratory speaking efforts in addition to acquisition of special breathing techniques during speech therapy improve airﬂow stability as well as effectiveness of respiration, thus leading to enhanced quality of life.

HL 45 Difﬁculties and complications of endo-extralaryngeal lateroﬁxation of the vocal cords in the treatment of bilateral recurrent laryngeal nerve pals Jovic´ Rajko1, Mitrovic´ Slobodan1, Janjevic´ Dusˇ ica2, Dragicˇevic´ Danijela1, Cˇanji Karol1 1 University ENT Clinic, Medical Faculty, Clinical Center, Hajduk Veljkova 1 Novi Sad 21000 Serbia, 2 Anaestesiology Department of ENT Clinic, Clinical Center, Novi Sad Objective: The aim of this study is to point out our experiences in using endo-extralaryngeal lateroﬁxation of the vocal cords as a method for treatment of bilateral recurrent laryngeal nerve palsy, as well as the complications of this method and the ways of their resolving. Methods: During the period from January 2003 to December 2006, we performed 14 endo-extralaryngeal vocal cord lateroﬁxations in patients with bilateral recurrent nerve palsy. There were 12 women and 2 men, ages from 26 to 78 years (average age 57.4). The cause of bilateral recurrent nerve palsy in 11 patients was thyroid gland surgery, in one patient it was ﬁre arm chest injury, in one patient it was esophageal diverticulum surgery and in one patient it developed after tracheal stenosis operation. Two of these patients were admitted with previously performed tracheostomy, while other 12 were without tracheostomy. Lateroﬁxation was performed in the period from 8 to 40 days after bilateral recurrent nerve palsy occured. The procedure was done under general anaesthesia with JET ventilation with using endoextralaryngeal lateroﬁxation suture technique by placement two sutures arround the vocal process of the arytenoid of the vocal cord. Results: During the postoperative period in all patients swelling of the arytenoid and other laryngeal structures on the side of

S27 lateroﬁxation developed. In four (28.6%) patients this swelling was minimal and with no inﬂuence on breathing. In seven (50%) patients the swelling of laryngeal structures on the side of lateroﬁxation caused heavy breathing 3 days after the intervention, specially during the night even with corticosteroid therapy. These patients were treated with desopstructive corticosteroid therapy, inhalations of ephedrine solutions, oxygenation and bed rest. At the end of the ﬁrst week after the intervention the swelling of the larynx as well as breathing difﬁculties were reduced. In two (14.3%) patients due to swelling of laryngeal structures and severe breathing problems we performed bilateral vocal cord lateroﬁxation, and then tracheostomy. One patient died even after the tracheostomy was performed. Values of thyroid gland hormones (T3 and T4) as well as TSH were within normal ranges. Four months after the intervention vocal cord function unilateraly recovered in two patients and the sutures arround the vocal cords were removed. Two patients remained tracheotomised while others had satisfactory lung functions according to body pletysmography. Conclusions: Endo-extralaryngeal lateroﬁxation of vocal cords is an alternative method to urgent tracheostomy in early treatment of patients with bilateral recurrent nerve palsy. Critical period during the ﬁrst week after the procedure requires corticosteroid therapy with inhalations of symphatheticomimetics and oxygenotherapy. In certain number of patients, in spite of conservative treatment, permanent swelling of laryngeal structures requires tracheostomy.

HL 46 Exercise induced stridor due to obstruction at the laryngeal or tracheal level Robert C. Maat1, Ola D. Roksund2, John-Helge Heimdal1, Thomas Halvorsen2, Britt T. Skadberg2, Jan Olofsson1 1 Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway 2 Department of Paediatrics, Haukeland University Hospital, Bergen, Norway Objectives: Exercise related breathing difﬁculties concurrent with noisy breathing and wheeze are often treated as exercise induced asthma. Breathing difﬁculties during exercise can however, be caused by airway obstruction at the laryngeal or tracheal level. Methods: A method for combined ergospirometry and continuous laryngeal inspection during exercise, Continuous Laryngoscopy Exercise test (CLE-test), has been used to verify this problem. Until now 81 youngster’s complaining of exercise related breathing difﬁculties have been investigated. When stridor was observed without sign of laryngeal dysfunction further examination as tracheal CT scan and tracheoscopy were performed. Results: From the 81 subjects, investigated with the CLE-test, eight had no objective pathology at the laryngeal level. Seventyeight showed a minor or major obstruction at the laryngeal level while exercising. Eight subjects who developed stridor without any visual pathology, where followed with a CT scan of the trachea and thorax. They showed pathology at subglottic or tracheal level like stenoses and impressions. Conclusions: Pathology in the larynx and trachea may be relatively rare, but this area should be kept in mind in patients with exercise related breathing difﬁculties and particularly with stridor. The described CLE-test is of great value for a correct diagnosis, and to select patients for further investigation and treatment.

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HL 47 Endoscopic arytenoid lateralization for the treatment of bilateral vocal cord immobility L. Rovo´, S. Madani, G. Smeha´k, J. Czigner, J. Jo´ri ENT Department, University of Szeged, Hungary, Tisza L krt 111 Szeged, Hungary Objective: One of the treatment options for the bilateral vocal cord immobility (bVCI) is the ‘‘simple’’ suture lateralization of the vocal cord(s) (VC) from external or endoscopic approach. Methods: Between 1986 and 2006 146 patients with bVCI were treated at the ENT department of Szeged University. From 1995 a minimally invasive technique was applied in 112 patients (75 women, 37 men, ranged 18–81 years), which provided the lateralization of the arytenoid cartilage in a physiological abducted position by an endoscopically inserted suture loop. The ﬁxated cricoarytenoidal joints were previously mobilized by CO2 laser and a special blade designed by the authors. Seventy-four bVCIs were due to nerve injury, and most of the 38 mechanical ﬁxation cases developed after prolonged intubation. Results: Immediate postoperative adequate airway was achieved in 102 cases. One patient required postoperative tracheostomy and in nine ones, the preroperatively existing tracheostomy had to be sustained for more than a week. Three of them remained canulated. Two elderly women were later tracheostomized for aspiration. After the recovery of the VC movement the suture was removed in 52 cases, which ensured further voice improvement. In 46 of the 55 permanent bVCIs the airway remained stable over a year. Conclusion: This method is a good primary solution of bVCI, because it can provide immediate and stable airway with the preservation of the laryngeal function to a large extent.

HL 48 Cricotracheal resection in non-tracheotomized adults: a prospective case series Christian Sittel, Alexandra Streckfuss, Sebastian Blum, Peter K. Plinkert University of Heidelberg, Department of Otolaryngology/Head and Neck Surgery, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany Objective: Cricotracheal resection (CTR) is a modern technique of airway reconstruction in case of subglottic stenosis (SS). We report a case series of adult, non-tracheotomized patients. Methods: Fifteen patients with signiﬁcant SS were identiﬁed, presenting with dyspnea and stridor. Grade of stenosis was III in 14 cases and II in 1 case, according to the Cotton-classiﬁcation. Etiology was manifold, with intubation and tracheotomy being the predominant risk factors. CTR was performed in all cases with pre- and postoperative videotracheoscopy. Results: Mean postoperative intubation time was 41.7 h (11– 103 h), mean length of ICU-stay was 2.6 days (3–9 days). Videotracheoscopy for reassessment was performed after 69 days in the average. In 13/15 patients the subglottic lumen had been normalized. In one case a restenosis could be managed with repeated endoscopic interventions. One patient died at post-OP day 4 due to a fulminant pulmonary embolism. Further complications comprised one axillary vein embolism, ventilator-associated pneumonia in four cases and one transient unilateral recurrent nerve palsy, which recovered completely. Conclusion: CTR is a reliable and versatile technique for reconstructing the subglottic airway, almost regardless of the underlying etiology. Most complications observed have not been associated directly to the procedure, but reﬂect the complex morbidity of the

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 patient population. There seems to be an increased risk for thrombo-embolic incidents, which may be attributable to preoperative immobilisation of the dyspnoeic patients.

HL 49 Self-expanding Nitinol stents in the treatment of malignant tracheal stenoses B. M. Lippert, D. Koutsimpelas, H. Gouveris, W. J. Mann Department of Otorhinolaryngology, Head and neck Surgery, University of Mainz Objective: Cancer of the upper aerodigestive tract can cause airway stenosis or tracheoesophageal ﬁstula with servere aspiration. Since surgery and radio-chemotherapy is limited, palliative treatment modalities are necessary. In recent years nitinol stents have been used increasingly in these cases. Patients and methods: Tracheal stenoses or ﬁstula had occurred in 25 patients (19 men, 6 women, mean age 68.8 years) with esophageal carcinoma (n = 13), peristomal recurrent tumor after hypopharyngeal carcinoma (n = 7), primary carcinoma of the trachea (n = 4), and one mediastinal metastasis (hypopharyngeal carcinoma). Thirty-two self-expanding nitinol-stents were placed under general anesthesia with endoscopical and ﬂuoroscopical guidance. Results: Stent insertion was successful in all cases and led to an immediate relief of the morphological and functional airway obstruction. No immediate complications were noted. In ﬁve cases additional stents were necessary because of tumor over growth, stent dislocation, and tumor related tracheoesophageal ﬁstula. Conclusion: Tracheobronchial stents have proved their efﬁcacy in the treatment of malignant incurable tracheobronchial obstructions and ﬁstula. The main advantage is the rapid and effective opening of the stenosed central airway leading to a better quality of life.

HL 50 Treatment of laryngeal stenosis V. N. Bakumov, V. V. Reznikov, E. A. Nabatova, A. S. Drannikov, I. V. Andreeva, B. O. Shahab, V. V. Uskova Volgograd, Russia Laryngeal stenosis is one of the most difﬁcult problems of modern ORL. In the period of 1995–2006 we have had 127 patients. The stenosis duration ranged from 2 weeks up to 21 years. Twelve patients had complete or almost complete atresia of the larynx and upper ring of trachea. The surgery was performed externally through laryngoﬁssure with the ﬁxation of endolaryngeal-stent, T-shape tube or prosthetics of other form in the larynx cavity. The stent remained in the larynx for 7.5 months in average. To one of the patients, the endolaryngealstent was put 2 weeks after the trauma after the elimination of the shock and mediastinitis. Eighteen patients after the stent removal had stenosis in the tracheostoma looking like ’’sand glass‘‘. They had to undergo the circular resection of the trachea. The treatment if performed in close contact with non-ORL doctors. As a result of the treatment, all the patients were released from the canules and the natural way of breathing was gained in 101 cases. Noticeable changes in the voice were stated. The voice function of 28 patients was fully restored. The rest had voice malfunctions of different degree. Recurrence of the stenosis treated this way was ﬁxed 5 years after the surgery in 15.2% of cases. Re-stenosis was treated by repeated tracheotomy, CO2 laser, repeated endoprosthetics, which allowed 16 patients to be decanulated within 2 years and their level of life is satisfactory. Three patients failed to get decanulated even after the surgery.

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HL 51 Tracheal injuries in percutaneous tracheotomy Michael Wolf1, Adi Primov-Fever1, Ilya Novikov2 1 Department of Otorhinolaryngology, Head and Neck Surgery, Chaim Sheba Medical Center, Tel-Hashomer and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel 2 The Gertner Institute for Epidemiology and Health Policy research, Chaim Sheba Medical Center, Tel-Hashomer and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel Objective: To prospectively examine the incidence and extent of tracheal injury during guide-wire dilatational tracheotomy (GWDT) in relation to patients’ characteristics and technique. Methods: Prospective randomized controlled study in a tertiary referral medical center. Consecutive 185 patients undergoing GWDT by otolaryngology surgeons under endoscopy and video-monitor-control by one of three surgeons (senior attending and two senior residents). Surgical details were described by each surgeon, and follow-up was prospectively registered. Statistical analysis used t-test when comparing age between two groups and one-way ANOVA when comparing more groups. The Pearson chisquare and Fisher exact test were used for testing independence between categorical variables. The following parameters were examined: site of tracheal puncture and extent of tracheal injury, procedure-related complications. Results: Site of tracheal puncture was signiﬁcantly dependent upon age (P < 0.0013), also, signiﬁcant differences were encountered between surgeons in distribution of site of tracheal puncture (P < 0.001). Tracheal fracture was noted in 43 cases (23.2%). The incidence of fractures was dependent on surgeons (P < 0.04) and positively correlated with age (P = 0.07). Complications were not found to correlate with any of the examined parameters. Conclusions: Age was found to be a detrimental factor upon the site of GWDT and the incidence of cartilaginous fracture. It may suggest that GWDT in the elderly should be cautiously considered, especially when neck extension is limited.

HL 52 Argon plasma surgery in the subglottic stenosis in children Lidia Zawadzka-Glos, Mieczyslaw Chmielik Paediatric ENT Department, Warsaw, Poland Objective: Subglottic laryngeal stenosis develops in most cases as a result of prolonged intubation. A lot of methods for treatment of postintubation stenosis are known, both classic methods for reconstruction of the larynx through an external approach, and endoscopic methods for dilation of the larynx. The selection of the method of treatment depends on the degree of stenosis and kind of operations performed earlier. One of them is argon plasma surgery (APC). Sixteen children aged from 6 months to 12 years, with postintubation laryngeal stenosis from I to IV degrees according to the Meyer-Cotton grading system, were qualiﬁed for treatment of laryngeal stenosis with APC. Methods: Argon plasma coagulation was applied to treat laryngeal stenosis.Different coagulation times were used, ranging from 1 to 3 s repeated a few times. The ﬂow rate of the argon gas

S29 during coagulation was set at 1, 0–1, 2 l/min. All operations were performed under general anaesthesia. Results: We observed different improvements in each treated child. In all cases no complications occurred and no progression of the cicatrix in the subglottic region was observed. The application of APC during endoscopic dilation of the larynx enabled the decannulation of six children, and ten other patients are still being treated. Conclusions: An analysis of the effects of treatment of postintubation laryngeal stenosis shows that treatment with argon plasma coagulation seems safe and effective in cases with I and II degree of stenosis.

HL 53 The end to end anastomosis in the tracheal stenosis P. Theodosis, D. Gourziotis, B. Gregoriou, S. Papaspyrou General Hospital Of Athens ‘‘Eyaggelismos’’ Introduction: The stenosis of cervical trachea is a challenge for every ENT surgeon. There are many suggested techniques developed by the years. The resection of tracheal segments and the end to end anastomosis provide reliable and long term results by one stage operation. Materials and methods: We examined 19 patients with tracheal stenosis with the resection of the segments and end to end anastomosis the last 4 years, four of them were treated at ﬁrst with other technique, Laser beam (CO2), stents, grafts. Most of them were hospitalized in intensive care units for various reasons at the past. The MRI of the neck–trachea and laryngotracheoscopy with the ﬂexible ﬁber optic laryngoscope have been performed preoperative. The high points of the end to end technique are at ﬁrst a U shaped cervical incision to expose the trachea up to the sternum. A tracheostomy is performed if there is not any, only for the needs of the operation, below to the point of the stenosis. Once the trachea has been exposed and mobilized with ﬁnd the lesion and determine the number of the segments that we will resect. Blunt dissection of the trachea from the surrounding tissues at the tracheal wall follows step by step careful maneuvers for separation from the esophagus. An incision is made at the lesion and we resect the defect rings up to the healthy tissue. The release of the muscles above and below the hyoid bone takes place only when the defect is more than 5 cm. The ﬁrst leading sutures are made to the posterior wall, while at that point intubation is carried out in the open ﬁeld. The use of absorbable sutures with the nodes outside the trachea and an end to end anastomosis is carried out. The number of the resected segments varied from 2 to 8 in different cases. Results: All patients had a follow up from 9 months to 4 years. The postoperative lumen of the trachea reaches the normal. Complications presented only two patients, one with a small pneumothorax that conservatively dealed and another one with a vocal cord paralysis that was treated surgically by Kashima cordotomy with Laser beam CO2. Conclusions: After years of using various techniques we concussed to the end to end anastomosis. The end to end anastomosis is a reliable method of treating selected cases of tracheal stenosis. In comparison with the other surgical techniques provides long term safe results at a one stage operation and requires less hospitalization.

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HL 54 Laryngeal and tracheobronchial amyloidosis Kenneth Wu1, Samit Majumdar1, Peter Bull1 1 Department of ENT Surgery, Royal Hallamshire Hospital, Shefﬁeld, UK Objective: Amyloidosis in the airway is a rare condition which presents with respiratory symptoms. Knowledge of the natural history of the condition thus is still not well established. To better determine the course of the disease we reviewed existing literature and clinical features of patients seen at our institution. Methods: Literature review of papers discussing regional and systemic amyloidosis. Retrospective review of cases from our institution. Results: Analysis of information from papers and patient records was conducted. Amyloidosis is a general term for a spectrum of disorders that cause deposition of protein in an abnormal ﬁbrillar form. Biochemically, several forms exist such as primary idiopathic and reactive. There are localized and systemic manifestations. Laryngeal amyloidosis is the most common site for localized disease. It can also be a component of systemic amyloidosis. Three cases (three women) are discussed with disease involvement of the larynx, trachea and bronchus. Treatment included endoscopic laser resection of lesions. Conclusions Localized amyloidosis does not normally progress to systemic disease. However, there may be involvement of surrounding organs. Clinical investigations are only of limited use. Regular follow-up of patients is mainstay of management due to long-term disease progression. Appropriate surgical intervention should be reserved for patients with resistant clinical symptoms.

HL 55 Ethiologic factors for Reinke’s edema on vocal folds Alenka Kravos1, Irena Hocevar-Boltezar2, Bogdan Cizmarevic1, Avgust Zupevc2 1 Department of Otorhinolaryngology and Head and Neck Surgery, General Hospital Maribor, Ljubljanska 5, SI-2000 Maribor, Slovenia 2 Department of Otorhinolaryngology and Head and Neck Surgery, University Medical Center Ljubljana, Slovenia Objective: In order to avoid the recurrence of the disease, all etiologic factors should be identiﬁed even before the surgery. The aim of the study was to evaluate different etiologic factors for RE. Methods: Eighty patients with RE and 80 control subjects were included in the study. In all subjects a precise history about the

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 risk factors for the development of RE (smoking, gastroesophageal reﬂux-GER, allergy, thyroid dysfunction, vocal overuse and misuse, the unfavourable microclimate at work) was taken. Skin prick allergic tests, and the determination of serum IgE and TSH levels were also performed. ENT examination revealed the signs of GER and allergy. The test and the control group were compared regarding etiologic factors using v2-test and Mann–Whitney test. Results: Smoking (P = 0.000), GER (P = 0.003), voice misuse and overuse (P = 0.040) appeared in the majority of the patients and demonstrated to be signiﬁcantly more often present in the patients with RE than in the control group. The unfavourable microclimate at work, thyroid hypofunction and allergy appeared as less important factors which were present in the minority of the patients. In 65% of patients at least two risk factors were found. Conclusions: For a permanent cure of RE all possible etiologic factors must be actively searched for and treated properly.

HL 56 Immunohistochemical examinations of sex hormone receptors (ER alpha, PR, AR) in the human vocal fold Berit Schneider, Eleonora Cohen, Andrea Kolbus, Joseﬁne Stani, Margarethe Rudas, Reinhard Horvat, Wolfgang Bigenzahn, Michael van Trotsenburg Department of Otorhinolaryngology/Division of Phoniatrics-Logopedics, University Hospital of Vienna, Austria Background: Several voice disorders are assumed to be caused by the direct inﬂuence of hormones on the larynx. There is only very limited data on the evidence of steroid receptors in the vocal folds, although voice alterations due to hormonal inﬂuence and treatment have been found. Goal of the study: To investigate the expression of estrogen a, progesterone and androgen receptors in human vocal folds. Methods: Immunohistochemically, vocal fold cadaver specimens of 15 autopsied patients (six female, nine male) which were taken approximately 4–8 h postmortem were investigated. Results: No speciﬁc immunohistochemical staining for the different types of steroid hormones investigated could be seen in either the post-mortem taken biopsies nor the intraoperatively one. However, several unspeciﬁc staining patterns could be observed. Conclusion: The results of this study contradict recently published data and question the expression of sex hormone receptors in the vocal folds. Main causes of false interpretations of unspeciﬁc staining are discussed.

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HL 57 Experimental examinations on cleaning and reuse of cuffed tracheostomy tubes under hospital conditions Matthias Leonhard1, Ojan Assadian2, Florian Daxbo¨ck2, Maria Stadler2, Michaela Zumtobel1, Wolfgang Bigenzahn1, Berit Schneider1 1 Department of Otorhinolaryngology, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria 2 Clinical Institute for Hygiene and Medical Microbiology, Division of Hospital Hygiene, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria Objective: Due to the lack of accepted recommendations on reprocessing cuffed tracheostomy tubes, the theoretically possible reuse is not introduced in clinical practice yet. Goal of this study was the application of selected cleaning methods giving special emphasis to reduction of microbial contamination, economical aspects and material deterioration. Methods: Cuffed tracheostomy tubes of different types and manufacturers were contaminated under controlled laboratory conditions with deﬁned suspensions of clinically relevant microorganisms and reprocessed using ﬁve cleaning methods: manual cleaning using brushes; manual cleaning combined with chemical disinfection; cleaning using a dishwasher; ultrasound cleaning; enzymatic cleaning Results: The theoretically required reduction of 103 microorganisms, was achieved by all methods tested, but they differed in reliability, related costs, hands-on-time and material deterioration. Manual cleaning reached the required reduction of microbes only in combination with time consuming disinfection. Ultrasound and enzymatic cleaning showed sufﬁcient reduction of micro-organisms in a shorter period of time. The dishwasher reached a very good and reliable reduction of micro-organisms, but with longer processing time and increased thermal stress of material. Conclusions: In summary, intraindividual reuse of cuffed tracheostomy tubes is possible. The cleaning methods tested in this study differ in regard to costs, expenditure of time, availability, waste management and endangerment of staff. Automated cleaning processes imply higher acquisition costs, but work more costefﬁcient with increasing numbers of tracheostomy tubes.

HL 58 Perineural spread in squamous cell carcinoma of the larynx: histopathological evaluation of inferior and superior laryngeal nerve proximal stumps Emre Vural1,2, Chun Y. Fan3, Paul Spring1,2, Brendan C. Stack Jr1, Mimi Kokoska2, Ehab Hanna4, James Y. Suen1 1 Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 West Markham, Slot 543, Little Rock, AR 72205, USA 2 Division of Otolaryngology-Head and Neck Surgery, John McClellan VA Hospital, Little Rock, AR 72205, USA 3 Department of Pathology, John McClellan VA Hospital, Little Rock, AR 72205, USA 4 Department of Head and Neck Surgery, MD Anderson Cancer Center, Houston, TX, USA Objective: Perineural spread (PNS) is an important risk factor for locoregional failure and correlated with reduced survival rates in squamous cell carcinoma of the larynx. PNS may extend proximally and/or distally in the nerve sheath by leaving uninvolved

S31 nerve segments along their spread (skip metastasis). This may preclude obtaining tumor-free surgical margins, since there may still be viable tumor cells beyond the surgeon’s resection limits, which may be responsible for recurrent disease. The purpose of this study is to investigate if more proximal segments of superior and inferior laryngeal nerve stumps involved by PNS in a routine laryngectomy. Methods: Average of 2 cm extralaryngeal segments of superior and inferior laryngeal nerves were resected in 15 consecutive laryngectomies (60 nerve segments). Both laryngectomy specimens and the harvested nerve segments were histopathologically examined for the presence or absence of PNS. Results: Regardless of the presence or absence of PNS in the larynx, none of the nerve segments showed evidence of PNS (0 out of 60 nerve samples). Conclusion: It is highly unlikely that PNS extends beyond the surgical resection limits in routine laryngectomies. Therefore, reported worse outcomes in the presence of PNS in laryngeal cancer does not seem to be related to residual tumor cells in more proximal portions of these nerves.

HL 59 Efﬁcacy of endoscopic tracheoplasty for treating tracheostomy-related airway stenosis Reza Nouraei1, Khalid Ghufoor2, Karan Kapoor1, David J. Howard1, Guri Sandhu1 1 Department of Otolaryngology, Charing Cross Hospital, London, UK 2 Department of Otolaryngology, Barts and London Hospital, London, UK Objective: To evaluate the results of endoscopic tracheoplasty as an alternative to open tracheal resection for treating post-tracheostomy stomal stenosis caused by inward collapse of overresected tracheal rings. Methods: Patients treated for post-tracheostomy ‘lambdoid’ tracheal deformity between April 2004 and 2006 were reviewed. Patients were treated with endoscopic CO2 laser resection of collapsed tracheal rings, dilatation and endotracheal mitomycin C application. Shared-airway surgery was undertaken using suspension micro-laryngo-tracheoscopy and high-frequency supraglottic jet ventilation. Perioperative patient and lesion characteristics and results of treatment were assessed. Results: There were seven males and four females. The average age at presentation was 56 years. The average lesion height and distance from glottis were 11 ± 5 and 35 ± 12 mm, respectively. The median number of treatments was 3, falling from 4 at the start of the series to 2 at the end (P = 0.08). Three patients required temporary tracheal stents, and one patient also underwent laryngoﬁssure and anterior augmentation with hyoid-on-sternohyoid composite ﬂap for concomitant glottic stenosis. The average follow-up was 17 ± 8 months and no patient relapsed after six symptom-free months. All but one patient with pre-existing pulmonary disease achieved and maintained a Medical Research Council Dyspnea Scale of I or II, and resumed normal activities. There were no cases of dysphonia or dysphagia. Conclusions: Endoscopic tracheoplasty is a successful treatment for airway stenosis caused by the post-tracheostomy lambdoid deformity of the trachea. It achieves a successful outcome while avoiding the operative risks, prolonged hospitalization, and morbidity that is associated with tracheal resection. We recommend it as the standard of care for treating patients with this injury.

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HL 60 Outcome of endoscopic treatment of adult postintubation tracheal stenosis Reza Nouraei1,2, Khalid Ghufoor2, Anil Patel2, Tina Ferguson2, David Howard1,2, Guri Sandhu1,2 1 Department of Otolaryngology, Charing Cross Hospital, London, UK 2 Royal National Throat Nose and Ear Hospital, London, UK Objective: To assess the results of primary endoscopic treatment of adult postintubation tracheal stenosis, to identify predictors of a successful outcome, and better deﬁne the scope and limitations of minimally invasive surgery for this condition. Methods: Sixty-two consecutive patients treated between April 2003 and 2006 with initial endoscopic surgery were prospectively studied. Patient and lesion characteristics, treatment details, complications, and decannulation and open surgery rates were recorded. Actuarial analysis and Cox regression were used to identify predictors of decannulation and freedom from external surgery. Results: There were 34 males and the average age was 45 ± 16 years. The average stenosis height was 18 mm (range 5– 55 mm), and 82% of lesions were Myer-Cotton grades III or IV. Lesion height and intubation-to-treatment latency independently predicted success of endoscopic surgery. Ninety six percent of patients with lesions < 30 mm in height were treated endoscopically, but success rate fell to 20% for lesions longer than 30 mm. Patients with recalcitrant lesions underwent airway augmentation (n = 11) or resection (n = 3), with a 79% success rate. All patients were decannulated, but some with morbid obesity required long-term stents for dynamic airway compromise. Ninety-eight percent of re-interventions occurred within 6 months. Conclusions: Endoscopic surgery is effective in postintubation airway stenosis and obviates the need for external surgery in most patients. Patients with old and long lesions are less likely to be cured endoscopically. For most patients in this subgroup, endoscopic surgery makes airway augmentation a viable, less-invasive alternative to resection. Patients were unlikely to require further therapy after 6 months of symptom-free follow-up.

HL 61 Laryngeal reconstruction by Platysma myofascial ﬂap after vertical partial laryngectomy Ozan Bagis Ozgursoy, Gursel Dursun Department of Otorhinolaryngology-Head and Neck Surgery, Ankara University Faculty of Medicine, Ibni Sina Hastanesi KBB AD, 06100, Ankara, Turkey Objective: The purpose of this study was to reestablish the glottic integrity by platysma myofascial ﬂap after vertical partial laryngectomy and to evaluate the outcomes of this technique. Methods: Eighteen patients with T2 squamous cell carcinoma of the glottis were included in this prospective clinical trial. All

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 patients were treated by vertical partial laryngectomy with laryngeal reconstruction by platysma myofascial ﬂap. The surgical procedure and ﬂap design were described. Vocal function was assessed by videolaryngostroboscopy and subjective and objective voice analysis before and after surgery. Results: No ﬂap necrosis and no disturbance of airway patency or deglutition were noted during 1-year follow-up. Complete neoglottic closure and acceptable quality of voice were obtained by platysma myofascial ﬂap in all cases. However, no statistically signiﬁcant difference was found between the preoperative and postoperative acoustic parameters including GRBAS scores, the average fundamental frequency, the jitter, the shimmer and the harmonic to noise ratio. Conclusions: Platysma myofascial ﬂap provides the basic requirements for laryngeal reconstruction with its own favourable characteristics and also allows complete glottic closure without interfering respiration and deglutition. This tecnique of laryngeal reconstruction may constitute an effective alternative achieving acceptable quality of voice.

HL 62 Inﬂuence of age on laryngeal cancer Elvir Zvrko, Mirko Popovic´, Vladan Knezevic´, Slavko Janjusˇ evic´ Clinic for ORL and MFS, Clinical center of Montenegro, Podgorica, Montenegro The frequency of head and neck cancer in older patients is now higher as a result of constant increase in human life expectancy. Also, there is the hypothesis of a different biological behavior of the tumor in relation to age. The aim of this study was to compare clinicopathologic characteristics of laryngeal cancer between the patients older than 65 and younger patients. The data for 108 patients with laryngeal cancer were analyzed. All cases were diagnosed and treated at the Clinic for otorhinolaryngology and maxillofacial surgery of the Clinical center of Montenegro in Podgorica. The clinicopathological characteristics of 76 patients (Group A) with laryngeal carcinoma diagnosed when they were 65 or younger are compared with a group B of 32 older patients. In our study, 30% of cases were diagnosed when the patient was older than 65. Male–female ratio was 4:1 in group A and 5.4:1 in group B. The group of elderly patients had a higher proportion of tumors located in the glottis. In the group of younger patients the incidence of supraglottic location was higher. A higher proportion of N+ category was found in younger patients (11% in Group A, compared to 6% in Group B). Advanced laryngeal cancer (Stage III, IV) had 26% of patients in group A and 12% of patients in group B. The group of elderly patients (older than 65) with laryngeal cancer showed a higher proportion of men, a higher incidence of glottic location, a higher proportion of early laryngeal cancer, less use of tobacco.

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HL 63 Carbon dioxide laser laryngectomy: preliminary results Calarasu Romeo, Ion Carmen, Codreanu Sorina Institute of Phonoaudiology and Otorhinolaryngology Functional Surgery, 21 Mihail Cioranu Street, Bucharest, Romania The current tendency of laryngeal oncologic surgery in our institute is to approach laryngeal tumors by endoscopic CO2 laser surgery. Methods: This is a retrospective study of 238 patients with laryngeal cancer stage T1–T3 who underwent endoscopic CO2 laser surgery from 1992 to 2006. We have applied the oncologic surgery principles, this meaning resection the lesion with healthy surrounding tissue and pathologic assessment of the margins. Depending on the extent of the lesions, we performed one of the following types of endoscopic techniques: cordectomy or partial endoscopic laryngectomies (frontolateral, frontoanterior, horizontal supraglottic, horizontal glottic, endolaryngeal evisceration). The endoscopic surgery was performed alone or followed by adjuvant radiotherapy administered early (3–5 days) or late (4–6 weeks). Results: The 3-, 5- and 10-year survival rates were analysed. From the 238 patients who underwent surgery, only 174 (73.1%) patients checked in for the postoperative follow-up. From the 131 patients who underwent laser laryngectomy alone or combined with late radiotherapy, 93.9% (123 patients) survived disease-free and 6.1% (8 patients) developped local recurrence. From the 43 patients who underwent laser laryngectomy combined with early radiotherapy, 83.7% (36 patients) survived disease-free, 16.3% (7 patients) developped local recurrence. Conclusions: Endoscopic laser laryngectomy was the classic indication as a curative treatment for laryngeal cancer stage T1. The good oncologic results obtained after long-term follow-up in patients who underwent laser surgery combined with early radiotherapy extended the indication of this therapy to stage T2, T3.

HL 64 Laser-cordectomy is the best treatment option for early glottic carcinoma: 20 years of experience Jen} o Czigner, Ro´bert Paczona, Miklo´s Csana´dy, Jo´zsef Jo´ri Department of Otorhinolaryngol., Head and neck Surgery, University of Szeged, Hungary Objective: Twenty years of experiences with endoscopic-microscopic laser-cordectomy for early glottic carcinoma. Familiarization with the practicability of this surgery in relation to the stages of vocal cord lesions resulted in subgroups, i.e., ‘‘superﬁcial’’, ‘‘partial’’, ‘‘total’’ and ‘‘extended’’ cordectomy which was adapted by the E. L. S. (2000).

S33 Methods: The present study is based on a retrospective clinicalpathological analysis of ’’en bloc‘‘ resected glottic specimens and patient’s charts obtained from 232 patients having vocal cord carcinoma treated by endoscopic-microscopic laser surgery. Results: For minimum 3-year follow-up (May 1987–March 2004), the endoscopic CO2-laser surgery alone controlled the early vocal cord carcinoma in 87% (194/224), 13% required salvage therapy. After ’’laser-salvage’’, the local control rate was mounted to 93%, and with the conventional salvage therapy ﬁnally resulted in 97%. The organ preservation’s rate achieved 96%, and eight patients had lost their larynges. The vocal function was really good in most patients, because no excess of normal tissue was sacriﬁced. Conclusions: Based on 20 years of experience with laser-cordectomy, the excellent re-treatment options in case of local failure and these favorable oncological results, endoscopic minimally invasive laser cordectomy should be the ﬁrst choice of treatment for early glottic cancer. Radiotherapy and open partial laryngectomy should be reserved for salvage therapy.

HL 65 Endolaryngeal CO2 laser resection for early supraglottic carcinoma combined with neck dissection Miklo´s Csana´dy, Jen} o Czigner, Bala´zs Sztano´, Jo´zsef Jo´ri Department of Otorhinolaryngology, Head and Neck Surgery, University of Szeged, Hungary Objective: Authors present the option of endolaryngeal CO2 laser resection of T1N1, T2N1 supraglottic (marginal) tumours and neck dissectionin selected cases. Methods: Fifty-ﬁve patients with supraglottic cancer underwent laryngomicroscopic CO2 laser resection (1987–2007). Neck dissection (mRND) was performed simultaneously, in order to remove metastatic lymphnodes in 7 of 55 patients, that were resected with laser (three epigottis, two vallecula and two marginal tumours). Results: Forty of ﬁfty-ﬁve (73%) patients after laser surgery showed no recurrence after a single laser-excision. In 15 patients locally recurred tumour was found, so six patients underwent repeated laser-resection, three patients got radiation therapy, four horizontal supraglottic resection and two laryngectomy (salvage-therapy). Development of late metastasis required 5 RNDs. One of those seven patients after CO2 laser surgery and neck dissection underwent 1 RND of the 5 RNDs, another patient had a supraglottic resection and radiation therapy of a local recurrence. No postoperativ oedema, but moderate aspiration was observed. Conclusions: Endoscopic CO2 laser resection could be a method of choice in selected patients of supraglottic cancer and can be combined with primary neck dissection in one stage to manage metastatic lymph nodes. Late manifest metastasis was treated by secondery neck dissection (RNDs). Of the total of 30 epiglottis, 9 other supraglottic, 6 vallecula e´s 3 supraglottic-marginal (hypopharyngeal extension) tumours.

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HL 66 Endoscopic CO2 laser surgery in supraglottic cancer Stan Cotulbea, Stelian Lupescu, Caius Doros, Alin Horia Marin, Horatiu Stefanescu ENT Department, University of Medicine and Pharmacy ‘‘Victor Babes’’ Timisoara Objective: This study presents the indications, general principles, contraindications, limits and results of this modern therapeutic method. Supraglottic cancer is an aggressive, with high tendency for nodal metastasis. Therefore early detection and effective treatment is of outmost importance. Methods: Between 1996 and 2006, 27 patients with supraglottic cancer T1 or T2 and N0, have been treated with supraglottic laryngectomy with CO2 Laser. All patients were carefully selected using modern video-endoscopical procedures (ﬂexible laryngoscopy, suspended microlaryngoscopy) and CT-scan or neck ultrasonography. Carefull preoperative selection is of outmost importance for the clinical outcome of patients. In the studied group we applied simple epiglotectomy—8 cases, extended epiglotectomy—12 cases, HSL (horizontal supraglottic laryngectomy)—7 cases. Postoperative follow-up was between 12 and 48 month, average 36 month. Naso-gastric feeding tube was necessary in only two cases for a few days postoperative (patients with HSL). Results: In our group we obtained the following oncological results: no evidence of disease (NED)—24 cases (88.9%) and local reccurrence in three cases (11.1%). All patients who presented local reccurrence in larynx were in stage T2 N0 of the disease; the salvation treatment we applied consisted in total laryngectomy. Immediate functional results were very good and good in all cases. Conclusions: Endosocopic CO2 laser surgery appears to be an effective and safe alternative treatment for T1–T2, N0 supraglottic cancer, with superior oncologic and functional results than the other techniques, requiring short hospitalization, no tracheostomy and feeding tube and providing superior rehabilitative result with a good quality of life.

HL 67 Supracricoid partial laryngectomy. Oncological and functional results de Vincentiis Marco, Fanfoni Fabio, Pagliuca Giulio, Del Gaizo Raffaele, Bianco Nicola, Gallo Andrea ENT Department, ‘‘G. Ferreri’’, ‘‘La Sapienza’’ University, Rome, Italy Objective: The purpose of laryngeal partial surgery is to keep the patient under control from an oncological point of view, but also to restore phonatory, respiratory and swallowing functions. Supracricoid partial laryngectomies, and in particular Cricohyoidopexy (CHP) and Cricohyoidoepiglottopexy (CHEP), are surgical procedures that permit, through the conservation of a cricoarytenoid unit, the creation of a neolarynx adequate for swallowing as well as for speaking. Methods: The study population comprised 290 consecutive patients (267 men and 23 women) with glottic and supraglottic

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 squamous cell carcinoma. The mean age was 58.2 years for men and 59.2 years for women. 274 patients underwent CHP and 76 CHEP. Evaluation of patients included onchological and functional results. Results: The 3, 5, 10 year over survival rates were 86, 79 and 58%, respectively. Tumor category, lymph node category, tumor stage and recurrence all had a signiﬁcant inﬂuence on the survival rate. Functional outcomes had better results in patients who underwent CHEP in short time evaluation. In long time evaluation results become similar for both groups of patients and with no age difference. Conclusion: Evaluation of post-operative swallowing disorders included a careful observation of the patients by the physician, ﬁberoptic endoscopic evaluation of swallowing (FEES), and videoﬂuoroscopy (VFS). Supracricoid partial laringectomy has shown excellents results in functional and onchologic outcomes, whereas surgical indications are respected.

HL 68 Endoscopic imaging of precancerous lesions of the vocal folds Christoph Arens, Hiltrud Glanz, Marcel Kraft Department of Otorhinolaryngology/Head and Neck Surgery, University Hospitals Giessen and Marburg, Giessen, Germany Objective: The early detection of precancerous and cancerous lesions of the vocal folds is associated with improved survival and the potential for complete endoscopic resection. It may be enhanced by several promising diagnostic imaging techniques such as ﬂuorescence endoscopy, contact endocopy and optical coherence tomography (OCT), as these modalities offer the potential to identify in real-time lesions that are inconspicuous under conventional endoscopy. Methods: Patients in different stages of laryngeal dysplasia, carcinoma in situ and laryngeal cancer were examined by means of the previous mentioned imaging techniques during microlaryngoscopy. Results were compared to histological ﬁndings. Results: During the autoﬂuorescence (AF) examination of the endolaryngeal mucosa precancerous and cancerous lesions showed a red to violet ﬂuorescence outlined against the light green AF of the normal mucosa. During 5-Aminolevulinic acid (5-ALA) induced ﬂuorescence protoporphyrin IX accumulated in these lesions presenting a bright red orange ﬂuorescence. After staining the vocal cords with methylene blue, it was possible to observe the cells, nuclei and cytoplasm. OCT imaging of the vocal folds provided information on the thickness of the epithelium, integrity of the basement membrane, and structure of the lamina propria. Conclusion: Fluorescence endoscopy, contact endoscopy as well as OCT are promising new imaging techniques supplementing microlaryngoscopy. They are suitable to differentiate dysplasia, carcinoma in situ, microinvasive lesions as well as the evaluation of tumorous margins, while coherence tomography especially improves the assessment of tumorous inﬁltration into the mucosa and the lamina propria.

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HL 69 Adjuvant therapy in laryngeal papillomatosis Irena Hocevar-Boltezar1, Mojca Maticic2, Maja Sereg-Bahar1 1 University Medical Center Ljubljana, Department of Otorhinolaryngology and Head and Neck Surgery, Zaloska 2, SI-1000 Ljubljana, Slovenia 2 University Medical Centre Ljubljana, Department for Infectious Diseases and Febrille Illnessess, Slovenia Objective: Adjuvant therapy is indicated only in the aggressive forms of laryngeal papillomatosis. The aim of the study was to assess the success of adjuvant therapy with acyclovir/valacyclovir in our patients. Methods: Fifty-ﬁve patients (17 juvenile and 38 adult cases) were included in the study. In the case of an aggressive disease or accelerated growth of the papillomas the serologic testing for possible infection with herpesviruses (HSV-1, HSV-2, EBV, and CMV) was performed. Adjuvant therapy was used when infection with HSV-1 or HSV-2 was detected. The number of operations, the length of the period between the operations and the estimation of the laryngeal disease were compared before and after adjuvant therapy using paired t-test. Results: Seventeen patients had aggressive form of the disease. One juvenile and 12 adult cases with HSV-1 infection and one juvenile case with HSV-2 infection were treated with acyclovir or valacyclovir in standard dose for 2 months. The number of the necessary surgical procedures signiﬁcantly decreased after the therapy (P = 0.019). The length of the interval between the operations increased and the extent of the papilloma growth decreased after the therapy but not signiﬁcantly (P = 0.154, P = 0.390, respectively). Twelve patients had no evidence of the disease, and two patients had a recurrence 4–103 months after the treatment (mean 29 months). Conclusions: The adjuvant therapy with acyclovir/valacyclovir can help in selected patients with proven infection with HSV viruses. We suppose that the antiviral therapy against HSV can decrease the aggressiveness of the laryngeal papillomatosis because HSV helps in duplication of HPV.

HL 70 Supraglottic horizontal laryngectomy: modiﬁed Calcaterra technique Patricia Steinwender, Robert Jakse, Klaus Jakse HNO Krankenhaus der Elisabethinen, Graz, Austria Objective: In most cases of supraglottic carcinoma with mobile vocal folds, the primary lesion can be sucessfully eradicated by supraglottic horizontal laryngectomy. The greatest postoperative functional problems are deglutition disorders with aspiration. The suspension technique described by Calcaterra allows better protection of the laryngeal inlet by the base of the tongue and provides a laryngeal tilt to promote clearing of residual liquid on the glottis.

S35 Patients and methods: Fifty-one (m 35, f 16, 37–85 years with an average of 60) patients at ENT Elisabethinen Graz underwent a supraglottic horizontal laryngectomy by a modiﬁcation of the Calcaterra technique during the period from 1992 to 2006. The TN stages were T1N0 (4), T2N0 (17), T2N1 (11), T2N2b (16), T2N3 (1) and T2N2c (2). Results: In the period of observation from 7 months to 14 years, three patients died with local recurrence, two with regional lymphnode metastases and two with metastases in the lung and in the brain. Conclusions: The advantage of this technique is that it is a singlestage resection with good cure rates for early lesions and satisfactory maintenance of the voice and deglutition.

HL 71 Extended supracricoid partial laryngectomies: preliminary experience of ten cases G. Peretti, C. Piazza, D. Cocco, P. Nicolai Department of Otolaryngology, University of Brescia, Spedali Civili, Piazza Spedali Civili 1, 25123 Brescia, Italy Objective: Neoplastic subglottic extension below the crico-thyroid membrane is usually considered a contraindication to supracricoid partial laryngectomy (SCPL). Initial reports have been published concerning extended SCPLs with removal of the cricoid arch with or without half of the cricoid plate and corresponding arytenoid with tracheo-hyoido-pexy (THP). Aim of this paper is to present techniques, functional outcomes, and preliminary oncologic results of such a surgical option. Methods: Between 2002 and 2006, ten males affected by T3–T4 laryngeal cancer involving the cricoid arch, plate, or the ﬁrst tracheal ring have been treated by extended SCPL (in three cases with removal of one arytenoid) with THP at our Institution. Two of them were recurrences after RT and the others refused or cannot tolerate chemo-RT. Clinical, functional, and oncologic outcomes were prospectively collected. Results: Perioperative complications occurred in two (20%) patients: bleeding requiring revision of the surgical ﬁeld in one case and minimal dehiscence of the pexy healed by hyperbaric oxygen therapy in another. All patients were decannulated after 7– 30 days (mean 13). All of them resumed normal oral intake with removal of the nasogastric feeding tube after 14–25 days (mean 20). No postoperative ab ingestis pneumonia was recorded. Two of them (20%) had local recurrence 7 and 6 months after extended SCPL and were treated by total laryngectomy plus RT. Eight (80%) are free of local-regional disease (mean 21 months; range 2–61). Conclusions: Extended SCPL with THP is feasible without an increased burden of complications and morbidity when compared to standard SCPLs. Oncologic outcomes seem equally encouraging even though the short follow-up of our series should be taken into account.

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HL 72 Near-total laryngectomy: a failure analysis Alok Thakar, Sudhir Bahadur, K. C. Toran, Bidhu K. Mohanti, P.K. Julka All India Instiute of Medical Sciences, New Delhi Objective: To improve case selection for Near-Total laryngectomy (NTL) by identifying causes of poor oncologic and functional outcomes. Methods: Analysis of prospectively accrued data of 28 consecutive cases of near-total laryngectomy undertaken from 1996 to 2005 at a tertiary care centre. Analysis of impact of tumor extent and location, patient physiological status, and surgical technique on disease free survival and on functional outcome. Functional status graded as per a scale comprising of speech and swallowing function. Results: Four year actuarial disease free survival was 79.6%. Eighty-two percent (23/28) had good to excellent functional outcomes. Pre-operative tumor extension to the Ipsilateral arytenoid signiﬁcantly compromised disease free survival (2 year survival—40%, P < 0.001). Internal communicating ﬁstula formation (ﬁstula between neopharynx and myomucosal shunt lumens) occurred in 5/28 cases and was uniformly associated with poor functional outcome (lack of phonation with/ without aspiration). Fistula formation was signiﬁcantly more likely in cases with tumor involving the ipsilateral arytenoid (3/6, RR—5.25) and the ipsilateral subglottis (2/4, RR—3.83). Conclusions: Signiﬁcant disparity exists in functional outcomes of NTL among cases that develop post surgical internal ﬁstula versus those with uneventful healing. Tumor involvement of the ipsilateral arytenoid compromises the oncological and functional results. Tumor extension to the subglottis compromises functional outcome. NTL should be avoided in cases with ipsilateral arytenoid involvement and undertaken with caution in cases with subglottic extension.

HL 73 Transventricular chondroplastic laryngotomy: a new surgical technique for the endolarynx Marcos Sarvat, Nedio Steffen, Henrique Olival-Costa, Paulo Pontes UNIFESP, ICAO and INLARIO, Rua Conde de Iraja´ 148, Botafogo, Rio de Janeiro RJ 22271-020, Brazil In spite of the number of techniques allowing direct access to the endolarynx through an external approach, the literature remains evasive about one well-established, standardized, safe and easy surgery that promotes the full restitution of the framework after the procedure. Objectives: To verify in a reproducible experimental model the surgical feasibility and clinical impact of an endolaryngeal access procedure called Transventricular Chondroplastic Laryngotomy (TCL). Methods: Three pigs were submitted to thyroid cartilage ﬂap raising without opening of the laryngeal ventricle, and seven were

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 submitted to the complete approach to the endolarynx, with included a wide ventricular opening and suturing. The animals were followed for 20 days and their clinical condition was observed. At the 20th day, a laryngoscopic examination under general anesthesia was performed prior to euthanasia, to accomplish macroscopically the larynx and cervical area. The larynxes were removed and examined. Results: It was possible to access the ipsilateral vocal fold and the contralateral hemilarynx through a wide opening of the laryngeal ventricle. The procedure enabled bi-instrumental handling of the vestibular fold, laryngeal ventricle, vocal fold, anterior commissure and arytenoids. No animal showed any clinical complications during the follow-up period, and the histology show good cicatrisation without visible scar formation or sequelae. Conclusions: This technique, performed in animal model, can be well standardized in its surgical steps and initial objectives; its application was successful, and proved to be feasible, providing wide endolarynx exposure and adequate organ reconstitution. After this, some clinical applications can be suggested.

HL 74 Total resection of the cricoid cartilage with thyrotracheal anastomosis in the treatment of low-grade chondrosarcoma of the larynx de Vincentiis Marco, Soldo Pietro, Bigelli Cristina, Pagliuca Giulio, Del Gaizo Raffaele ENT Department, ‘‘G. Ferreri’’, ‘‘La Sapienza’’ University, Rome, Italy Objective: The objective of our study was to describe a partial laryngeal surgery technique for the treatment of cartilaginous tumors of the larynx (chondroma and low-grade chondrosarcoma of the larynx). These tumors are well-deﬁned masses that arise within the endolaryngeal structures, predominantly on cricoid cartilage. They are rarely found in an ENT location and have similar histological features. The most common surgical management consist in a total excision of the tumor but a total laryngectomy and permanent tracheostomy could be avoided. Methods: On November 2006 two patients, a male and a female with the diagnosis of low-grade chondrosarcoma, were undergone to total removal of the cricoid cartilage. A pexy was performed between the trachea and the remaining part of the larynx. Results and conclusions: We present our functional results regarding swallowing and speaking. Postoperative follow-up has not shown any evidence of tumor recurrence, airway compromise, or laryngeal collapse. One month after the operation, all patient were able to tolerate a soft diet. However no deﬁnitive oncologic conclusions can be drawn, at present, as a result of the short follow up. This new reconstructive procedure may obviate the need for total laryngectomy when the integrity of the cricoid ring must be violated for benign tumor.

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Oncology HL 75 Cancer of the mobile tongue: analysis of 150 cases treated by one surgical team over a 15 years period Alexander D. Rapidis1, Evgenia Tsompanaki2, Spyros Valsamis1, Efstathios Eleftheriadis1, Spyros D. Stavrianos1, Gregory Faratzis1, Anastasia Kostaki2 1 Department of Head and Neck/Maxillofacial Surgery, Greek Anticancer Institute, Saint Savvas Hospital, 171 Alexandras Avenue, 115 22 Athens, Greece 2 Department of Statistics, Athens School of Economics, 76 Patision Avenue, 104 34 Athens, Greece Objective: Squamous cell carcinoma (SCC) of the tongue represents the most common intraoral malignancy in western countries. More than two thirds of tongue cancers affect the oral tongue. Methods: Between the years 1992 and 2006, 150 consecutive cases of SCC of the tongue were treated in our Department and were analyzed. Multivariate statistical analysis of various clinical and pathological features were correlated for their statistical signiﬁcance to patients prognosis and survival. There were 91 men (60.7%) (mean 60.41) and 59 female (39.3%) (mean 63.25). Results: From the predisposing factors smoking was found in 58% of the patients, alcohol consumption in 35.3% whereas preexisting leukoplakia 11.7%. In 12.3% of the patients no predisposing factor was identiﬁed. Ninety-two percent of the patients were treated surgically and 55% had an elective or therapeutic neck dissection. The overall recurrence rate was 31.3%. T1 lesions were found in 21.3%, T2 in 48%, T3 in 14.6% and T4 in 16%. About 57.4% of the patients presented with N0 neck. In 79.4% surgical margins were clear of tumor, 17.5% were near to resection ( < 1 cm) and in 3.05% were positive. Stage I disease had 40% of the patients, Stage II 35.33%, Stage III 18% and Stage IV 6.67%. The 5-year disease speciﬁc survival was found to be 57% and the difference in survival between the various stages were signiﬁcant Conclusions: Our study showed an increasingly higher incidence among young adult males without predisposing factors. The survival and the results from the statistical analysis did not differ from those reported from other centers.

HL 76 Epithelial malignancies of the middle third of the face. Clinicostatistical analysis of 92 patients treated over a 15 year period Alexander D. Rapidis1, Gregory Faratzis1, Spyros Valsamis1, Efstathios Eleftheriadis1, Spyros D. Stavrianos1, Evgenia Tsompanaki2, Anastasia Kostaki2 1 Department of Head and Neck/Maxillofacial Surgery, Greek Anticancer Institute, Saint Savvas Hospital, 171 Alexandras Avenue, 115 22 Athens, Greece 2 Department of Statistics, Athens School of Economics, 76 Patision Avenue, 104 34 Athens, Greece Objective: Malignant neoplasms of the paranasal sinuses, nasal cavity and the maxillary alveolus are uncommon and represent

S37 less than 5% of carcinomas involving the upper respiratory tract. We retrospectively reviewed all cases treated in our Department during the last 15 years. Methods: Ninety-two patients aged between 32and 87 years (mean 67.5) were included. 49% were male and 51% female. In 45% the maxillary sinus was either the site of origin of the tumors or was affected from the direct extension of disease. Fifty-three percent had an intraoral extension through the palate. Ten percent presented with cervical lymphadenopathy. Sixty (65%) had squamous cell carcinoma and 32 (35%) had glandular type malignancies. Results: Ninety-two percent of the patients were treated surgically and in 42% surgery was complimented with radiotherapy and/or chemotherapy. In 14% a neck dissection was also performed. Negative surgical margins were achieved in 80% of the cases. Locoregional recurrence occurred in 40% of the patients. The overall 5 year survival rate was 48% whereas the 5 year disease speciﬁc survival was 72%. Survival differences between glandular and squamous cell carcinomas were not statistically signiﬁcant. Factors that strongly inﬂuenced survival were the surgical margins (P < 0.0001). Conclusions: Epithelial malignancies of the middle third of the face present the same biologic behavior with their counterparts encountered in the oral cavity. Surgery is the method of treatment and survival depends from a safe disease-free margin resection. Elective neck dissection is not recommended in N0 neck.

HL 77 Evaluation of marking superﬁcial head and neck skin cancer lesions with the naked eye and microscope Samit Ghosh, Paul Goodyear, Krishna Reddy, Sucha Hampal Department of Otolaryngology, North Cheshire Hospitals NHS Trust, Warrington Hospital, Lovely Lane, Warrington, UK Objective: To study the accuracy of marking surgical margins for excision of skin lesions with naked eye and microscope and to assess if the percentage error would differ in margin measurements between the two methods. Methods: Experimental study using the British dermatological guidelines for excision of skin cancer. Twenty-four ENT surgeons interested in facial plastic surgery of various grades with differing experience were asked to mark different margins around different lesions at different sites on the face using the above mentioned two methods (Naked eye and Microscope) and to assess the reproducibility of drawing different margins. Results: The percentage error found was 8, 7.5, 14.2, 10.5 and 28% for the 3, 4, 5, 8 and 10 mm margins with naked eye and 7.6, 6.0, 8.0, 10.5, 23.0% with microscope, respectively (regardless of the grade of surgeon). Repetition of the experiment on paper with out the lesions but to draw different circles of various sizes 3, 5, 8 mm revealed 6.6, 8.6, 10.5% errors with naked eye and 4.3, 5.8, 8.6% with microscope. Conclusions: This study has deﬁned the errors inherent in the marking of surgical margins, and these should be taken into account speciﬁcally when deﬁned histological margins are required. Neither the naked eye nor the microscope is accurate but the microscope usage can reduce the error.

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HL 78 Role of US and CT in detection of neck metastases of squamous cell carcinomas Giancarlo Tirelli1, Barbara Cutrera1, Andrea Palmieri1, Roberto Di Lenarda2 University of Trieste, 1ENT Clinic, 2Maxillofacial Clinic Objective: To optimize the selection of patients eligible for surgical neck treatment optimizing a diagnostic routine to identify neck metastases. Methods: Comparison between sensibility, speciﬁcity and diagnostic accuracy of clinical examination, echography (US), computed tomography (CT) in detection of cervical metastases in 53 patients with carcinoma of the upper aerodigestive tract. Results: Clinical examination: sensibility 82.1%, speciﬁcity 80%, diagnostic accuracy 81.1%—US with a cut off point for minimal adenopathy diameter of 0.5 cm sensibility 92.8%, speciﬁcity 77.3%, diagnostic accuracy 77.3%—US with a cut off point of 1 cm sensibility 82.1%, speciﬁcity 80%, diagnostic accuracy 81.1%—US with a cut off point of 1 cm, also considering round shape of multiplicity of the adenopathy: sensibility 82.1%, speciﬁcity 80%, diagnostic accuracy 81.1%—CT with cut off point 0.5 cm: sensibility 92.8%, speciﬁcity 32%, diagnostic accuracy 64.1%—CT with cut off point 1 cm: sensibility 85.7%, speciﬁcity 64%, diagnostic accuracy 75.4%—CT with cut off point 1 cm, also considering central necrosis, extracapsular spread, multiplicity of adenopathy: sensibility 89.2%, speciﬁcity 60%, diagnostic accuracy 75.5%. Conclusions: (a) A neck positive to palpation must be submitted to neck dissection (81.1% possibility of having a metastases); (b) a neck negative to palpation must be further investigated using the US and CT cut off point of 1 cm; (c) the combined use of US and TC does not offer remarkable advantages in detection of metastases.

HL 79 Relevance of ultrasound for post-therapeutic follow-up of 584 patients with head and neck cancer Andreas E. Albers1, Daniel Winter2, Ulrike Schulz2, Martin Laudien2, Joachim Quetz2, Barbara Wollenberg3, Jens E. Meyer3 1 Univ. HNO-Klinik Charite Universita¨tsmedizin, Hindenburgdamm 30, 12200 Berlin, Germany 2 Univ. HNO-Klinik UKSH, Ratzeburger Allee 160, 23538 Lu¨beck, Germany 3 Univ. HNO-Klinik UKSH, Brunswiker Straße 10, 24105 Kiel, Germany The application of ultrasound in the post-therapeutic care of patients is well established and relies on its good availability, biologic safety and diagnostic precision. Aim was to deﬁne time intervals relevant for early diagnosis of recurrent disease and to investigate whether patients beneﬁt from second line therapy. Of 584 patients 101 were diagnosed by ultrasound with a recurrence, subsequently secured by histology. The distribution of UICCstages was as follows: I 21%, II 16%, III 26%, IV 36%. The percentages of recurrence of metastases, early- and late metastases

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 were 32, 22 and 27%, respectively. The proportion of late metastases and residual disease was 11 and 9%. After 2 years 67% and after 3 years 80% of metastases had occurred with a clustering between the 13th and 21st month. After 50 months 95% of non-primary metastases and after 80 months 95% of primary metastases were diagnosed. Seventy-one percent of the metastases were treated with curative intention. This group showed a 24% higher survival, with a 5-year-survival of 34%. Late- and recurrent metastases were treated with curable intention in 64 and 54%, respectively (5-year survival 34 and 38%). Statistical signiﬁcant metastasis-free survival of patients with primary metastases after therapy compared to patients with non-primary metastases gives cause to deﬁne two different follow-up periods. The results underscore the relevance of postoperative ultrasound investigations and short follow-up intervals to identify patients that could beneﬁt from a second time surgery in connection with improved survival.

HL 80 Sentinel lymph node biopsy for patients with early stage cutaneous melanoma in the head and neck M. Ivkic1, V. Bedekovic1, D. Vagic1,A. Balenovic2, H. Cupic3, M. Situm4 1 University Hospital ’’Sestre milosrdnice‘‘ Department of ENT and Head and Neck Surgery, Vinogradska c. 29, Zagreb, Croatia 2 Department of Oncology and Nuclear Medicine, Vinogradska c. 29, Zagreb, Croatia 3 Department of Pathohystology, Vinogradska c. 29, Zagreb, Croatia 4 Department of Dermatology, Vinogradska c. 29, Zagreb, Croatia Objective: The aim of this study is to evaluate a 7 year experience in preoperative lymphoscintigraphy, as well as accuracy of sentinel lymph node biopsy (SLNB) performed at our institution in early stage melanoma patients. Also, the aim of the study is to evaluate the recurrence rate related to pathohistological ﬁndings. Methods: Seventy-eight patients who underwent an SLNB for cutaneous melanoma were included into a prospective study starting in January 2000. The indications for SLNB were histologicaly proven melanoma with a minimum Breslow thickness of 1.0 mm or less if other adverse factors, such as tumor ulceration, were present and clinically regional or distant metastases were absent. SLNB was performed with gamma probe after preoperative technetium Tc 99 m lymphoscintigraphy. Results: Intraoperative sentinel node identiﬁcation rate was 98 and 23% of patients had tumor-positive sentinel lymph nodes. Sentinel node was identiﬁed by preoperative lymphoscintigraphy in all but two patient. Rate of false-negative SLNB as measured by nodal recurrence in a tumor-negative sentinel lymph node patients was 1.4%. Anomalous lymphatic drainage patterns were observed in 15% of all patients. Conclusions: Preoperative lymphoscintigraphy and SLNB are sensitive, effective and important diagnostic methods for precise staging of patients with N0 cutaneous melanoma. All patients with positive SLNB or with locoregional metastasis identiﬁed on follow-up have all been offered therapeutic neck dissection and/or parotidectomy when indicated.

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HL 81 Follow-up of head and neck cancer patients: a prospective analysis Richard Hewitt, Prasad Kothari, Arvind Singh, Francis Vaz, Paul O’Flynn Centre for Head and Neck Oncology, University College London Hospital, 1st Floor East Wing, 250 Euston Road, London, NW1 2PG Objective: What does the current follow-up regimen in Head and Neck Cancer achieve? In all cancer orientated specialties there has been much debate into the best follow-up regimen. The provision of a service that meets the highest standards of care whilst being cost effective has never been more pertinent given the worldwide escalating cost of health care today. This study addresses the basis of the current guidelines and their relevance in the modern management of Head and Neck Cancer. Does routine follow-up facilitate the early diagnosis of recurrence or is diagnosis lead by patient symptoms? Is there a cohort of patients who require a more intensive follow-up regimen due to the nature of their disease, treatment or morbidity? And do the current guidelines represent the most cost effective system? Methods: One thousand consecutive, outpatient consultations were analysed by a tailored questionnaire in a prospective, multicentre study. Inclusion criteria: adult patients who had undergone multidisciplinary, multimodality management for head and neck carcinoma. Results: The case mix is representative of all head and neck tumour sites and stages. In excess of 90% of patients requesting an appointment and less than 5% of asymptomatic patients had a pertinent clinical ﬁnding. More than a third of patients required input from allied health care professionals. Conclusions: Follow-up should be tailored to individual cases. Patient education and close relationships with clinicians and allied health professionals is essential for the early diagnosis and management of recurrence and morbidity.

HL 82 Outcomes of patients with basaloid squamous cell carcinoma of the head and neck: comparative study of 62 cases versus 186 controls Miroslav Tedla1, Michael J. Rossi2, Pamela Roehm2, William Gooding3, Eugene N. Myers2, Robert L. Ferris2 1 1st ENT Department, Comenius University Bratislava, Slovakia 2 Department of Otolaryngology, UPMC, Pittsburgh, USA 3 Biostatistisc Facility, UPMC, Pittsburgh, USA Objective: Basaloid squamous cell carcinoma (BSCC) is a variant of squamous cell carcinoma, ﬁrst described in 1986. The outcomes of patients with BSCC has been controversial with some small studies suggesting a worse prognosis.

S39 Methods: Retrospective case-control of 62 BSCC patients matched to 186 patients with conventional squamous cell carcinoma (SCC) of an academic department of Otolaryngology, Head and Neck Surgery. Pathologic and clinical data for all 62 cases of BSCC were reviewed from 1985 to 2005. Each BSCC case was matched with three cases of conventional SCC according to TNM stage and head and neck subsite and statistically evaluated. Results: Our comparative study of stage and site matched controls of conventional SCC shows a statisticaly signiﬁcant difference in clinical outcome for BSCC patients. Most signiﬁcant difference is considering the formation of second primary tumor. Conclusions: BSCC is an aggressive SCC variant. Poorer outcomes suggest more intensive, multimodality approaches may be necessary in these patients.

HL 83 Primary tumor volume calculation: a better predictive factor of prognosis for nasopharyngeal carcinoma Ching-Chih Lee, Hsu-Chueh Ho Department of Otolaryngology, Buddhist Dalin Tzu -Chi General Hospital; 2, Ming-Shen Road, Dalin, Chiayi, 622, Taiwan Objective: The TNM staging system developed by American Joint Committee on Cancer (AJCC) is universally used and widely accepted but its prediction of prognosis in nasopharyngeal carcinoma (NPC) in endemic area receives a lot of challenge. Primary tumor volume had been reported to have close relationship with prognosis of head and neck cancer. We conduct a retrospective study to elucidate the effect of primary tumor volume on treatment outcomes in patients with NPC who were treated with radiotherapy of concurrent chemoradiotherapy (CCRT). Methods: Form 1999 to 2005, 71 patients with newly diagnosed NPC who were treated with radiotherapy or CCRT were enrolled. Using summation of area technique, computed tomography-derived or magnetic resonance-derived primary tumor volume was calculated. The correlation between AJCC disease stage, primary tumor volume and disease-speciﬁc survival were analyzed. Results: The median primary tumor volume for whole series was 11.39 ml (range 1.25–166.58 ml). The median primary tumor volume was 2.62 ml in T1 disease, 8.58 ml in T2 disease, 24.57 ml in T3 disease, and 64.47 ml in T4 disease. Disease and stage and T stage carried no prognostic signiﬁcance (P = 0.1424 and P = 0.0956, respectively). Thtee categories of primary tumor volume (£20, 20–40, >40 ml) had prognostic signiﬁcance (P = 0.0045). Conclusions: Primary tumor volume has closer relationship with survival rates of patients with NPC who. Besides the current AJCC staging system, calculation of primary tumor volume may be needed to predict prognosis of NPC and adjust treatment strategy.

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HL 84 Postoperative concomitant chemoradiation in advanced head and neck carcinoma Miha Zargi, Lojze Smid, Marjan Budihna, Branko Zakotnik, Primoz Strojan, Erika Soba, Hotimir Lesnicar, Igor Fajdiga University Department of Otorhinolaryngology and Cervicofacial Surgery, Ljubljana, Slovenia and Institute of Oncology, Ljubljana, Slovenia Between 1997 and 2001, 114 eligible patients with stage III or IV squamous cell head and neck carcinoma were randomized to receive postoperatively radiotherapy alone (group A) or radiotherapy combined with simultaneous mitomycin C and bleomycin (group B). Patients were stratiﬁed according to the stage and site of the primary tumor and presence or absence of high-risk prognostic factors. Primary surgical treatment was performed with curative intent in all patients. Patients in both groups were postoperatively irradiated to the total dose of 56–70 Gy. Chemotherapy included mitomycin C15 mg/m2 after 10 Gy, and 5 mg of bleomycin twice a week during irradiation to the planned total dose of 70 mg. At 5 years, in patients from radiochemotherapy group, locoregional control (86%) was better than in radiotherapy group (60%) (P = 0.014), as were disease free survival 70 and 55%, respectively (P = 0.099) and overall survival 51 and 37%, respectively (P = 0.144). Patients who beneﬁted by chemotherapy were those with risk factors. The results indicate that concomitant postoperative radiochemotherapy with mitomycin C and bleomycin improves locoregional control and survival in patients with advanced head and neck carcinoma.

HL 85 Improved survival in patients with locally advanced nasopharyngeal carcinomas after accelerated hyperfractionated radiotherapy with concurrent chemotherapy M. Fischer1, C. Po¨ttgen2, S. Wechsler1, M. Stuschke2, S. Lang1, K. Jahnke1 1 Department of Oto-Rhino-Laryngology, University of DuisburgEssen, Hufelandstr. 55, 45122 Essen, Germany 2 Department of Radiotherapy, University of Duisburg-Essen, Hufelandstr. 55, 45122 Essen, Germany Objective: The excellent results of hyperfractionated and accelerated radiotherapy with concurrent chemotherapy in locally advanced oropharyngeal and hypopharyngeal carcinomas lead to the investigation of this therapeutic regime in nasopharyngeal carcinomas as well. Methods: Thirty-ﬁve patients with nasopharyngeal carcinomas in stage III and IV received accelerated hyperfractionated radio-

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 therapy with concurrent chemotherapy (5-FU, mitomycin C ± leucovorin). Primary tumour and regional lymph nodes received 5 · 2 Gy/week during the ﬁrst three treatment weeks. Thereafter the fractionation was accelerated with 1.4 Gy given twice daily up to a total dose of 72 Gy. Results: The overall response rate was 100%. The median followup period was 71 months. In ten patients salvage surgery of the lymph nodes was performed revealing vital tumour in six cases. The actuarial 5-year local-control rate was 64% (95%CI 47– 81%), overall survival at 5 years was 70% (95%CI 53–86%). Conclusions: Hyperfractionated accelerated radiotherapy with concurrent chemotherapy in locally advanced nasopharyngeal carcinoma is effective and feasible.

HL 86 Use of complementary and alternative medicine by patients attending the head and neck clinic Muhammad Shakeel, Jonathan R. Newton, Kim W. Ah-See Department of Otolaryngology, Aberdeen Royal Inﬁrmary, Aberdeen, Scotland, AB25 2ZN, UK Objective: The Complementary and alternative medicine (CAM) is increasingly popular in the European hemisphere. Little UK data is available on its use in adults attending the Head and Neck oncology clinic. We studied the prevalence and pattern of CAM use among adult patients attending an Head and Neck clinic, in a university teaching hospital. Method: A structured anonymous questionnaire with an explanatory letter was distributed prospectively to all patients at their primary visit to the clinic. Data was collected over 8-week period from October to December 2005, and analyzed using SPSS v 12. Results: Response rate was 69% (138/200), 61% were male and 39% were female. Seventy-ﬁve percent (103/138) were older than 50 years, 62% (86/138) were married and 42% (58/138) had not completed high school education. Fifty percent (69/138) had used CAM, 26% in the preceding year. The popular herbal CAM were Cod liver oil, Primrose oil, Cranberry, Echinacea and St. Johns wort. Other therapies include Massage, Acupuncture, Chiropractic, Homeopathy, Reﬂexology and Reiki. Mostly these were used to promote health, to treat UTI and for relaxation. Only 14% (10/69) patients used CAM for their current illness, 41/69 stated CAM were effective and would recommend it to others. Fifty percent (34/69) stated that their family physician was unaware of their use of CAM. Conclusion: Despite concerns over CAM efﬁcacy, safety and cost effectiveness, use of CAM is popular among patients attending an H&N oncology clinic. Otolaryngologist should be abreast of available literature on CAM to counsel their patients effectively.

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HL 87 Primary malignant tumor of nose and paranasal sinuses. A series of 91 cases Giovanni Almadori, Mario Rigante, Francesco Bussu, Attilio Limongelli, Antonello Giunta, Michele Visocchi, Gaetano Paludetti Institute of Otolaryngology, Catholic University of Sacred Heart, Rome, Italy Objective: To evaluate the oncological outcome of the treatment of malignant tumors of nose and paranasal sinuses. Methods: Ninety-one patients (mean age 64.39) affected by nose and paranasal sinuses malignancies were retrospectively studied. Sixty-ﬁve of these neoplasm arised in the maxillary sinus, 21 in the nasal cavity, 5 in the ethmoid sinuses. 40.4% were SCC, 11.7% adenocarcinoma,10.6% melanoma, 8.5% esthesioneuroblastoma, 8.5% lymphoma, 8.5% sarcoma, 5.3% adenoidocystic carcinoma, 5.3%, neuroendocrine tumor, 1.2% cordoma. 75.9% of the patients underwent primary surgery partial maxillectomies (47.2%), total maxillectomies (10.9%), enlarged maxillectomies (7.6%), craniofacial resection (6.6%), endoscopic resection (3.3%). Results: Three-year overall survival was 61%, while disease speciﬁc survival was 67%. According to the histotype 3-year OS was 69% for SCC, 60% for adenocarcinoma, 45% for melanoma and 37% for esthesioneuroblastoma, while DSFS was respectively 70, 69, 60, 64%. 42.8% of patient presented recurrences: local in the 79% of the cases were, regional in 8%, both local and regional in 12% and distant in 2%. Conclusions: Surgery, if feasible, represents the treatment of choice, combined with adjuvant radiotherapy in advanced stages. The surgical approaches of choice remains the external transfacial or combined craniofacial ones, even if in the last years endoscopic resection is gaining room, especially for early well selected cases. Total maxillectomy possibly enlarged to the pterygomaxillary fossa in maxillary tumors with a spread through the posterior wall (T3–T4) improves the local control and decreases the incidence of local recurrence, which relevantly inﬂuences prognosis nose and paranasal sinus malignancies.

HL 88 Treatment of malignant parotid gland tumors: our experience Mario Rigante, Claudio Parrilla, Francesco Bussu, Eugenio De Corso, Alberto Artuso, Giovanni Almadori, Gaetano Paludetti Institute of Otolaryngology, Catholic University of Sacred Heart, Rome, Italy Objective: The best treatment of malignant parotid tumors is still debated. The low incidence and heterogeneity of histology of primary parotid carcinomas makes these tumors difﬁcult to evaluate. Methods: Sixty-one patients (40 males and 21 females) ranging in age from 37 to 79 years (mean 60 years) with a malignant tumor of the parotid gland over a 15-year period were analyzed retrospectively. Treatment consisted of surgery, radiation therapy or a combination. The effects of treatment modalities on locoregional control, the incidence of locoregional recurrences, distant metastases and survival rates were evaluated.

S41 Results: Adenocarcinomas were obsereved in 30% of the patients (18), squamous cell carcinomas in 24% (15), adenoid cystic tumors in 20% (12), undifferentiated tumors in 9% (6), mucoepidermoid carcinomas in 6% (4), malignant mixed tumors in 6% (4), and other types in 3% (2). All patients underwent surgery as primary modality. Neck dissection was performed only in 12 patients (30%), of whom four clinically N0 staged patients (but with high grade tumors) underwent elective neck dissection, two of them showed occult metastasis. Radiation therapy was performed in 20 patients (33%), depending on tumor size, node metastasis, residual tumor, perineural invasion and tumor grade. The overall survival rate at 5 years was 68% and the disease-free survival rate 52%. Pre-operative facial palsy were observed in four patients (7%), facial nerve sacriﬁce was performed in 10 patients (17%). Conclusions: Surgical excision, i.e., total parotidectomy associated with postoperative radiation and neck dissection in selected patients (depending on tumor size, node metastasis, residual tumor, perineural invasion and tumor grade) provides a good locoregional control and disease free survival in patients with malignant tumors of the parotid gland.

HL 89 Results: of primary simultaneous polychemotherapy in 174 advanced squamous cell cancer of the oral cavity and pharynx: critical comment H. Glanz, R. Engenhard-Cabillic, A. Kruchten, C. Caspari, A. Burkhard, C. Arens German ENT Society Objective: For organ preservation primary simultaneous polychemoradiotherapy (SPCR) is recommended in squamous cell cancer (SCC) of the upper aerodigestive tract. In a larger series of cases this therapeutical option should be analysed critically according to toxicity, oncological and functional outcome for better selection for this kind of therapy. Methods: In a retrospective study 971 patients with SCC of the oral cavity and the pharynx were treated during a 15 year period: 326 patients by primary surgery alone, 471 by surgery combined with postoperative irradiation and 174 advanced cancers were treated with primary SPCR. The cumulative survival rates were relied to the primary site of the tumour. Data were analysed according to TNM classiﬁcation, toxicity, oncological and functional results. Results: The cumulative 5-year survival rate was 27.6% in SCC of the oral cavity 43.7% in SCC of the oropharynx and 9.9% in SCC of the hypopharynx. Toxicity was high and quality of life was reduced distinctively. Poor Oncological results were observed especially when the bony skeleton of the larynx the cervical spine or the mandible was inﬁltrated by the tumour. Summary: According to our results we recommend primary SPCR in larger oropharyngeal cancer primarily in a more selectively in SCC of the oral cavity. In Hypopharyngeal cancer however with involvement of the laryngeal skeleton primary SPCR should not be recommended because of poor oncological and functional results and high toxicity as well as reduced quality of life caused by the therapy.

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HL 90 Elective neck dissections in early oral and oropharyngeal carcinoma in The Netherlands R. de Bree, I. Van der Waal, J. A. Castelijns, P. Doornaert, C. R. Leemans VU University Medical Center, Amsterdam, The Netherlands Objective: To investigate the management of the clinically negative neck in patient with early oral and oropharyngeal carcinomas in The Netherlands. Materials and methods: A questionnaire was sent to the eight head and neck centers of Dutch Head and Neck Oncology Cooperative Group (NWHHT). The questionnaire included factors inﬂuencing the decision making to perform an elective neck dissection and on cases with different tumour sites, stages and extensions. Results: All eight questionnaires were returned ﬁlled in. Site (n = 6), size (n = 7) and thickness (n = 6) of the primary tumour were important clinicopathological factors. Ultrasoundguided ﬁne needle aspiration cytology was the most (n = 7) frequently used diagnostic technique to detect occult metastases, but 50% of the centers considered negative ﬁndings not fully reliable to refrain from elective neck dissection. Depending on site and stage of the primary tumor presented in the cases 3–7 of the centers would perform an elective neck dissection. Selective neck dissections are more frequently performed than modiﬁed radical neck dissection and dissection of level I–III, sometimes extended to level IV was the most frequently performed type. Conclusions: There is no consensus regarding the management of the clinically negative neck in early stage oral and oropharyngeal carcinomas in The Netherlands.

HL 91 The role of elective neck dissection in T1T2N0M0 anterior tongue cancer patients Daniel Mirea, Serban Vifor Gabriel Bertesteanu, Raluca Grigore, Cristian Radu Popescu ENT Department, Coltea Clinical Hospital, Bucharest, Romania Objective: Elective neck dissection in T1T2N0 anterior tongue cancer patients is controversial. On the other hand, it had been demonstrated that the presence of metastatic lymphadenopathies reduce with 50% the 5 years survival. Our study show that elective neck dissection is necessary even in N0 patients with anterior tongue tumors. Methods: The results are based on a prospective study of 86 patients with T1 (30) and T2 (56) anterior tongue cancer, with no presence of cervical metastatic lymphadenopathies. Partial glossectomy and elective neck dissection was the standard treatment of this patients. Results: Histopathological examination of laterocervical lymphatic tissue demonstrated the presence of micrometastasis in ﬁve of T1 patients (16%) and 16 of T2 patients (29%). Laterocervical metastasis were found in 24.4% of all patients. Conclusions: Because of the poor prognosis of anterior tongue cancer patients with cervical metastasis, we considere that an elective neck dissection should be made in all patients with early anterior tongue cancer.

HL 92 Organ and function preservation after transoral CO2 laser resection in advanced tumors Manuel Bernal-Sprekelsen, Isabel Vilaseca, Jose-Luis Blanch ENT-Dept., Hospital Clinic, Villarroel, 170, 08036 Barcelona, Spain Objective: To assess the functional organ preservation and survival.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Materials and methods: Data obtained prospectively from patients treated by transoral laser surgery for a selected group of previously untreated T3 and T4 tumors. Minimum follow-up of 24 months. Results: One hundred and six met the criteria: 84 supraglottic, 26 glottic, 16 piriform sinus tumors. Thirty-one (25.6%) had a ﬁxed vocal cord. Most patients presented with a stadium III (n = 78; 61.9%) and stadium IVA (n = 44; 34.9%). Seventysix (60.3%) did not receive postoperative radiotherapy, 18 (14.3%) did on the neck, and 29 (23%) on the tumor and neck. Eight patients needed a temporal gastrostomy, four a deﬁnitve one. A total of eight (6.3%) aspiration pneumonia were registered. One hundred patients (79.4%) never had a tracheostomy, 18 (14.3%) needed a temporary, 8 (6.3%) a deﬁnitive one. Function was good or acceptable in 63/84 supraglottic (75%), 22/26 glottic (84.6%) and 7/16 piriform sinus (43.8%) tumors. 84/125 (67.2%) patients preserve a functional larynx, some needing temporary tracheostomy/gastrostomy. Adjusted survival rates: 71.2 and 60.7% for stages III and IV and 92.8 and 59.3% for glottic and and supraglottic T3–T4 tumors, respectively. Conclusions: Organ and function preservation is feasible by means of transoral laser resection showing no reduction of the survival rate.

HL 93 Management of N0 neck in supraglottic and transglottic carcinomas Cem Ozer1, Fulya Ozer1, Erdinc Aydin1, Osman Kızılkılıc2, Can Alper Cagici1, Levent Naci Ozluoglu1 1 Baskent University Faculty of Medicine, Department of Otorhinolaryngology Head and Neck Surgery, Ankara, Turkey 2 Baskent University Faculty of Medicine, Department of Radiology, Ankara, Turkey Objective: The aim of this study was to compare efﬁcacy of modiﬁed radical neck dissection type III (MRND) and lateral neck dissection (LND) in the management of supraglottic and transglottic laryngeal cancer patients with clinically and radiologically negative neck (N0) ﬁndings. Methods: The medical records of 70 patients with supraglottic and transglottic squamous cell carcinoma who underwent elective neck dissection (either MRND or LND) for the management of N0 neck were reviewed retrospectively. Patients who had previously treated with surgery or radiotherapy, had positive surgical margins at the time of primary resection, had multiple primary tumors or distant metastasis at the time of diagnosis were excluded from the study. A total of 61 patients were included in the study. Results: MRND and LND was performed in 38 (26 bilateral) and 23 (17 bilateral) patients, respectively. Occult lymph node metastasis were detected in 10 (16.4%) (6 in MRND group and 4 in LBD group) patients. Most commonly involved nodes were sited at levels II and III. Neck recurrences were observed in 3 (% 4.9) patients (2 in MRND group and 1 in LND group). Disease free survival and overall survival rates estimated by Kaplan-Meier method did not differ signiﬁcantly in both groups (log rank test P = 0.793 and 0.620, respectively). Conclusion: Our results conﬁrm the efﬁcacy of lateral neck dissection in the management of N0 neck in patients with supraglottic and transglottic carcinomas.

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HL 94 Evaluation of malignant cervical lymphadenopathy of unknown primary origin: changes in the relative frequency of primary tumor sites

mean age of patients was 60.5 ± 11.767 years, (range 31– 88 years) and the mean follow up was 21 months, (range 6– 36 months). The study revealed an overall accuracy for PET scanning of 80%. For the detection of suspected metastatic disease (n = 48 patients), PET had an accuracy of 90%. For the detection of suspected tumor recurrence (n = 12), PET revealed an accuracy of 86%. For the identiﬁcation of possible primary site (n = 20), PET showed an accuracy of 77%. Finally during post treatment surveillance (n = 24), PET had an accuracy of 67%. False positive results were largely due to inﬂammatory processes after treatment. Conclusion: FDG–PET can provide important information in the assessment of neoplastic disease in head and neck. In many instances PET is primarily a conﬁrmatory imaging modality to avoid unnecessary surgical interventions.

Stamatios Fergadis, Zissis Pappas, Sotirios Papouliakos, Eva Zacharioudaki The State General Hospital of Athens,154 Messoghion Avenue, Athens 115 27,Greece Objective: Aim of the study has been to compare frequency changes in the sites of unknown primary tumors in patients with malignant cervical lymphadenopathy, who underwent diagnostic workup towards detection of the primary site, in a single institution. Methods: Three hundred and thirty-six patients with malignant lymphadenopathy of unknown primary origin were evaluated within a 14-year period. Patients underwent panendoscopy under general anesthesia in an attempt to locate the primary tumor site. Since the introduction of endoscopes in that clinical setting, an initial endoscopic examination and endoscopically directed biopsy taking would take place and patients with negative biopsies would subsequently undergo panendoscopy. A comparison in the relative frequencies of unknown primary tumor sites was performed, between two periods. Results: Among patients within the ﬁrst 7-year period, the most common sites of primary tumor detection were the nasopharynx and hypopharynx (134 patients 40%), with tonsillar fossa and base of tongue sites accounting for 18% of cases. Among patients in the second 7-year period group, there has been a frequency shift towards the base of tongue and tonsillar fossa sites (33%). No changes were made to the technique and protocol of panendoscopy throughout this period. Conclusions: Since endoscopy has recently been integrated in the initial physical examination of patients with tumors of unknown primary origin, the ‘paradigm shift’ in the relative frequency of unknown primary sites may be attributed to more effective endoscopically directed biopsy taking, thus leading to the inclusion in the panendoscopy group of more cases of unknown tonsillar and base of tongue tumors.

HL 95 Positron emission tomography: a useful tool in diagnosis and management of head and neck cancer Efthimios Kyrodimos, Ioannis Aidonis, Laurence DiNardo, Aristides Sismanis Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA Objective: To evaluate the efﬁcacy and accuracy of [18F] ﬂurodeoxyglucose positron emission tomography (FDG-PET) in the assessment of suspected metastatic, persistent, or recurrent neoplastic disease and in the identiﬁcation of possible primary site in patients with unknown primary tumor in head and neck. Study design: Retrospective chart review at a tertiary referral center. Methods: PET scan’s diagnostic reports were reviewed among with reports from conventional imaging studies (CT and MRI). Histopathology reports from surgical interventions among with patient’s clinical outcome were used to conﬁrm the PET scan ﬁndings. Results: One hundred and four patients (80 males and 24 females) were evaluated between Aug-2000 and Aug-2005. The

HL 96 Best supportive care (Palliative care) for patients with incurable head and neck cancer Michaela Salzwimmer1, Hans Eckel2 1 ENT Universitiy Hospital Graz 2 ENT Hospital Klagenfurt Head and Neck cancer account for 6% of all cancers worldwide. More than 90% are SCC, and they are largely due to tobacco and alcohol abuse.1 More than two-third of patients present in stage III and IV (UICC). Unfortunately survival rates are not improving although efforts have been done in research and treatment combinations. Especially for patients with incurable head and neck cancer quality of life gains more importance. When we talk about quality of life, the basic definition of health and disability is required. The WHO deﬁnition (1948) says: ‘‘health is a state of complete physical, mental and social well-being and not merely the absence of disease or inﬁrmity is a fundamental human right.’’ A bit more recent reads the WHO deﬁnition of disability (1980): ‘‘…any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.’’ Both, health and disability, are the base for the quality of life assessment. Receiving a cancer diagnosis and tumorspeciﬁc treatment greatly impact on individuals living with the disease and their families. All persons with a cancer diagnosis need general supportive care, which represents a wide range of services to help the patients to live as actively as possible until death. The WHO deﬁnition of palliative care reads as follows: ’’Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identiﬁcation and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.‘‘ The following items will be discussed: pain therapy, therapy of anaemia and leukopenia, antimicrobial prophylaxis, prevention and therapy of mucositis, care of skin, antiemetic treatment, intravenous access and feeding tube, quality of life (psychosocial support), antithrombotic prophylaxis.

1 J-L Lefebvre (2005) Current clinical outcomes demand new treatment options. Ann Oncol 16(Suppl 6): vi7–vi12

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HL 97 The range of postoperative complications after surgery and microvascular reconstruction of tumors in the oral and maxillofacial region. Results from the study of 70 patients

distant or local metastasis disease. The oral realimentation can begin after 14 days. Conclusions: The oesophageal prosthesis is a safe method of reconstruction of the pharyngoesophageal segment, which allow an early oral refeeding, with a low rate of major complication and low cost.

Anastasia Loupatatzi, Spyros D. Stavrianos, Gregory Faratzis, Efstathios Eleftheriadis, Alexander D. Rapidis Department Head and Neck/Maxillofacial Surgery, Greek Anticancer Institute, Saint Savvas Hospital, 171 Alexandras Avenue, 115 22 Athens, Greece

HL 99 Trapezius ﬂap: an underutilized reliable reconstruction modality in ablative head and neck surgery

Objective: This is a retrospective study that analyzes the factors associated with postoperative complications in a series of 70 patients with cancer in the oral and maxillofacial region who underwent microvascular reconstruction. Methods: During the years 1999–2005, 71 free tissue transfers were performed in our institution on 70 patients. There were 51 male and 19 female. 65 ﬂaps were used for reconstruction after oncological craniofacial resections and 1 ﬂap for facial reanimation. Fifty-three radial forearm, ten rectus abdominis, ﬁve osteocutaneous ﬁbula, two latissimus dorsi, and one grasilis were used. Microvascular tissue transfer was successful in 94.3% of the cases. After a mean follow up period of 27.6 months, 49 of the 70 patients are alive and free of disease. Results: Complications were observed in 38 cases. Systemic complications occurred in 7 patients (10%) including cerebrovascular accident (1), pneumonia (2), pulmonary embolism (1), dysphagia (1), deaths (2). Twenty-nine (40.8%) patients developed complications from donor and recipient side such as wound dehiscence (8), bone fracture (2), mobility and sensitivity deﬁcit (3), total ﬂap loss (4), ﬁstula formation (1), seroma (2), and delayed wound healing (4). In ﬁve cases re-exploration of the anastomoses was mandatory. Conclusions: Despite the length of the operation time, the incidence of systemic complications was comparatively low and in agreement with the ﬁndings from other centers. Complications were found to be mostly dependent on speciﬁc factors such as the age, preoperative radiation, Charlson’s comorbidity index, and anatomical site of the primary tumor.

HL 98 Pharyngoesophageal reconstruction with synthetic prosthesis S¸erban Vifor Gabriel Bertesteanu, Daniel Mirea, Raluca Grigore, Cristian Radu Popescu ENT Department of Coltea Clinical Hospital, 1st I.C. Bratianu Blvd., Bucharest, Romania Objective: Circumferential pharyngoesophageal defect represents one of the biggest reconstructive challenges. Following ablative surgery, proper 3D reconstruction is necessary for a good quality of life. Our objective is to assess the oesophageal synthetic prosthesis as a method of pharyngoesophageal reconstruction in patients who have cancer of the hypopharynx and cervical oesophagus cancer. Methods: We diagnosed 21 patients with phayngoesophageal cancer, who underwent circular pharyngolaryngectomy and reconstruction with esophageal prosthesis. Each case was assessed for complications. Patients were also evaluated for their ability to maintain an oral diet. Patients were followed up for a minimum of 2 months after surgery. Results: Seventeen patients had received postoperative external beam irradiation. There were two ﬁstulae and ﬁve patients with other complications. Two patients died 3 months after surgery of

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Emre Vural Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 West Markham, Slot 543, Little Rock, AR 72205, USA Objective: Most surgeons currently consider microvascular free tissue transfer (MFTT) in reconstruction of the large head and neck defects. Although, there is deﬁnitely a need for MFTT in certain head and neck defects; trapezius ﬂap may offer the surgeon a faster, safer, less expensive and probably more reliable reconstructive alternative in various large head and neck defects. In this paper, the author presents his experience with trapezius ﬂap in reconstruction of various head and neck defects; and provides surgical anatomy and technical details for trapezius ﬂap. Methods: Various oropharyngeal, oral cavity, posterior neck and lateral temporal bone/composite parotidectomy defects were successfully reconstructed with trapezius ﬂap. Results: Except one partial skin paddle loss in an oropharyngeal repair, all of the ﬂaps were successful. All donor site defects were closed primarily. Two patients required needle aspiration for seroma formation in the donor site, after removal of the drains. Advantages of this ﬂap seemed to be its reliability, safety, lower cost, straightforward surgical technique and shorter operative time. The main disadvantages of this ﬂap is the necessity of changing the position of the patient in the operating room for harversting the ﬂap and its limitation of use with certain anatomic site defects due to its pedicle dependence. This ﬂap seemed to be the best suited for composite parotidectomy/auriculectomy defects with lateral temporal bone resections. Conclusion: Trapezius ﬂap is a fast, reliable, safe and less costly alternative to free ﬂaps in selected head and neck defects.

HL 100 Carbon-dioxide (CO2) laser in oral cancer Sanjoy Panda, P. C. Pathy, K. S. Panda Panda Medical Centre, Telengapenth, Cuttack, 753051 India CO2 laser has been historically used for hypopharyngeal and laryngeal lesions. Oral cancer is most common in Orissa state of India. Here people are mostly tobacco chewers and develop superﬁcial type of lesions. These lesions are very much amenable for surgery by CO2 laser. We have operated 128 cases of oral cancer since February 2006 with extremely good comparable tumor control. In 58 cases, we were able to avoid reconstruction like PMMC/free ﬂap. Neck was addressed appropriately and post-op RT given where indicated. Local failure was seen in four cases whereas one patient developed distance metastasis with another three developing neck nodes. Margins were positive in ﬁve cases. The follow-up was for nearly 1 year and additional secondary treatment was done by conventional protocols. Increased accuracy, improved accessibility, minimal collateral tissue damage, instantaneous lymphatic sealing, reduced pain and edema, minimal bleeding, fast epitheliasation, less medication and shortened hospital stay are the major deﬁnitive advantages.

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HL 101 Detection of pulmonary tumours in head and neck cancer patients

vascular history, tumor characteristics, details of surgery and postoperative recovery were recorded. Patients had a cardiac Troponin (TnI) assay on day 2 postoperatively. Logistic regression was used to identify risk factors for postoperative myocardial injury. Results: There were 46 males (71%) and the average age at presentation was 62 ± 12 years. Sixteen patients (25%) had postoperative myocardial injury, including three myocardial infarctions leading to one death. TnI+ and TnI- groups were matched for age, sex, cardiovascular risks and comorbidity, and for the site and TNM stage of tumors and length and nature of primary site, neck and reconstructive surgeries undertaken. Factors identiﬁed as predictors of postoperative injury were blood pressure level (117 ± 11 mmHg, TnI+, vs. 106 ± 10 mmHg, TnI–; P < 0.001), coefﬁcient of intraoperative heart rate variability (12.4 ± 5% vs. 7.5 ± 3%; P < 0.003) and the degree of postoperative inﬂammatory response (73 ± 34 mg/l/ day—CRP—vs. 31 ± 23 mg/l/day; P < 0.0001). Patients with myocardial injury were hospitalized for longer and had more complications. Conclusions: Myocardial injury manifested by postoperative TnI is a known independent predictor of cardiovascular prognosis. Its incidence in head and neck patients may be reduced with careful preoperative blood pressure management, tight intraoperative heart rate control, and through dampening of the postoperative inﬂammatory response.

Samit Ghosh1, Aman Kumar1, Nicholas Roland1, Sankalap Tandon1, Huw Lewis Jones2, Terry Jones1 1 Department of ENT-Head and Neck Surgery, University Hospital Aintree, Liverpool, UK 2 Department of Radiology, University Hospital Aintree, Liverpool, UK Objective: Screening for synchronous pulmonary tumours at initial presentation is held to be important as detection may alter subsequent management. There is currently no consensus in best practice. We present the largest series reported comparing CT and Chest X-ray (CXR) to examine the efﬁcacy of both modalities, and give statistical evidence for a rational screening policy. Methods: Retrospective review of patients presenting with squamous cell carcinoma from January 1996 to January 2007. Findings were assessed with respect to diagnosis or exclusion of pulmonary tumour. Results: One thousand eight hundred and seventy-nine patients identiﬁed. 1,143 had CT, and 741 had CT and CXR. Overall 66 (3.5%) pulmonary tumours [bronchial carcinomas (1.4%), metastases (2.1%) were found. In the CT/CXR subgroup 43 tumours (5.8%) were detected(bronchial carcinomas (2.6%), metastases (3.2%)]. The sensitivity for CXR was 62% for all synchronous lesions (68% for bronchial tumours, 58% for metastases) compared to 100% for CT. Using Fisher’s exact test the primary site does not have an effect on incidence of synchronous tumour. Stage group, T or N stage has no relation to bronchial carcinoma. Stage group I is signiﬁcant for predicting absence of metastases, IV for predicting metastases (P < 0.05). T1 stage (P < 0.05), is signiﬁcant against metastases, T3 tumours are signiﬁcant for metastases (P < 0.005). N0 is signiﬁcant against metastases and N3 is signiﬁcant for metastases. Conclusions: CT screening is far more sensitive then CXR in detecting pulmonary tumours. Metastases are predicted for by stage group IV, T3, and N3 disease. Recurrent disease has statistical signiﬁcance for predicting bronchial carcinoma in our series.

HL 102 Myocardial injury following head and neck surgery: role of perioperative inﬂammation and hemodynamic instability Reza Nouraei1, Chad Al-Yaghchi1, Guri Sandhu1, Dino Giussani2, Patrick Doyle1, Peter Clarke1 1 Department of Otolaryngology, Charing Cross Hospital, London, UK 2 Department of Neuroscience, Physiology and Development, Cambridge University, UK Objective: To review the incidence of and risk factors for myocardial injury following head and neck surgery, to help optimize patient care and develop perioperative cardio-protective strategies. Methods: Records of 65 patients undergoing oncological resections for squamous cell carcinoma of the upper aerodigestive tract between 2005 and 2006 were reviewed. Information about cardio-

HL 103 Innovative concepts in the treatment of head and neck cancer S. Lang1, S. Brandau1, R. Zeidler2 1 Department of Otorhinolaryngology, Head and Neck Surgery, University of Duisburg-Essen, Essen, Germany 2 Department of Otorhinolaryngology, Head and Neck Surgery, Großhadern Medical Center, Ludwig-Maximilians-University of Munich, Germany The overall survival in patients suffering from head and neck cancer remained poor and nearly unchanged over the last decades. This underlines the necessity for innovative diagnostic and therapeutic strategies. Above all, new adjuvant immunotherapeutical agents applied pre- or postoperatively may improve patients’ prognosis. In this context, we report on different oncological projects, which are currently under investigation in our clinic: (1) a phase I study in order to investigate the pharmacokinetics, safety and tolerability of a new serine protease inhibitor in patients with advanced head and neck carcinoma; (2) epidermal growth factor receptor inhibitors as chemopreventive agents that could also signiﬁcantly prolong patients survival, and (3) mesenchymal stem cells (MSC) as carrier for tumor antigens in order to eliminate tumor cells. Genetically modiﬁed MSC may as well help to to regenerate salivary gland function and thus alleviate xerostomiaafter head and neck irradiation. These therapeutic efforts are completed by a diagnostic program aiming at the detection and evaluation of new biomarkers for early cancer detection. In conclusion, the implementation of innovative concepts in clinical routine strategies will signiﬁcantly contribute to an improved prognosis as well as a better life quality in SCCHN patients in the future.

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Pediatrics HL 104 Paediatric neck abscesses: microbiology and management Isam Rustom, Zvoru Makura Department of Otolaryngology, Head and Neck Surgery, Leeds General Inﬁrmary, Great George Street, Leeds, LS1 3EX, UK Objective: To identify the presenting symptoms in children, the appropriateness of prescribed antibiotics and the role of atypical mycobacterium neck infection. Design: Retrospective analysis and literature review. Setting: University teaching hospital. Sixty-four children who underwent incision and drainage of neck abscesses at Leeds General Inﬁrmary from 1 February 2002 to 31 July 2006. Main outcome measure: Resolution of abscess. Results: The mean presenting age was 44.2 months (3.68 years). There were 46 (72%) patients under the age of four years old. The commonest signs and symptoms were neck mass (96.9%), fever (54.7%) and poor oral intake (12.6%). The commonest site of infection was in the submandibular region (37.5%), followed by posterior triangle (25%) and parotid (12.5%). The mean period of hospitalization was (3.7 days ±SD 1.9). Imaging facilities were used in 43.8% of the patients. Staphylococcus aureus (48.4%) was the commonest cultured organism. Atypical mycobacteria was found in 4.7% of the specimens. Flucloxacillin and amoxicillin were the most common antibiotics used by surgeons (57.8, 39.1%) respectively. The abscess recurrence rate was 4.7%. Tracheostomy was not required in any of the patients and no mortality has been reported in this series of patients. The outcome was satisfactory in 95.3%. Conclusions: Early diagnosis, appropriately prescribed intravenous antibiotics and surgical drainage remain the main core of the treatment. Our ﬁrst line of antibiotic treatment for neck abscesses is ﬂucloxacillin. Atypical mycobacterium infection is an important differential diagnosis of a cervico-facial mass.

HL 105 Tracheo-bronchial foreign bodies in children and adults Nicolae Balica, Stan Cotulbea, Stelian Lupescu, Caius Doros, Gheorghe Iovanescu ENT Department, University of Medicine and Pharmacy ‘‘Victor Babes’’ Timisoara Objective: The study presents the experience of our Department in the diagnosis and treatment of tracheobronchial foreign bodies in children and adults during a period of 15 years (1992–2006) on a study group of 150 cases with ages between 10 month and 44 years. Methods: The diagnosis was based on history, physical examination, cardiopulmnary X-ray and rigid tracheo-bronchoscopy

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 of the airways. The treatment and removal of the foreign bodies were performed using paediatric and adult Karl-Storz bronchoscopy set, under general anesthesia with video documentation. Results: The repartition of the cases according to age was: 118 cases—10 month to 3 years; 11 cases—3 years to 7 years, 12 cases—7 years to 16 years, 9 cases—16 to 44 years. In 81 cases the foreign body was located in the right bronchia, in 33 cases in the left bronchia, in 16 cases in both bronchia and in 15 cases in the trachea and 4 cases with subglottic localization. The nature of the foreign bodies extracted was organic (sunﬂower, pumpkin and corn seed, popcorn, beans, peanuts and nuts) in 131 cases and anorganic in 19 cases. In one patient there was necessary tracheostomy; same patient deceased during the intervention. All other patients had a good evolution, with no complication after extraction of the foreign body. Conclusions: Close cooperation between the ENT, endoscopist, radiologist and anesthesiologist are needed for a safe outcome and efﬁcient team-work is absolute necessary for these major emergency represented by tracheobronchial foreign bodies.

HL 106 Foreing body injuries in children: the Susy Safe Project Dario Gregory, The Susy Safe Study Group University of Turin Objective: Injuries due to foreign body (FB) aspiration/choking/ ingestion/insertion are common in children up to 14 years old. The objective of this study is to investigate paediatric foreign body injury. Methods: A total of 6,943 paediatric patients, gathered by the Susy Safe project in 28 European hospitals and 1 Pakistani hospital from 01/01/1987 to 31/12/2006, were included in this study. Data were statistically analyzed. Results: Median age was 3 (IR 2, 6), the 63% of children was older than three years and the 53% were males. FBs were mostly located in the nose (45%) and in the ears (24%). Fiftytwo percent of the FBs were inorganics. Among them pearl, ball and marble (13%), toy (5%), coin (4%). were the most recurrent objects. Among organics, ﬁsh bones and bones accounted for 23% of cases and nuts for 12%. The shape of the objects was spherical in the 34% of the cases. The volume was calculated and the median value was 37.7 mm3 (IR 16.76, 96.74). Complications arose in the 10% of the cases, and hospitalization was required in the 30% of the injuries with a median length of stay of one day. Injuries took place in the absence of adult supervision in the 51% of cases. The 52% of injuries occurred while children were playing and 42% while they were eating. Conclusion: The foreign body injury remains a major burden for children and the risk it presents makes it mandatory to increase the awareness in general population.

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HL 107 Characteristics of objects causing foreign body injuries in children Berchialla Paola, The Susy Safe Study Group Department of Public Health and Microbiology, University of Torino Objective: To characterize shape, consistency and sizes of no food objects causing foreign body (FB) aspiration/choking/ingestion/ insertion. Methods: A total of 2,295 paediatric patients, gathered by the Susy Safe project in 28 European hospitals from 01/01/1987 to 31/12/ 2006, were included in this study. Objects causing injuries were characterized by shape, consistency and size. According to their shape, they were assigned to one of the following four categories: spherical, 3D, cylinder and needle shape. Thus their volume was calculated. Data were statistically analyzed. Results: The most common extracted objects were pearl, ball and marble (30%), toy (12.78%), pebble (7.56%) and stationery (5.65%) such as pen cap and lead. Rigid objects caused a significantly (P < 0.001) higher proportion of hospitalization in children younger than three years (81%) versus those older than three years (37%). Spherical objects were associated to the presence of complications (OR = 1.34, P = 0.0156). The median volume was 50.27 mm3 (IR 16.76, 104.72). Conclusion: Rigid objects with spherical shape such as part of toy, pearl, ball and marble pose a high risk of aspiration/choking/ ingestion and insertion in children of any age. Since prevention is the most essential key to deal with these types of injuries, more effort in caregivers’ public education is warranted.

HL 108 Endoscopic laser surgery for laryngomalacia Sachin Gandhi1, Vasant Oswal2 1 Voice Disorder Clinic, Deenanath Mangeshkar Hospital Pune, Maharshtra, India 2 James Cook University Hospital, Cleveland, UK Objective: To judge the efﬁcacy of endoscopic laser management in severe cases of laryngomalacia. Methods: Nine cases with age ranging from 7 days to 11 years at the time of intervention were operated with endoscopic laser in last 3 years. Diagnosis was conﬁrmed with ﬂexible laryngoscopy and 30 degree sinus endoscope with Macintosh (anaesthetist’s) laryngosocpe. The laser supraglottoplasty was done with diode laser.

S47 Results: However, in three patients the stridor was seen occasionally but of mild degree. Obstructive apnea and cyanosis resolved in all patients. In six patients the associated symptoms responded favorably. Oral intake increased and weight gain was noticed following resolution of airway obstruction in all the cases. Conclusion: Endoscopic laser surgery has avoided the need of doing tracheostomy in infants and children with severe laryngomalacia. Coordination between laryngologist, paediatrician, anaesthetist and intensive care team is of prime importance in managing these cases. Endoscopic laser management of the most severe cases of laryngomalacia has now been established as surgical method of choice.

HL 109 Botulinum toxin into salivary glands to reduce saliva in neurological children Dayse Manrique AACD (Associac¸a˜o de Assisteˆncia a` Crianc¸a Deﬁciente- Disabled Child Assistance Association), Rua Cana´rio, 1112 -61. Sa˜o Paulo, Brazil, CEP 04521-005 Objective: To demonstrate the effect of local application of botulinum toxin type A (BTA) in children with neurological diseases, following our 2002 institutional protocol of sialorrhea treatment. Study design: Clinical prospective. Methods: Twenty-ﬁve children assisted at Clinic of Otolaryngology of AACD (Associac¸a˜o de Assisteˆncia a` Crianc¸a Deﬁciente). They were all submitted to local injection of BTA in salivary glands and followed up for a year. The protocol consists of clinical questionnaire about the inability of swallowing saliva and its repercussions in quality of life. Patients must be previous dental treatment, intolerance to the adverse effects of anti-cholinergic agents and no use of TBA in others sites at least 6 months. The injection was ultra-sound guided and the dose was 30 U in one point for submandibular gland, and 20 U in two points for each parotid gland. Results: Twenty-ﬁve patients with neurological diseases and sialorrea, aged 9–7 years old have been undergone to TBA into salivary glands injection. We observed that the symptoms of sialorrhea changed dramatically in twenty patients. Fifteen children stayed almost 4 months without complaints with repercussion in the quality of life. No patient presented local or systemic effects with local injection of TBA. Conclusion:Saliva reduction is an effective, safe and temporary technique to reduce saliva and the repercussions of sialorrhea in drooling, oral disabilities, chronic pulmonary aspiration, with improvement in general health and social integration.

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HL 110 High frequency radiosurgery in pediatric otorhinolaryngology

HL 112 Long term phoniatric results of arytenoid lateralisation

Gabor Katona Budapest, Hungary

G. Smeha´k, L. Rovo´, A. Szamosko¨zi, J.Jo´ri ENT Department, University of Szeged, Hungary, Tisza L krt 111 Szeged, Hungary

Objective: Report on own experiences using high radiofrequency (HFRF) surgery in special pediatric otorhinolaryngologic cases and comparing this technique with conventional methods Methods: In a tertiary level pediatric hospital, HFRF surgery was used in special cases: facial and buccal haemolymphangiomatosis, laryngeal and hypopharyngeal papillomatosis, velopharyngeal papilloma, epiglottis granulomatosis in Haberland syndrome, parotid tumors, etc. Conventional surgery in same cases served as the control. Comparisons were made in the following categories: excessive blood loss, time of surgery, postoperative pain, and wound healing. Results: HFRF was superior to conventional methods in almost all types of surgeries. The operating time was signiﬁcantly shortened because the need to control bleeding was minimized. In a drooling surgery, HFRF achieved an almost bloodless preparation which was important to the precision of the work. In the haemolympnagioma case, HFRF resulted in an excellent outcome; no other method (including LASER) provided a better cosmetic and functional result. After removal of granulomas from the laryngeal surface of the epiglottis in Haberland syndrome, no edema occurred and healing was excellent. In aryepiglottoplasty HFRF made surgery shorter and because of less bleeding, easier. Same observations were seen in cleft lip and palate surgery. Conclusion: HFRF surgery proved to be very useful in pediatric otorhinolaryngology. In special cases HFRF provided a much better result and made for a more efﬁcient surgery compared to conventional methods. Operating time was shorter, postoperative pain was minimized, and blood loss was diminished when compared to conventional surgical methods.

Phoniatrics HL 111 Objective study of the voice in dysphonia caused by vocal polyps Renzo Mora, Massimo Dellepiane, Francesco Mora, Barbara Jankowska ENT Department, University of Genoa, Italy Objective: Endolaryngeal microsurgery is functionally oriented, therefore, assessment of vocal function is important to evaluate the effect of the surgery on voice. Methods: A study of the objective evaluation of voice was made of 20 voices of healthy adults and 20 with disphonia by vocal cord polyps. Before and after surgery, a laryngostroboscopy and an acoustic analysis was made to everyone. A sustained vowel ’’a‘‘ was carried out and digitalized with MDVP (Multi Dimensional Voice Program, Kay Elemetrics). These parameters were estimated: fundamental frequency (Fo), Jitt, Shim, noise to harmonics ratio (NHR), voice turbulence index (VTI), soft phonation index (SPI), degree of voiceless (DUV), degree of voice breaks (DVB). Results: In the patients affected by disphonia, the analysis of Jitt, Shim, NHR, VTI, SPI, DUV and DVB showed a postsurgical decrease. Comparison with healthy adults highlighted a postsurgical normalization of Fo, Jitt, Shim, NHR, VTI, SPI, DUV and DVB. Conclusions: We highlight the importance of objective evaluation of voice disorders, the MDVP method may be useful for analyzing abnormal vocal function and quantitatively evaluating the effects of surgical excision of vocal nodules and polyps: our results conﬁrm a high degree of effectiveness of endolaryngeal microsurgery on vocal rehabilitation.

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Objective: Endoscopic arytenoid lateralization is one of the treatment options of bilateral vocal cord palsy. This method causes only a minimal damage in laryngeal structures, thus good phoniatric outcome can be expected after surgery. Methods: Twenty-eight consecutive patients (follow-up period is more than 1 year) operated for bilateral palsy, were divided into three main groups. The movement of the vocal cord recovered in one or both sides in 12 patients thus the lateralization was suspended. In seven patients only partial recovery was detected, hence the lateralization was sustained. In nine patients the palsy was complete on both sides. The measured patameters were F0, MPT, harmonicity, Jitt and Shimm. Results: In full recovery of one or both sides good voice quality was detected. In partial recovery (persisting lateralization) the voice in four out of seven was good, three was hoarse but acceptable. In four out of nine patients with no movement recovery acceptable voice was detected by using false vocal cord phonation and ﬁve had whispering, hoarse voice. Conclusion: Results show that endoscopic arytenoid lateralisation can be used in temporary palsy without signiﬁcant damage in phonation. In cases of permanent palsy in the most cases voice was socially acceptable due to the residual movements of the larynx.

HL 113 Hoarseness in school-age children Robert Sˇifrer, Irena Hocˇevar-Boltezˇar, Miha Zˇargi University Department of Otorhinolaryngology and Head and Neck Surgery, Ljubljana, Zalosˇ ka 2, Ljubljana, Slovenia Objective: The aim of the study was to establish the incidence and causes of dysphonia in school children and to determine the acoustic properties of the hoarse and healthy voices. Methods: The research was prospective. The studied group consisted of 100 10-year-old and 102 14-year-old children. They answered the questionnaires on diseases and habits affecting voice. The voice samples (spontaneous speech, text reading) were recorded and subjectively assessed using an analogue visual scale. Acoustic analysis of the vowel/a/samples was performed and fundamental frequency (F0), jitter and shimmer measured. One to 3 months after the voice recording, the hoarse children were examined and the causes of dysphonia were assessed. The results were statistically analysed with Mann–Whitney’s test and v2-test. Results: The voices of 34.2% children were dysphonic. Boys (60.9%) and 10-year-old children (52.2%) were more often affected. After 1–3 months there were still 14.9% dysphonic children. The causes for dysphonia were respiratory infection (19.3%), allergic catarrhal laryngitis, muscle tension dysphonia, mutational voice disorder and reﬂux laryngitis. In the group of children with persistent dysphonia there were signiﬁcantly more children with fast speaking rate and asthma. Lower F0, higher jitter and shimmer were signiﬁcant for dysphonic voices. Conclusions: Dysphonia is quite frequent in school children. Acute respiratory tract infection is the most common cause of dysphonia. In children with persistent dysphonia the cause for it should be treated. Healthy voice is a necessary condition for undisturbed choice of the future profession.

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HL 114 Perception of the transgender voice Emma McNeill, Janet A. Wilson, Susan Clark, Jayne Deakin School of Surgical and Reproductive Sciences, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, NE2 4HH, UK Objective: Fundamental frequency (F0) of speech is used to measure the success of voice therapy in male-to-female transgender clients. This study evaluates the relationship between fundamental frequency and patients’ happiness with their voice. Methods: Twelve male-to-female transgender participants completed visual analogue scales, rating happiness with and self-perceived femininity of their voice. Fifteen speech and language therapists and 40 naive observers evaluated the anonymised recordings, using the same rating system. The correlation between mean F0 and participant happiness was established. Relationships between participant happiness and rater opinions were explored. Results: A signiﬁcant relationship between F0 and participant happiness could not be demonstrated (r = 0.32, P = 0.32). There was a moderately strong positive correlation between self-perception of vocal femininity and perception of femininity by speech and language therapists and naive observers (r = 0.76 and 0.68, P = 0.003 and P = 0.01, respectively). Conclusions: This study demonstrates that happiness with voice in male-to-female transgender clients is not directly related to F0. Clients can assess femininity of their voice in the form of perceived pitch. This may not affect happiness scores. Voice satisfaction may not correlate with perceptions of supervising voice professionals. However, professionals can reliably evaluate how the voice will be received by the lay public. Subjective measures of patient satisfaction, including visual analogue scales, are reliable and valid tools in evaluating therapeutic success.

HL 115 Voice therapy after vocal fold polyp operation Maja Sereg Bahar, Irena Hocevar Boltezar University Department of otorhinolaryngology and Head and Neck Surgery Ljubljana, Zaloska 2, 1000 Ljubljana, Slovenia Objective: To ﬁnd out etiological factors of vocal fold polyps and to assess factors that may be predictive to have a need of voice therapy after surgery. Methods: Ninety-ﬁve patients with vocal fold polyp (61 F, 34 M) and 48 healthy volunteers (32 F, 16 M) were included in the study. History, Voice Handicap Index (VHI) and acoustic analysis of voice (Fo, jitter, shimmer) were made before and 3 months after the operation. The treatment was supplemented by voice therapy at patients who were suspected to have muscle tension dysphonia concomitant. Both groups were compared and the patients before and after the operation and those who had and who did not have a voice therapy. Results: Groups did not differ in age (P = 0.72) and gender. The patients with vocal fold polyps were statistically more often professional voice users (P = 0.001), vocal misuse (P = 0.03) and smoking (P = 0.001). VHI and sub-tests differed signiﬁcantly in both groups before and after surgery. VHI score improved signiﬁcantly after the operation and the jitter too. Voice therapy needed more often patients with VHI score after the operation more than 21 (P = 0.011), VHI-F 5 (P = 0.04) and VHI-P 11 (P = 0.004) and those with jitter more than 2.0 (P = 0.0). Women needed voice therapy 8-times frequently than man. Conclusions: Factors predicting vocal fold polyps are professional voice use, voice misuse and smoking. VHI score more than 21, VHI-F 5, VHI-P 11, jitter 2.0 after the operation and female sex

S49 are predictive for a need of voice therapy after the successful operation.

HL 116 Transverse laser cordotomy (TLC) for adductor spasmodic dysphonia Muhammad Shakeel, Akhtar Hussain Department of Otolaryngology and Head and Neck Surgery, Aberdeen Royal Inﬁrmary, Aberdeen, Scotland AB25 2ZN, UK Objective: Adductor Spasmodic Dysphonia (ASD) is a central neurological disorder with focal manifestation. Botulinum toxin (BTX) remains the gold standard treatment but is temporary. Reported surgical procedures are invasive with signiﬁcant morbidity and variable long term success rate. We have modiﬁed and employed Laser Cordotomy as a curative procedure and to reduce the morbidity and present our early experience. Method: Patients who have been treated with BTX were given the option of surgical intervention. Informed institutional consent was obtained for TLC. All procedures were performed by the senior author (AH), with the CO2 laser set at 10 W and a spot size of 1.5 mm and a depth of 2 mm. One to three transverse cuts were made in the lateral Thyroarytenoid muscle. The lamina propria and the vocalis muscle were preserved. Results: Four patients (2 male, 2 female; mean age 65 years) were included. The mean duration of ASD was 11 years while average BTX sessions being 17. Elimination of voice break was observed clinically. No complications were observed during the follow-up. All patients reported improvement in voice quality, ﬂuency and no voice breaks or straining. The average follow-up was 10 weeks. Conclusion: Modiﬁed TLC appears to be successful in relieving the strained voice and eliminating the voice breaks and enhance ﬂuency without any dysphonia. No alteration was observed postoperatively on the vibratory surface of the vocal fold and the stroboscopy showed normal mucosal wave. Long term follow-up will be necessary but the short term results are very encouraging.

HL 117 Assessment of acoustic examination in patients with rhinolalia aperta R. Markowska, A. Szkiekowska, J. Ratyn´ska, W. Be˛dzin´ski International Center of Hearing and Speech Objective: The aim of this study was to assess the usefulness of acoustic analysis (SPG, FFT) for measuring degree of hypernasality in patients with rhinolalia aperta. Methods: Subjects includes 30 patients (males 14 and 16 females, their mean age was 22 years, with a range of 6–46 years) with hypernasality due to: cleft palate (n = 10), short palate (n = 10) and velopharyngeal incompetence (n = 10). Each patient was subjected to the following assessment: clinical ENT examination with ﬁberoptic ﬂexible nasopharyngoscopy, perceptual speech assessment and acoustic analysis (FFT, SPG) of vowel ‘‘i’’ using progrm of KAY CSL 4300B Results: The results showed that patients with hypernasality had signiﬁcantly higher energy level for the bands range from 500 to 1,300 Hz than speakers with normal resonance. The authors showed four-point scale for hypernasality rating. Conclusion: SPG and FFT are good tool to measurung in objective way the progress of rehabilitation in patients with hypernasality and this examination is easy to perform and do not require additional software.

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HL 118 Second generation videokymography in routine clinical vocal fold assessment Tjouwke A. van Kalkeren1, Harm K. Schutte2, Qingjun Qiu2, Jan G Sˇvec2, Hans F. Mahieu1 1 Department of Otorhinolaryngology and Head and Neck Surgery, Meander Medical Centre, Amersfoort, The Netherlands 2 Groningen Voice Research Lab, Biomedical Technology, Faculty of Medical Sciences, University Medical Centre Groningen, Groningen, The Netherlands Design and method of study and analysis: Vibrational characteristics of the vocal folds are a fundamental component of voice production. Stroboscopic examination is currently the golden standard for investigating vocal fold behaviour, but has limitations. Quantiﬁcation is difﬁcult; furthermore irregular vibrations of the vocal folds cannot be studied at all. High-speed imaging does enable investigation of irregular vibrations and qualitative evaluation. But the tradeoff between spatial resolution and recording speed remains an important limitation in most high-speed imaging techniques. Because of this most high-speed cameras now available have a comparatively low image quality. In contrast, videokymography (VK), as initially developed by Sˇvec and Schutte, is based on oneline scanning with an image rate of about 8,000 frames per second as a replacement for full image, can support both high speed as well as high resolution qualities. However, widespread use was hampered by a number of shortcomings; ﬁrstly the scan position along glottal length was not shown. Secondly the scanning line was ﬁxed at the top of the endoscopic image. Summary of results: A second generation videokymograph was developed in collaboration with the Groningen Voice Research Lab. It now has a scanning line in the middle of the endoscopic image. The new system provides an even better resolution than the ﬁrst kymographic image. Furthermore the possibility to apply the technique to ﬂexible endoscopes further broadens its clinical application.

HL 119 Advanced voice assessment: videostroboscopy and objective voice measurement Mette Pedersen M.D., Umbreen Yousaf The Medical Centre Objective:In the larynx the arytenoid regions and not only the vocal cords are often severely affected by infection, allergy and reﬂux. Methods: We have earlier measured the glottis closure% and standards deviations with laryngograms (glottograms), jitter%

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 and shimmer% in relation to a grading of abnormal videostroboscopies of the larynx (hardware and software by Laryngograph, Ltd). In this study we try to implement results of irregularity percent of reading The Northwin and the Sun and intonation of an /ah/ for 4 sin a supplementary statistical setting in relation to the earlier results. The second aspect focuses on irregularity percent before and after treatment. Results and conclusion: There are statistical differences between normal and pathological measures of voice with all parameters. The supplement with voice measures gives a more secure evaluation of pathology than videostroboscopy alone.

T+A HL 120 Experience of the endoscopic adenoidectomy Mikhail Melnikov Novosibirsk State Medical University, Russian Federation Endoscopic surgery of adenoids has got broad spreading in the world, including in Russia. The modern concept to surgery of adenoids expects: (1) endotracheal narcosis; (2) visual checking; (3) using of shaver. However in Russia is to date practised using the procedure of adenotomy on local anesthesia. Objective: (1) study the frequency of the complications after endoscopic adenoidectomy; (2) compare the amount of the complications after endoscopic adenoidectomy and after adenotomy, executed under local anesthesia. Methods. Under observation are found 1,496 patients, which is executed endoscopic adenoidectomy for period since 1996 on present time. The group of the comparison were results of the operative treatment adenoid beside 202 children, which was executed operation under local anesthesia. Results: The complications were in all group patients. Among them: postoperative bleedings beside 2.9% in the ﬁrst group and 7.5% in the second group. In group patients after endoscopic operation, only beside 4 not to manage to stop the bleeding without using back tamponade. A complications were in the second group in the manner of aspiration by blood beside one patient (0.5%), subluxation of atlanto-occipitale joint beside one patient (0.5%), cervical lymphadenitis beside two patients (1%). Total, the early complications observed beside 5.4% in the ﬁrst group and 9.5% in the second group. The repeated growing adenoid is registered beside 2 patients (0,13%) ﬁrst groups and beside 6% patients second group. Conclusion: Endoscopic adenoidectomy is more efﬁcient and safe in contrast with adenotomy, executed under local anasthesia.

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HL 121 Radiofrequency adenoidectomy

have standards of data submission similar to ours, the conclusions drawn upon those data should be regarded with great caution.

Ragab Sameh Bayan, Kuwait

HL 123 Aspects on histopathology following adenoidectomy and tonsillectomy in children

Objectives/hypothesis: The objective was to conduct a prospective randomized controlled trial describing and investigating the efﬁcacy and safety of transoral telescopic-assisted radiofrequency adenoidectomy in young children. Study design: Prospective randomized controlled trial. Methods: One hundred and twenty patients who were 36 months of age or less and planned to undergo adenoidectomy or adenoidectomy with insertion of tympanostomy tubes were included in the study. Children were prospectively and randomly assigned into two equal treatment groups: the telescopic-assisted adenoidectomy using radiofrequency curette and the conventional adenoid-curette adenoidectomy. The main parameters included visual analogue scale score for nasal breathing, amount of blood loss, operating time, completeness of adenoid resection, smoothness of postoperative recovery, and complications. Results: Both groups had a signiﬁcant improvement in the visual analogue scale score after surgery with no evidence for a signiﬁcant difference between the conventional adenoid-curette and radiofrequency groups. The amount of blood lost during radiofrequency adenoidectomy was minimal, with a mean difference of 31 ml and a median difference of 26 ml. There was a tendency for shorter operative time in the radiofrequency group, but this did not reach a statistical signiﬁcance. No evidence for a signiﬁcant difference was noticed in the smoothness of postoperative recovery or complication rate. Conclusion: Telescopic-assisted radiofrequency-curette adenoidectomy allows removal of huge adenoids completely in a precise, easy, and cost-effective procedure, with minimal blood loss and short operating time. The use of transoral telescopes provides a clear visualization that helps complete removal of the adenoids, reduction of unnecessary trauma, and effective control of bleeding. NB: video presentation is included.

HL 122 NPTA: an audit of an audit and some worrying conclusions Paul Nankivell, Swami Hunagathatta, David D. Pothier ENT Department, Royal United Hospital, Combe Park, Bath BA1 3NG, UK Objective: The UK National Prospective Tonsillectomy Audit (NPTA) was set up to record data concerning all tonsillectomies performed in England and Wales over a 15 month period. It was the largest prospective study of tonsillectomy ever undertaken. Unfortunately, a great deal of reliance was placed on accurate recording of complication data. We aimed to assess whether the audit is ﬂawed by systemic bias and therefore underestimates the rates of haemorrhage. Methods: Case notes of tonsillectomy patients whose data were sent to the NPTA were retrieved (Gloucestershire Royal 250 and Bath 300). These notes were reviewed independently of the NPTA form for data that was required by NPTA. Results: The review of the case notes showed a far higher rate of complications than the data sent to the NPTA. Rates of delayed discharge were 58% higher, the readmission rate was 54% higher and the return to theatre rate from the case note review was over double that of the data we sent to the NPTA. Conclusion: The value of the results of the NPTA is dependant on the quality of data submitted to it. If the other participants in the NPTA

Philipp Dost Hals-Nasen-Ohren-Heilkunde, Plastische Operationen, Marienhospital, Virchowstrasse 135, 45886 Gelsenkirchen Objective: Is histological work-up of tonsils and adenoids in Germany performed routinely in paediatric cases? How frequent are unexpected histological results in children? Methods: German ORL-specialists (n = 299) were surveyed by a questionnaire. They were asked if they would routinely send tonsils or adenoids for histological examination in the case of a child, up to 10 years old, presenting with a history and a status of chronic inﬂammation or hyperplasia and undergoing adenoidectomy or tonsillectomy. Furthermore 400 children, 10 years old or less, were identiﬁed from our charts, that consecutively underwent adenoidectomy/ tonsillectomy due to recurrent throat infection or stenotic symptoms of the throat. Results: The survey resulted in a feedback of 79%. All tissue was send for examination by 59% of the ENT-specialists; palatine tonsils only were send for examination by 14%; no tissue at all was send for examination by 27%. The histological results of the 400 children showed no other diagnosis than ‘‘lymphatic hyperplasia’’ or ‘‘chronic tonsillitis’’. Conclusions: We do not have any consensus practiced in Germany concerning the necessity to send tissues for histological examination following adenoidectomy or tonsillectomy in children. The results from our own patients support the opinion, that unexpected histological results following adenoidectomy/tonsillectomy in children are very rare. Therefore the necessity of routine histological examination should be discussed under ethical and economical aspects.

HL 124 Outpatient laser partial tonsillectomy for chronic tonsillitis in 527 patients Y.-V. Kamami, L. Pandraud, A. Bougara Saint-Cloud Hospital, 3 place Silly, 92, Saint-Cloud, France Objective: (1) Report the risks and beneﬁts of Laser-Assisted Intracapsular Partial Tonsillectomy (LAIPT) as an outpatient technique for the treatment of chronic tonsillitis in adults. (2) Report the complication rate of LAIPT and compare this with other techniques. (3) Demonstrate that adult LAIPT is a safe and effective procedure for chronic tonsillitis. Methods: A retrospective review was performed over a 17-years period, from March 1989 to March 2006. All patients aged 13 or over undergoing LAIPT for chronic tonsillitis were reviewed. Postoperative pain, complications, and day taken to return to work and normal diet were compared to conventional surgery. All patients were followed for a minimum of 6 months. Results: Five hundred and twenty-seven patients (340 women, 187 men) were treated. Eighty-nine percentof patients noted an improvement of their initial symptoms (recurrent infections, catarrh, bad breath, tiredness, crypts). They were all able to return to normal diet in a short space of time following LAIPT. They were likely to recommend LAIPT, feeling more a discomfort than a real post-operative pain. Recurrent tonsillitis occurred in 4.9% (26 out of 527), requiring additionnal laser treatment. Conclusions: LAIPT is a quick, simple, safe and effective in-ofﬁce procedure for adults with symptoms of chronic tonsillitis

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HL 125 Evaluation of humoral and cellular immunity parameters in children before and after adenotonsillectomy Mohammad Hossein Baradaranfar1, Fereshteh Dodangeh2, Shokouh Taghipour Zahir3, Mehdi Atar4, M. Sadeghi5 1 Associate Professor and Chairman, Department of Otolaryngology and Head and Neck Surgery, Yazd University of Medical Science 2 Otolaryngologist and Head and Neck Surgen, ChaharmahalBakhtiari University of Medical Science 3 Assistant Professor of Pathology, Yazd University of Medical Science 4 Hematologist, Yazd Blood Transfusion Center 5 Assistant Professor of Otolaryngology and Head and Neck Surgery, Tehran University of Medical Science Objective: Adenoids and tonsils are active lymphoid organs and play an important role against invading antigens of upper aerodigestive tract in children. The present study analyes the changes in cellular and humoral immunity of children 6 months after adenotonsillectomy. Materials and methods: The study population consisted of 30 children (aged 4–10 years)whit chronic adenotonsillar hypertrophy and 30 age-matched healthy children. In all children serum level of IgM and IgG, percentage of T lymphocytes (CD3), T helper (CD4), T (CD8) and B lymphocyts(CD20) were measured.These parameters were remeasured in patients 6 months after adenotonsillectomy. Results: Before the operation,a reduction in percentage of T lymphocytes (CD3),TCD4,TC8 and B CD20 was seen compared to control group.This reduction was only signiﬁcant in T lymphocytes (CD3) (P value = 0.03).The serum IgM level was not different in two groups and IgG level was elevated in two groups but not signiﬁcantly different. Six months after operation the percentage of lymphocytes T CD3,T CD8 and BCD20 was increased and reached the control group.The IgM level was also signiﬁcantly decreased in patients after operation (P value = 0.00). Conclusion: Our results indicate that cellular and humoral immunity decreases in children with chronic adenotonsiller hypertrophy preoperatively and increases to healthy children level, 6 months postoperatively.It means that chronic adenotosillar hypertrophy affect’ some parameters of cellular and humoral immunity and adenotonsillectomy by removing chronic stimulations and reverses these changes without any negative effect on immune function of pationts.

HL 126 Extracorporeal immunocorrection in complicated cases of chronic tonsillitis with amikacin and plasmapheresis Alexander P. Gonchar-Zaykin, Igor A. Shulga, Andrey I. Shulga Orenburg, Russia Generalization of the infection manifesting itself as a systemic inﬂammatory response aggravates the secondary immunodeﬁ-

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 ciency despite of conventional massive antimicrobic therapy. Twenty-four patients with the pronounced symptoms of endotoxicosis as a result of chronic tonsillitis complicated with peritonsillar phlegmon were examined. All patients simultaneously with conventional antimicrobic and intensive therapy combined with surgery, every 24 h were treated with membranous plasmapheresis in a volume of 1% of the patient’s weight. At the same time the extracorporeal loading of autoerythrocytic mass with the minimal single dose of amikacin was performed in a volume of 3 ml RBC and 1 ml of 1% solution of sodium adenosine triphosphate per 1 kg of the patient’s weight after 20 min incubation. The control group consisted of the patients receiving conventional therapy. During the carried out treatment all patients of the basic group showed accelerated improvement of the general condition, biochemical and clinical parameters of blood, normalization of hemodynamics as compared with the control group. Signiﬁcant improvement of the immune status was registered: the increase of CD4 cells count, normalization of CD4 /CD8 ratio, increase of lgG, rise of the phagocytic activity of neutrophils.

HL 127 Intravenous hydration can reduce pain following tonsillectomy Ruta Pribuisiene, Virgilijus Ulozas, Algis Babarskas Kaunas University of Medicine, Lithuania Objective: To determine the beneﬁt of intravenous hydration for postoperative pain following tonsillectomy. Methods: The study is consisting of two groups of patients following tonsillectomy performed in a university hospital. One group received adequate intravenous hydration during and after operation while the other did not have and dehydration was detected. 100 mm visual analogue scale (VAS) for detecting postoperative throat pain was used. Two-tailed unpaired Student’s t-test was used to compare the two independent groups. P < 0.05 was accepted as statistically signiﬁcant. Results: The total amount of the intravenous solutions was in mean: 1,591.7 (SD 666.7) ml for male (weight 79.1 SD 10.5 kg), 1,269.2 (SD 525.0) ml for female (weight 70.4 SD 12.7 kg), 1,281.3 (SD 625.6) ml for boys (weight 52.1 SD 13.5 kg), and 1,188.5 (SD 641.0) ml for girls (weight 45.1 SD 12.3 kg). The dehydration in 35 (76.1%) patients was detected. There were 19 adults (9 male, 10 female) and 16 children (5 boys, 11 girls) in this group. The hydration (H) group had signiﬁcantly (P < 0.05) less postoperative pain compared with the dehydration (D) group. The mean pain in H group was 21.4 (SD 17.5) VAS points and 36.5 (SD 21.1) points in D group, respectively. There was no age dependence. Conclusions: Results of the current study suggest that adequate intravenous hydration can reduce postoperative pain in postoperative period following tonsillectomy in children and adults.

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HL 128 Advantages of ultrasonic harmonic scalpel tonsilectomy Miroslav Kendrisic, Goran Ivic, Mirjana L. Kendrisic Health Centre Sremska Mitrovica, ENT Department Objective: The ultrasonic harmonic scalpel tonsillectomy has become safe alternative to traditional cold steel tonsillectomy. We compared two techniques—Ultrasonic harmonic scalpel (UHS) and traditional cold steel technique (CS) tonsillectomies by: intraoperative blood loss, primary haemorrhage (within 24 h), delayed haemorrhage (7–10 days after the operations), postoperative pain and operating time. Method: After approval of the local ethical comittee two groups of patients were included in this prospective randomised study. UHS group of 620 patients aged 6.6 ± 3.8 years (med 5, mod 5) and group CS of 583 patients aged 7.4 ± 4.5 years (med 5, mod 5). Intraoperative blood loss was analised by measuring of the volume blood in the suction unit. Postoperative pain was analised by Visual Analog Scal (VAS). Statistics were analysed with the ChiSquared test and Student‘s t test. Results:

UHT

CS

P value

Age (years) Intraoperative blood loss (ml) Primary haemorrhage (no) Delayed haemorrhage (no) Operating time (min) Postoperative pain (VAS)

6.6 ± 3.8 35 ± 15 0 3 7 ± l.7 5

7.4 ± 4.5 125 ± 37 2 8 12 ± 1.6 5

NS P < 0.01 NS NS P < 0.005 NS

Conclusions: Intraoperative blood loss and operating time were signiﬁcantly lower in UHS group. Immediate haemorrhage, delayed haemorrhage and postoperative pain were lower, but not signiﬁcantly in UHS group.

HL 129 Group A b-hemolytic Streptococci in the adenoid of tonsillectomy patients Laura J. Orvidas1, Jonathan H. Lee1, Franklin R. Cockerill2, James R. Uhl2 1 Department of Otorhinolaryngology/Head and Neck Surgery, Mayo College of Medicine, Rochester, MN, USA 2 Division of Clinical Microbiology, Mayo College of Medicine, Rochester, MN, USA Objective: Using standard swabbing techniques, rapid-cycle real time PCR (rcPCR) has been shown to detect group A b-hemolytic Streptococci (GABHS) at rates equal to standard culture (SCx), and requires only a few hours for results. This study examines the rates of GABHS detection by rcPCR and SCx at the adenoid in tonsillectomy patients.

S53 Study design: Prospective study of 130 patients undergoing tonsillectomy with or without adenoidectomy. Methods: At tonsillectomy, swabs were taken of the pharyngeal tonsil surface, the pharyngeal tonsillar core, and the adenoid surface. Tissue samples were taken from the tonsil core, and the adenoid. Each sample was analyzed for GABHS by rcPCR and SCx. Results: GABHS was detected at the tonsil surface in 29 of 130 patients. Adenoidectomy was performed in 23 of those 29 patients and GABHS was detected at the adenoid of all 23 (100%). Of the six patients with GABHS on the tonsil surface with no adenoidectomy performed, 75% had GABHS detected by adenoid swab at the time of surgery. In the 23 patients with GABHS detected at the tonsil surface and the adenoid, 12 (52%) had infectious indications for tonsillectomy. Conclusions: All patients undergoing both tonsillectomy and adenoidectomy had detectable GABHS at the adenoid when GABHS was detected at the tonsil surface. This study suggests a role of adenoidectomy in patients with GABHS positive tonsils undergoing tonsillectomy for both infectious and obstructive indications.

HL 130 Hazards, precautions, advantages of diathermy tonsillectomy M. K.Taneja Chief, Indian Institute of Ear Diseases, E-982, C.R. Park, New Delhi, National Treasurer-Association of Otolaryngologists of India, Editor-Indian Journal of Otology Objective: To asses the advantage of bipolar diathermy tonsillectomy over blunt dissection. Method: First group—retrospective review of amount of bleeding, hospital stay and severity of pain was assessed of last 20 years. Second group—118 cases right side was operated by blunt dissection and left was operated by bipolar diathermy. Result: In ﬁrst group by blunt dissection and ligature mean time and blood loss was 33 min, 138 ml, with blunt dissection and cautery 22 min, 76 ml and with bipolar diathermy dissection and cautery 17 min, 12 ml. Second Group—right side mean time was 3.4 min, bleeding 18 ml, left side (diathermy) mean time was 3.5 min, bleeding 8 ml. To prevent ﬁre measures adopted (Rule of 20). Diathermy current should not exceed 20 W. Unipolar should not be used in adenoidectomy, may lead to subluxation of atlantoaxial joint. Endotracheal tube should be pushed a little more in trachea to minimize retrograde gas ﬂow (20 mm). Positive pressure should be kept below 20 mm of water. Endotracheal tube should be 20 mm away from site of surgical area. Bipolar forceps should be at right angle to anterior pillar. Continuous suction to be used from another nostril to maintain oxygen level at atmospheric level in surgical area, suck all fumes (carcinogenic). Conclusion: Bipolar diathermy forceps dissection is safe, trusted and established procedure speciﬁcally in anemia and blood dyscrasia, with comparable pain to blunt dissection tonsillectomy with gross reduction in bleeding.

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HL 131 Peritonsillar abscess: indication for tonsillectomy? G. Kecskes, E. Sauvaget, P. Tran Ba Huy, P. Herman Albert Szent-Gyo¨rgyi Medical and Pharmaceutical Centre, Department of Pediatrics and Child Health Center, Szeged, Hungary Department of Oto Rhino Laryngology, Hopital Lariboisiere, Paris, France Objective: To evaluate the recurrence rate of tonsillar or peritonsillar infection following peritonsillar abscess (PTA); and to identify the factors of the risk of recurrence. Methods: Retrospective study of 333 patients admitted in a tertiary ENT Emergency Centre in Hopital Lariboisiere with PTA between January 1999 and December 2000. Inclusion criteria: First episode of PTA, ascertained by aspiration or CT. One hundred and forty-six patients were included. The recurrence rate was evaluated by a questionnaire, which has been completed by 48 patients (33%). Results: The population consisted of 26 males (54%) and 22 females (46%). The mean age was 32 years (17–79 years). The mean follow-up period was 5.4 years (4.1–7 years). Recurrent PTA developed among seven patients (14.6%). Four patients (8.33%) had one episode, three patients (6.25%) had two episodes of recurrence. The mean delay between the episodes of recurrence was 1.71 years (1.5–5 years). The recurrence rate of PTA was remarkably higher by patients with positive medical history (33.3%) than by patients without medical history (3.3%). Episodes of tonsillitis would not become more frequent after the episode of PTA. Conclusions: A 14.6% recurrence rate was evidenced, with a great difference between patients with (33%) or without medical history (3.3%). In view of this low rate, indications for interval tonsillectomy following PTA should remain minimal.

HL 132 The use of disposable instruments in adenoid and tonsil surgery the detection of instrument consumption and the detection of failure rates. The requirement for long-term surveillance David Owens1, Wendy Harrison2, Victoria Mcclure2, Sue Harris2, Mark Temple2, Alun Tomkinson1 1 University Hospital of Wales, Heath Park, Cardiff, Wales 2 Centre for Disease Control (Wales), Abton House, Wedal Rd, Cardiff, Wales Objective: To establish the use of disposable instruments and the detection of their failure in adenoid and tonsil surgery. To discuss the requirement of long-term surveillance with disposable instruments. Method: Data was collected between Feb 2003 and Dec 31st 2005 was using Single use Instrument Program (SISP) database. Instrument use and failure were recorded. Instrument failure

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 described as minor or major depending whether the instrument was discarded or replaced intra-operatively. Results: Eleven thousand one hundred and forty operations were performed consuming 110,886 individual instruments. Failure levels over 0.5% were considered high. Three hundred and eight minor faults and 263 major faults were reported. Timeline studies reveal a pattern of increasing faults followed by correction. Faults in instruments with high usage are ameliorated more rapidly than those with less widespread use. Haemorrhage was not signiﬁcantly different where instruments had failed or not, primary haemorrhage with surgical management (95%CI 0.76–1.12 and 0.12–1.63) and secondary haemorrhage requiring surgical management (95%CI 0.40–0.67 and 0.48–2.61), respectively. Conclusions: Surveillance of single use instruments is a necessary part of their use, to maintain standards and drive improvement. Instruments failure is rare but due to clustering can be identiﬁed, failure of instruments with high consumption are more identiﬁed easily. No statistical increase in post-operative haemorrhage rate is seen when instrument failure occurred.

HL 133 Coblation versus CO2 laser scanning system for tonsil ablation in adults Marc Remacle, Georges Lawson, Jacques Jamart Department of ORL, Head and Neck Surgery, Center for biostatistics, University hospital of Louvain at Mont-Godinne New technologies have been proposed for tonsil ablation aiming at decreasing the pain and the risk of bleeding. CO2 laser scanning system and radiofrequency (coblation) are two of these efﬁcient tools. Objective: To compare the two techniques with regard; (1) to pain; (2) time for surgery; (3) bleeding. Methods: Fifty-two adult patients underwent tonsil ablation and were randomly assigned to have one tonsil removed with coblation and the other subtotally ablated (intracapsular vaporization of 80–90% of the tonsil lymphoid tissue) with CO2 laser scanning system. Outcome measures included time to treat each tonsil, intraoperative blood loss, patient-reported pain intensity measured with a visual analog scale of 10 cm, number of days of pain, day of maximum pain, postoperative hemorrhage and amount of healing 2 weeks after surgery. Results: Mean time of surgery was 24.3 ± 5.8 min for CO2 laser and 10.6 ± 2.8 min for coblation (P < 0.001), intraoperative bleeding was 0.7 ± 0.5 ml for CO2 laser and 0.5 ± 0.7 ml for coblation (P = 0.031), pain intensity was 4.2 ± 2.4 for CO2 laser and 5.1 ± 2.7 for coblation (P < 0.001) with the day of maximum pain being the third for the both techniques. Duration of pain was 5.7 ± 3.4 days for CO2 laser and 6.8 ± 3.8 for coblation (P = 0.001). Postoperative hemorrhage was observed in one case after coblation tonsillectomy. Healing was similar between the two techniques after 2 weeks.

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HL 134 Adherent bioﬁlms in adenotonsillar diseases in children Khalid A. Al-Mazrou, Abdulaziz Al-Khattaf King Saud University, PO Box 245, Riyadh 11411, Saudi Arabia Objective: Adenotonsillar diseases are common in children. Bioﬁlms have been demonstrated in adenoid surface in association with sinusitis and otitis media. Our aim is to study bioﬁlms formation on the epithelial surfaces of tonsils and adenoids of children undergoing adenotonsillectomy (A&T). Design: A prospective study. Setting: A tertiary academic hospital. Patients and methods: Between September 2005 and August 2006, 76 children below the age of 18 years undergoing adenotonsillectomy due to infections, obstruction, or both were included. Bioﬁlms were detected using the Scanning Electron Microscopy (SEM). Results: Male to female ratio was 1.8:1 and their mean age was 5.7 years. Forty-four patients (58%) had obstruction, 26 patients (39%) had infections, and 6 (8%) had both. Adherent bioﬁlm formation was demonstrated in 46 patients (60.5%). Bioﬁlm was detected in 22/26 patients undergoing A&T for infectious causes compared with 18/44 patients undergoing A&T for obstruction (P < 0.05). Conclusion: Bioﬁlms were identiﬁed on the surfaces of infected or enlarged (inﬂamed) tonsils and adenoids. These developed bioﬁlms are thought to have played a signiﬁcant role in the pathogenesis of adenotonsillar diseases in children. A better understanding of this role may aid in the development of a new approach of treatment and more effective antibacterial strategies in the ﬁeld of pediatric otolaryngology.

HL 135 Surgical revision of haemorrhage after cold steel tonsillectomy: a review of 6,995 cases in a 14 years tertiary hospital experience Christoph Arnoldner, Dietmar Thurnher, Jafar-Sasan Hamzavi, Markus Brunner, Boban M. Erovic Department of Otorhinolaryngology, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria Objective: The aim of this study was to evaluate the incidence and possible predictive factors of post tonsillectomy haemorrhage needing surgical revision in patients undergoing cold dissection tonsillectomy for different indications. Methods: We performed a single institution retrospective study of 6,995 patients who underwent tonsillectomy between 1993 and 2006. Indications for tonsillectomy were chronic tonsillitis, peritonsillar abscess and obstructive sleep apnoea. Surgery was

S55 performed using cold steel dissection with bipolar diathermy for haemostasis. Results: Postoperative haemorrhage needing surgical revision occurred in 121 patients (1.73%). The peak incidences were between the day of surgery and the third postoperative day and between the sixth and ninth postoperative day. No seasonal correlation was observed. Neither indication for tonsillectomy nor the experience of the surgeon (trainee/resident) was found to be a risk factor for the incidence of post-tonsillectomy haemorrhage. Conclusion: To provide optimal care for post-tonsillectomy patients a hospitalisation until the 9th postoperative day is actually necessary. However, economical considerations might interfere with this notion.

HL 136 Benchmarking post-tonsillectomy hemorrhage: a reﬂection of surgical skills only? National Norwegian data 1999–2005 K. J. Kvaerner University of Oslo, Medinnova, The National Hospital, Norway Objective: Control of postoperative bleeding, the major complication following tonsillectomy, serves as a landmark for the safety of operations. In Norway, hospitalization due to post-tonsillectomy hemorrhage (ICD-10 code T81.9) is a national bench marker for otolaryngologic surgery. The aim of the study was to estimate hospitalizations for post-hemorrhage bleeding and -surgery, identify treatment trends and markers for re-bleeding surgery requiring general anesthetics. Methods: National study using data from the Norwegian Patient Registry 1999 through 2005 with complete information on the incidence of post-haemorrhage hospitalizations (ICD-10 diagnosis T81.0), the incidence of re-bleeding surgery (surgical code EWE00), and (adeno)tonsillectomy rates, age, gender, duration of stay and time of onset of re-bleeding. Results: One patient per 200 tonsillectomies was hospitalized and diagnosed post-tonsillectomy hemorrhage during the 6 year study period. Re-operations requiring general anesthetics were found in less than one per 1,000 tonsillectomies. The incidence of tonsillectomies increased from 1.2 to 2.1 per 100,000 (36%), and in-patient treatment became rarer. While there was in increase in the incidence of post-tonsillectomy bleeding during the study period, the re-bleeding surgery requiring general anesthetics remained stable and was performed in approximately 1 per 1,000 surgeries. Markers for re-bleeding surgery will be presented. Conclusions: The slight increase in surgery requiring general anesthetic may be explained by the activity based increase in Norwegian tonsillectomies, more day-care surgery or surgical skills.

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HL 137 Long-term improvement of life quality after tonsillotomy in youths Elisabeth Ericsson, Torbjo¨rn Ledin, Elisabeth Hultcrantz Division of Otorhinolaryngology, Department of Neuroscience and Locomotion, Faculty of Health Sciences, University of Linko¨ping, Sweden Objective: This is a 1 year follow-up to compare the effects of partial tonsil resection using radiofrequency technique (RF), ‘‘tonsillotomy’’ (TT), with total tonsillectomy (TE) (blunt dissection). Obstructive symptoms, tendency for infections and health related quality of life (HRQL) were studied and compared with the HRQL-data from a normal population. Methods: The study-group consisted of 76 patients (16–25 years) randomized to TT (n = 32) or TE (n = 44) with obstructive throat problems with or without recurrent tonsillitis. Short-Form (SF-36) and EuroQul Visual Analogue Scale were used to evaluate HRQL. A questionnaire investigated the degree of obstruction and history of infections. Results: Preoperatively both groups reported signiﬁcantly lower HRQL in all dimensions of SF-36 compared with the normal population (P < 0.05–P < 0.001). After 1 year, a large improvement (P < 0.01–P < 0.001) in both groups in HRQL was found. No differences were found when compared with normal population or between the study-groups. The effect on snoring was the same for both groups and the rate of recurrence of infections was low and not higher in the TT-group. Conclusion: Preoperative obstructive problems, in combination with recurrent tonsillitis have a negative impact on HRQL. Both TT and TE-groups demonstrate large improvements on HRQL, infections and obstructive problems one year after surgery, indicating that both surgical methods are equally effective. With its reduced post-operative complications, less pain, shorter recovery time, and cost reduction, tonsillotomy with the radiofrequency technique ought to be considered as the method of choice.

HL 138 Tonsillectomy and adenoidectomy as a day-case procedure I. Vlastos, I. Athanasopoulos, S. Kegioglou, E. Koudoumnakis, P. Leotsakos, J. Ekonomides, M. Houlakis Department of Otolaryngology, Head and Neck Surgery, Aghia Sophia Children’s Hospital of Athens, Athens, Greece Objective: To evaluate whether tonsillectomy and adenoidectomy can be performed safely as a day case procedure by investigating complicating rates and possible contraindications. Methods: A retrospective review of the records of all the children admitted to the day surgery clinic of the Department of Otolaryngology Head and Neck Surgery of Aghia Sophia Children’s Hospital, the major pediatric hospital of Athens, during a 2 years period. Type and reason of operation, age and kind of complication that resulted to an overnight stay in the hospital were recorded.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Results: Of the 2,266 children that have been operated from January 2005 to December 2006, 795 have tonsillectomy with or without adenoidectomy and tubes insertion, 1,028 have adenoidectomy ± tubes insertion, 218 had tonsillotomy (subcapsular tonsillectomy) with adenoidectomy and 225 had other procedures like tubes insertion, ankyloglossia or ranula treatment. Twenty-six (0.032%) children of the ﬁrst group, 15(0.015%) of the second, 4(0.014%) of the third and one (0.004%) of the fourth group were admitted because of a complication. Laryngitis or airway distress and postoperative hemorrhage were the two most common complications recorded. The tonsillectomy group had signiﬁcant higher major complication rate (P = 0.012). Fifty-four children younger than 3 years old had tonsillectomy and the major complication rate of this group did not differ statistically with that of older children. Conclusion: Major complication rates are low even in those less than 3 years old, indicating that tonsillectomy and/or adenoidectomy is a safe procedure when performed as a day surgery in otherwise healthy children living in relative close distance to the hospital.

HL 139 Comparison of the post-operative haemorrhage rates of tonsillectomy in relation to diathermy and pure cold steel techniques and implications for consent David Owens1, Wendy Harrison2, Victoria Mcclure2, Sue Harrison2, Mark Temple2, Alun Tomkinson1 1 University Hospital of Wales, Heath Park, Cardiff, Wales 2 Centre for Disease Control (Wales), Abton House, Wedal Rd, Cardiff, Wales Objective: To compare the effect of using diathermy on the timing of complications post tonsillectomy (without adenoidectomy) haemorrhage rates. Methods: Data was collected from May 2003 to Feb 2006, and analysed for surgical technique, patient demographics and rate of primary (R1) and secondary (R2) haemorrhage requiring return to theatre in relation to pure cold steel and all techniques involving the use of diathermy. Results: Seven thousand six hundred and nineteen tonsillectomies were undertaken, 2,667 male 4,952 female. Pure cold steel techniques were used in were used in 3,215 (male 33% female 67%) R1 was 26 (1% CI 0.85–1.18) R2 was 7 (0.22% CI 0.11– 0.45). Diathermy was used in 3,827 cases (male 36% female 64%) R1 was 31 (1.08% CI 0.76–1.53) and R2 was 31 (1.08% CI 0.76–1.53). Serious secondary haemorrhage rates were three times higher where diathermy had been used. Conclusions: The timing of serious haemorrhage is affected by choice of technique. Secondary haemorrhage is three times more likely if diathermy has been used. The choice or requirement to use diathermy may inform both clinician and patient of a higher risk of returning with potentially serious haemorrhage after discharge from hospital.

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HL 140 Tonsillectomy improves long-term morbidity associated with chronic tonsillitis above the effect of time. A longitudinal study Rosemary Fox1, David Owens2, Mark Temple3, Alun Tomkinson2 1 National Public Health Service for Wales, Temple of Peace and Health, Cardiff, Wales 2 University Hospital of Wales, Heath Park, Cardiff, Wales 3 Centre for Disease Control (Wales), Abton House, Wedal Rd, Cardiff, Wales Objective: To compare the effect of surgical intervention with nonintervention on the morbidity associated with chronic tonsillitis. Method: Tonsil surgery ceased between 2001 and 2003 in Wales due to a perceived risk of vCJD transmission. The morbidity of all patients placed on the waiting list at the University of Wales who had been waiting 2 years or more were evaluated by questionnaire in 2003. In 2005 following recommencement of tonsil surgery two cohorts were identiﬁed, 1. where tonsillectomy had been undertaken and 2. where tonsillectomy was still awaited. The questionnaire was re-issued and comparison of the cohort results evaluated. Results: Of 415 initial responders 2003, 195 responded in 2005 (48%) 69 adults and 129 children. Thirty-ﬁve adults and 102 children had undergone tonsillectomy. All respondents experienced less morbidity in 2005 than described in 2003. Matched pair comparison, of individual respondent’s overall condition in 2003 and 2005 revealed that respondents who had tonsillectomy had signiﬁcantly less morbidity compared to those who had not (P = 0.03). Children who had undergone surgery experienced signiﬁcantly less morbidity than those who had not in all areas apart from long-term absence from school. Conclusions: The severity of severe chronic tonsillitis, if left untreated, appears to diminish with time; however, intervention by tonsillectomy provides signiﬁcant additional beneﬁt in effecting a much greater reduction in morbidity than time alone.

HL 141 Assessment of the effectiveness of sucralfate in reducing pain of tonsillectomy patients Chasem Karimi, Mohammed Hossein Baradaranfar, Abbas Mirvakily, Saeid Atighehi, MohamadReza Vahidy Department of Otolaryngology and Head and Neck Surgery, Yazd University of Medical Sciences Introduction: Pain is one of the serious compilcations in patients after tonsillectomy. It is essential to use a medication which reduces the pain with least side effects, cost, and availability. The purpose of this study was to study the effectiveness of sucralfate in reduction of pain and dosage of acetaminophen post tonsillectomy Methods: This was an analytic study performed as a clinical trial. In this study, 60 patients (older than 7 years) admitted to Shaheed Sadoughi hospital, Yazd undergoing tonsillectomies were chosen

S57 randomly and divided into two groups; case and control. Both groups received 40 mg/kg/day Amoxicillin and 10 mg/kg/dose Acetaminophen syrup. The case group was administered 1g/10 cm3 sucralfate, while the control group was given 10 cc dimethicone every 6 h. The severity of sore throat was assessed using a visual analog scale (from 0 to 5) and the frequency of acetaminophen use on the ﬁrst, second and third day, post operatively. For statistical analysis of results, t test and a = 95% with P value < 0.05 was used and analyzed by SPSS. Results: The difference between the intensity of sore throat in the two groups was signiﬁcant. (P value < 0.0001) The difference in the mean amount of acetaminophen consumed was also signiﬁcant (P value < 0.0001). The results of the study were in line with other similar studies which prove that sucralfate by coating the tonsillar bed sore acts as an effective analgesic. Conclusion: Considering the efﬁcacy of sucralfate in reduction of post tonsillectomy pain and its few side effects including cost effectiveness and availability, sucralfate usage is recommended in tonsillectomy patients, post operatively.

Thyroid HL 142 Remote results of surgical treatment of patients with cancer of the thyroid gland I. Zinkevich, N. Prokodanova, O. Zinkevich Rostov-on-Don Regional Hospital, Department of Endocrine Surgery In our hospital 412 operations for cancer of the thyroid gland were performed from 1999 to 2003. Two groups of patients were singled out: the ﬁrst group—217 patients were under observation for 5 years; the second group of patients were under observation from 3 to 5 years. The mortality was 2.9% (12 patients): in the ﬁrst group—2 patients, in the second—10 patients. The histopathology of these were medullary carcinoma in six, follicular carcinoma in three and papillary carcinoma in three. An overwhelming number of lethal results were observed in the second group. Recurrences were found in 11 cases. Seven patients were operated for a second time. The volume of operative intervention (412 patients) depended on stages of the tumorous process: thyroidectomy with central lymphodissection in 144 patients. Thyroidectomy with central + compartment-fascial (one-side) lymphodissection—60, thyroidectomy with central + double compartment-fascial lymphodissection—12, total-subtotal resection with central lymphodissection—183, subtotal resection of the thyroid gland—13. The volume of operative intervention by means of hemithyroidectomy + isthmus with subtotal resection of contralateral part in the ﬁrst or second stage of the tumor (T1–T2) seems to be sufﬁcient. With more vast lesions (T3–T4) a total laryngectomy is necessary. Probability of development of a recurrence after 5 years of observation is signiﬁcantly reduced.

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HL 143 Tumors of uncertain malignant potential (UMP) of the thyroid Guevara Nicolas1, Lassalle Sandra2, Haddad Antoine1, Hofman Ve´ronique2, Brucker-Davis Franc¸oise3, Sadoul Jean-Louis3, Santini Jose´1 1 Thyroid Surgery Unit, University of Nice, France 2 Pathology Unit, University of Nice, France 3 Endocrinology Unit, University of Nice, France Objective: A few thyroid encapsulated vesicular lesions do not meet standard criteria of histopathologic assessment because of focal nuclear changes or questionable capsular invasion. Those two morphological features were reported in the last WHO classiﬁcation of endocrine tumors (2004), as tumors of UMP. Features accounting for these lesions are not well and therapeutic strategies are not codiﬁed yet. The goal of our study was, to (1) evaluate the incidence of the thyroid UMP, (2) recognize their clinical, ultrasonic, histopathological features and, (3) discuss the best therapeutic approach when dealing with them. Methods: A prospective study was conducted over 18 months (2004–2006); all patients were undergoing thyroid surgery for nodular disease. Results: Four hundred and forty-one samples from thyroidectomies were studied. Fourteen (3.2%) were UMP tumors (diagnosis established by a double expert pathologist reviewing). Eightyeight (20%) were malignant carcinomas with a size over than 1 cm. UMP tumors represented 16% of the non medullar malignant tumors. The sex ratio was 0.75 (8F/6M), the mean age was 54.5 years. No clinical or ultrasonic features were speciﬁc. We found ﬁve well-differentiated tumors of UMP and nine follicular tumors of UMP. No pejorative evolution was noted. Conclusions: Thyroid tumors of UMP were found in our experience to represent a signiﬁcant percentage of thyroid lesions encountered. We propose a therapeutic protocol including a diagnostic conﬁrmation (double checking of histopathologic ﬁndings by an expert specialist), and an extensive patient information, including long term follow-up. We have also initiated a data tissue biobank gathering in an effort to lead to a prospective multicentric study on these tumors.

HL 144 Hemithyroidectomy for benign disease: who needs follow-up? R. N. Wormald, M. Toner, C. Timon Department of Otolaryngology-Head and Neck Surgery and Pathology, St. James’s Hospital, Dublin, Ireland Objective: Hypothyroidism is a recognized complication following hemithyroidectomy. The reported incidence varies from 5.0 to 41.9%. There are no universally accepted guidelines for the monitoring of thyroid function after hemithyroidectomy. The objectives of this study were to assess the incidence of hypothyroidism after hemithyroidectomy, to identify possible risk factors for the development of hypothyroidism and to determine a simple protocol for the post-op monitoring of thyroid function for these patients Methods: This was a prospective study on all consecutive patients undergoing hemithyroidectomy. All euthyroid patients were suit-

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 able for inclusion. Patients who were diagnosed with malignant disease post-operatively were excluded. Histological examination of the resected thyroid lobe was performed for pathological diagnosis and the degree of lymphocytic inﬁltration present. Assessment was made of the relationship between the presence of post-operative hypothyroidism and the pre-operative (TSH), the pathological diagnosis, and the presence of lymphocytic inﬁltration. Results: Ninety-two patients were suitable for inclusion in this study. Fifteen (18.3%) patients developed hypothyroidism, clinical or subclinical, post-operatively. Conclusion: A relatively raised pre-operative (TSH) and the presence of lymphocytic inﬁltration in the resected specimen are signiﬁcant risk factors for the development of post-operative hypothyroidism. The presence of these risk factors requires a patient to undergo yearly thyroid function testing for life. In the absence of these risk factors a patient can be discharged from further follow up at 12 months.

HL 145 The management of locally invasive thyroid carcinoma Ricard Simo3, Jean-Pierre Jeannon3, Ben Wallwork3, Guillem Bruch3, Mary O’Connell1, Sue Clarke2 1 Department of Otorhinolaryngology Head and Neck Surgery, London, UK 2 Clinical and Radiation Oncology and Nuclear Medicine, London, UK 3 Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK Objective: The aim of this paper is to analyze our experience in the management of these cases using a uniform approach to surgical and adjuvant treatment. Methods: Retrospective study of 131 patients with thyroid carcinoma treated with thyroid carcinoma between January 2000 and January 2007. One hundred and eleven patients had well differenciated thyroid carcinoma (WDTC). All patients underwent ultrasound-guided ﬁne needle aspiration, MRI scanning of the head and neck and CT scanning of the chest. All patients were assessed in a multidisciplinary clinic and received post-operative radioiodine treatment. 30 patients received external beam radiotherapy according to a standard protocol. Follow-up ranged from 3 months to 6 years. Results: One hundred and eleven patients with WDTC were treated. Seventy-nine were women and 32 were men. The average age was 51 years (range 25–86). Twenty-two patients had strap muscle invasion, 16 had recurrent laryngeal nerve involvement and nine had pre-operative evidence of nerve paralysis. Seven patients had tracheal involvement, four had laryngeal involvement and two patients both. One had gross invasion of the internal jugular vein. Overall survival was 95%. For patients without local invasion the survival is 100%. For those with local invasion is 93%. Conclusion: The optimal management of locally invasive differentiated thyroid carcinoma continues to evolve. A multidisciplinary approach is essential. Surgery remains the mainstay for treatment of loco-regional disease and should aim to remove all disease whilst minimizing morbidity. Postoperative radioiodine ablation has a well-established role. External beam radiotherapy may improve local control and possibly survival.

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HL 146 The management of retrosternal goitres: indications for sternotomy Ricard Simo1, Jean-Pierre Jeannon1, Guillem Bruch1, Ben Wallwork1, Karen Harrison-Phipps2 1 Guy’s and St Thomas NHS Trust, London, UK 2 Head and Neck Surgery and Thoracic Units, Guy’s and St Thomas NHS Trust, London, UK Objective: To analyze the presentation, evaluation, indications for sternotomy and surgical management of patients with retrosternal or intrathoracic non-toxic goitres. Methods: Retrospective review of 640 patients who underwent thyroidectomy in our unit between January 2000 and January 2007. Ninety-seven patients had goitres with either retrosternal or intrathoracic extension. All patients were evaluated with ultrasound-guided ﬁne needle aspiration, MRI and/or CT scan of the neck and chest. Results: Of the 97 patients, 86 were women and 11 were men. Ninety-one patients underwent surgery via a cervical approach. Only six required a transthoracic approach via a sternotomy. Patients required sternotomy due to: Giant intrathoracic extension (1), complex anatomical distribution (1), retroesophagic extension (1) and previous failed cervical approach (3). In all cases the transverse diameter of the retrosternal component was signiﬁcantly larger than the thoracic inlet (3). No patients in this group had vocal cord paresis Complications included two pneumothorax and two patients had temporary hypocalcaemia that recovered after 3 months. Conclusions: The optimal management of retrosternal goiters requires careful evaluation and planning. Although the large majority of this NTG can be approached and successfully excised by a transcervical approach a signiﬁcant minority will require sternotomy for access. MRI and CT scanning with multiplanar reconstructions is essential to determine the anatomy of the goitres and allowing adequate surgical planning. A multidisciplinary team approach between the head and neck and thoracic surgery teams is essential.

HL 147 Postthyroidectomy haematoma requiring urgent reexploration Pavol Prazˇenica, Richard Holy´ ENT Department, Central Military Hospital Prague, Czech Republic Objective: The study was undertaken to assess the risk of cervical haematoma following thyroidectomy requiring urgent reexploration. Methods: A retrospective study includes 432 patients who underwent total thyroidectomy or hemithyroidectomy between 2001 and 2006. All patients were treated by the same surgeon. Speciﬁc risk factors and risk patients, timing of haematoma, surgeon’s experience, clinical picture and morbidity of reexploration were studied.

S59 Results: Seven patients (all women, mean age of 50 years) developed postoperative haematoma. Case control (n = 7) were selected. Perioperative factors did not show difference between groups. The most common symptoms included neck swelling in ﬁve patients, drain tube looses in three, pain/pressure in the neck in three, respiratory distress in three, laryngeal oedema in three patients. Five patients were reexplored within 6 h, one between 7 and 24 h and one beyond 24 h. Bedside evacuation was necessary in four patients. The bleeding site was superior thyroid artery three times, inferior thyroid artery three times, Berry ligament area six times. Within the ﬁrst 130 procedures ﬁve incidents occurred. Mean hospital stay was longer in the study group (12 vs. 6 days). The rate of complications (prolonged intubations, tracheostomy, hypocalcemia and recurrent nerve palsy) was higher in the study group (5 vs. 1). Conclusions: Postoperative haematoma is uncommon, but potentially serious complication of the thyroid surgery. The risk factors are unpredictable. The more experienced surgeon, the less chance of development of haematoma. The meticulous haemostasis is the basic prevention of this complication. If developed, an urgent reintervention is strongly advised. Reexploration has an impact of the length of hospital stay and postoperative morbidity.

HL 148 Expanded indications and technique of minimally invasive thyroidectomy Robert L. Ferris, Stephen Lai, Seungwon Kim, Rohan Walvekar Unviersity of Pittsburgh Objective: Thyroid disease is increasing in frequency for several reasons, including improved methods of detecting thyroid nodules through ultrasound evaluation. Unfortunately, current standard of care often includes open thyroid lobectomy to determine the histologic nature of many nodules. We have performed endoscopic assisted, minimally invasive thyroidectomy for indeterminate thyroid nodules and for small thyroid cancers. In addition, recently we have expanded our indications to include larger multinodular goiters and completion thyroidectomy procedures. Methods: Retrospective patient review. Results: Our review of 48 prospectively studies thyroidectomy procedures using these expanded indications supports the safety and efﬁcacy of this approach, including up to 6 cm thyroid masses. Routine outpatient surgery is possible in approximately half of our patients undergoing partial thyroidectomy (lobectomy) without drainage tube use. No bleeding event occurred. Postoperative pain and cosmesis is signiﬁcantly enhanced. Hypoparathyroidism or residual thyroid tissue on radioiodine scanning was not signiﬁcantly increased, as compared to our open procedures. Concusions: The results of this study support the expanded indications and technical modiﬁcations based on our series.

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HL 149 Thyroid surgery from point of view of Otorhinolaryngology Jo´zsef Pytel, Pe´ter Mo´ricz, Krisztina Somogyva´ri Department of Otorhinolaryngology, Head and Neck Surgery, Medical School, Pe´cs University, Hungary Objective: More and more thyroid surgery is done by ENT surgeons. The authors discuss the surgical problems during the thyroid surgery. Study design: Three problems may arise during thyroid surgery. (1) The recurrent laryngeal nerve lesion. (2) The superior laryngeal nerve lesion. (3) Parathyroid gland injury or removal. The authors discuss how to avoid these complications. Setting: Otorhinolaryngological university department. Participants: Two hundred and forty-four thyroid surgeries was done in the ENT Department in Pe´cs. The authors demonstrate the technique of searching and saving the recurrent nerve, the superior laryngeal nerve. E special new technique is demonstrated to identify the parathyroid glands with contact hysteroscopy (video demonstration). Results: There was no recurrent paresis. One case occurred with hypoparathyroidismus. One temporary superior laryngeal nerve damage occurred. Conclusion: We can avoid the nerve injury with the special preparation technique and the contact hysteroscopy is a very useful intraoperative technique to identify and save in vivo the parathyroid glands.

HL 150 Difﬁcult thyroid surgery M. Bura, G. Poje, R. Prstacˇic´, H. Galic´, M. Zˇizˇic´-Mitrecˇic´, I. Botica University Hospital Center Zagreb Objective: Difﬁcult thyroid surgery occurs in substernal goiter, recurrent thyroid cancer and locally aggressive thyroid cancer. Most important step for recurrent thyroid cancer is to evaluate initial surgical procedure combining with histological evaluation, parathyroid reserve evaluation,disease extension, thyroid function and intralaryngeal examination. If recidive occurs in lobe or isthmus after one-side lobectomy, isthmectomia or partial lobectomy is in order.Difﬁcult surgical procedures occurs after subtotal bilateral resection or recidive metastasis in thracheooesophageal groove and ﬁbrous scars. Most difﬁcult are identiﬁcation of nervus reccurens and remaining parathyroid glands. Substernal goiters are those which at least 50% of gland is in mediastinum. It occurs in ﬁve to six decade with incidence three to four times greater in women. Regarding to vessels and nerve,it can be anterior or posterior. Substernal goiter is best diagnosed by radiological studies,ultrasound, cytological and radionuclide scintigraphic methods. Due to location ultrasound,cytological and scintigraphic methods are not always reliable. CT or MR imaging is useful for evaluation of goiter substernal extension and tracheal dislocation and compression. Indication are pressure effects in longstanding goiter,potential for acute airway

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 problems,potential for malignancy when medical therapy was unsuccessful. Methods: Ninety-six patients with substernal goiter were operated at our Department. Results: Most common symptoms of goiter were cervical mass (95.8%), respiratory symptoms (91.6%) and dysphagia (48.9%). Acute airway occurred in 11.4% and some were asymptomatic 12.5%. All goiters were removed through cervical incision. In 3.1% cases occurred postoperative hypocalcaemia. There were no operative deaths. Conclusions: Transcervical approach for substernal goiter is different from that used for routine thyroid surgery and need experienced surgeon. Difﬁcult phase of surgery are identiﬁcation of RNL and parathyroid glands. The majority of substernal goiters can be resected transcervicaly, but rarely will require a sternal split (in case of recurrency).

Miscellaneous HL 151 Evaluation of preoperative investigations in elective ENT surgery Amrita Sinha, Yohanna M. Takwoingi, Arun Sinha Department of ENT, City Hospital, Dudley Road, Birmingham B18 7QH, UK Objective: Pre-operative investigations are routinely carried out in patients undergoing elective ENT surgery. Some of these investigations may be unnecessary. The objectives of this study are: To determine the level of compliance to the UK National Institute of Clinical Excellence (NICE) guidelines for pre-operative investigations for elective ENT operations; To assess the ﬁnancial implications; To develop appropriate guidelines for pre-admission clinics Methods: Medical notes of 100 random patients undergoing elective ENT procedures under general anaesthesia were subject to retrospective audit. Pre-operative screening investigations (full blood count, haemostasis, urea and electrolytes, random glucose, chest X-ray and urine analysis) were analysed for individual grades of surgery and American Society of Anaesthesiologist (ASA) grades of patients and compared to the recommendations in keeping with the NICE guidelines. Results: Of the 100 patients selected, a total of 256 tests were performed. It was found that 45% (n = 114) of pre-operative investigations ordered were ‘not recommended’ according to the NICE guidelines. Only 12% (n = 32) of investigations were ‘recommended’. Of the ‘not recommended’ tests, 80% (n = 90) comprised of full blood count, renal and liver function tests. This led to four times as much spending on the ‘not recommended’ tests. Overall 0.9% (n = 25) investigations yielded abnormal results which did not cause surgical delay or post-operative complications. Conclusions: The results indicate that some routine pre-operative investigations are unnecessary. They should be done selectively in keeping with the NICE guidelines. This will result in substantial time and ﬁnancial savings without compromising patient safety.

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HL 152 Angulation of the styloid process in eagle’s syndrome Fatma Caylakli1, Haluk Yavuz1, Tulin Yildirim2; Levent N. Ozluoglu1 1 Baskent University Faculty of Medicine, Otorhinolaryngology Head and Neck Surgery, Ankara, Turkey 2 Baskent University Faculty of Medicine, Radiology, Ankara, Turkey Objective: The aim of this study was to investigate and compare the angulation, length of the styloid process between the patients operated for symptomatic elongated styloid process and control group with plain radiographs. Methods: Thirty patients with 51 elongated styloid processes underwent surgery. There were 27 females and three males, with mean age of 48.2 years. As control group, patients with chronic otitis media and trauma were included in the study. There were 28 females and three males in the control group with mean age of 45.5 and none of them had symptoms characteristic of an elongated styloid process. The length, medial and anterior angulation of the styloid processes of the patient and control groups were measured on lateral skull and Towne’s radiographs. Patients who received antiinﬂammatory drug therapy to rule out tendinitis or myositis preoperatively and did not relieve of their complaints were included into this study. Results: The length of the styloid process in the patient group was 5 cm on average on right and 5.2 cm on left which was 2.8 and 2.6 cm, respectively, in control group. There is a difference between two groups for the length of the styloid process on both sides (P = 0.001). Medial angulation of the process on average was 14 on right, 18.1 on left in patient group, whereas these were 15 and 16.3 in control group respectively and there is no difference between the patient and control groups for medial angulation on right and left sides (P = 0.459 and P = 0.191 respectively). And measurements for anterior angulation, in patient group it was 33.6 on right, 36.7 on left on average which were 21.4 and 18.5 respectively in control group. There is a difference between the patient and control groups for anterior angulation on both sides (P = 0.001). On long term control of patients, only 2 of 51 procedures did not result in improvement of symptoms which shows that this surgery is really efﬁcient. Conclusions: Our study revealed that length and anterior angulation of the styloid process are responsible for the symptoms rather than medial angulation when the patient and control groups are compared.

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HL 153 Management of facial hemangiomas: circular excision and ‘‘purse string suture’’ A. Vlahovic, R. Simic, V. Subarevic, Dj. Kravljanac Department of Pediatric surgery, Department of Otorhinolaryngology, Institute for Mother and Child Health Care of Serbia, Radoja Dakica street 6–8, Belgrade, Serbia Objective: Hemangiomas are the most common soft tissue tumors of infancy. Tretament options for hemangioma are numerous. The scar after lenticular excision and linear closure is often unacceptable. Localized cutaneus infantile hemangioma acts like tissue expander. Therefore circular excision and purse string suture are applicable for hemangioma in any stage. Methods: In 2-year period we have operated fourteen patients with hemangioma usin circular excision and purse string suture. In eight patients hemangioma was localized in the head and neck region. Two infants with large hemangioma are presented. One patient had hemangioma with ulceration resistant to conservative treatment. Second patient had the giant hemangioma which caused partial obstruction of visual axis with unacceptable aesthetic performance. We performed circular excision, purse-string suture with placement of a small full thickenes graft in the center of defect in both patients. Results: There were no intra- or postoperative complications. The aesthetic result was satisfactory. Upon follow up, the patients had adequate facial simetry and functional impairments. Conlusions: After circular excision of hemangioma and pursestring suture the scar was markedly shorter comparing to single or staged lenticular excision and linear closure. Circular excision and purse string suture minimize the distorsion of surrounding structures and should be the ﬁrst choise for resection of hemangioma, particulary in the head and neck region.

HL 154 Necrotizing fasciitis of the head and neck-34 cases in single institution experience! Bostjan Lanisnik, Bogdan Cizmarevic, Vojko Didanovic Department for ENT-Head and Neck Surgery, General Hospital Maribor, Ljubljanksa 5, 2000 Maribor, Slovenia Objective: To analyze the occurrence and course in aggressive management of the head and neck necrotizing fasciitis. Methods: A prospective cohort study of the patients with necrotizing fasciits (NF) of the head and neck. A NF was divided in two broad catergories: NF of the neck with/without mediastinits and NF of the face. The NF of the neck was further subdivided according to the fascial plane involved (superﬁcial and deep). Results: From 1992 to 2006 34 patients with NF were treated in our department. Among those patients ﬁve patients presented with facial NF. The most severe complication in these group was a skin nsecrosis which was a uniformal ﬁnding. Twenty-nine patients had a NF of the neck, 16 (55%) of them presenting with mediastinits. The common feature of the patients with mediastinits was pretracheal fascia NF. From 34 patients with NF only one died from uncontrolled infection. Fifteen patients (44%) had no signiﬁcant comorbidity. All patients were treated with aggressive surgical necrectomy, mediastinal drainage with or without thoracotomy/sternotomy. Conclusion: NF was considerd a disease with high mortality. We proved that it is not necessarily throuth, if infection is managed surgically, early in course of the disase and with multidisciplinary approach.

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HL 155 Neck trauma owed to car accidents Georgios Kloutsos, Dimitrios Balatsouras, Ioannis Anastasakis, Georgios Kourtis, Dimitris Achrianis, Nicolas C. Economou, Antonis Kaberos ENT Department, ‘‘Tzanion’’ General Hospital of Pireus, Greece Objective: Neck injuries owed to car accidents have become common occurrencies for ENT Emergency Departments. The aim of this presentation is to document the types and severity of these injuries, considering two factors: (1) the use of the safety belt or not; (2) driving under the inﬂuence of alcohol. Methods: The charts of 95 consecutive cases of neck injury that have presented to the ENT Department of our Hospital during the last year have been studied. Sixty-two (65%) drivers made use of the safety belts and 33 (35%) did not. Results: In the ﬁrst group the following injuries have been observed: (1) 36 (38%) cases with contusions and abrasions; (2) 17 (18%) cases with subcutaneous neck haematomas; (3) 6 (6%) cases with intraluminal laryngeal heamatomas; (4) 3 (3%) cases with hyoid bone fractures. In the second group the following injuries occurred: (1) 20 (21%) cases with neck contusions and abrasions, subcutaneous heamatomas, intraluminal laryngeal hematomas and thyroid cartilage fractures; (2) 7 (8%) cases with dislocation of the arytenoid cartilage; (3) 4 (4%) cases with cricoid cartilage fractures; (4) 2 (2%) cases with thyroid cartilage fracture. Of the 95 patients, 58 (61%) were driving under the inﬂuence of alcohol. Conclusions: From the study of these cases it is concluded that those of the drivers who used their safety belts had less severe injuries, in comparison with those who did not use it. Intake of alcohol before driving constitutes a major factor that increases the possibility of an accident.

HL 156 Trauma of cervical parts of respiratory and digestive organs D. I. Zabolotny, M. M. Bagirov, I. M. Bagirova Kiev Otholaryngology Institute Objective: Proving the efﬁciency of reconstructive operations on cervical parts of respiratory and digestive organs. Methods: We treated 45 patients with acute traumatic damages to respiratory and digestive organs (38 adults up to 77 years, 84.4%; and 7 children, 15.6%). Patients were admitted within ﬁrst hours after trauma in 42.2% of cases, 17.8%—within ﬁrst day and 40% cases—later (with cervical phlegmona, mediastinitis and pleural empyema). Twenty-one patients were admitted in grave condition with cervical phlegmona and mediastinitis (17 patients) and complete transsection of trachea and esophagus (four patients). Damages to trachea (larynx) took place in 46.7% cases, to esophagus (pharynx) in 40%, to digestive and respiratory organs concurrently in 13.3% cases. In 11 cases out of 26 damages to esophagus and pharynx the operation envisaged multiple drainage of cervix and mediastinum (42.3%) and suturing the wound in 12 cases (46.2%). In three patients (11.5%) we performed circumferencial esophagopharyngeal anastomosis. In cases of trauma to respiratory organs (26) the defect was sutured lengthwise (17, 65.4%), tracheocricothyroideus anastomosis (4, 15.4%) was

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 performed or prolonged tracheal tube placement with drainage was used (5, 19.2%). Results: Adequate abscess drainage, regeneration of organs, local treatment and appropriate antibacterial therapy enabled us to eliminate complications in all damaged organs with restoration of functions. No deaths occurred. Conclusions: Suturing of the defect along with anastomosis remains the major treatment in the cases of penetrating damages, extensive and circumferential ruptures of trachea and larynx. Surgical treatment of damages to esophagus and pharynx should be individualized and aimed at reconstruction of organs and elimination of consequences.

HL 157 Role of endoscopic surgery and intralesional steroid therapy for acute obstructive tracheobronchial Wegener’s Granulomatosis Reza Nouraei1, Rupert Obholzer1, Philip Ind2, Alan Salama3, David Howard1, Guri Sandhu1 1 Department of Otolaryngology, Charing Cross Hospital, London, UK 2 Department of Respiratory Medicine, Hammersmith Hospital, London, UK 3 Department of Renal Medicine, Hammersmith Hospital, London, UK Objective: Upper airway compromise due to tracheobronchial stenosis commonly occurs in patients with Wegener’s Granulomatosis (WG). There is at present no consensus on the optimal management of this life-threatening condition. We assessed the results of laryngo-tracheo-bronchoscopy, intralesional steroid therapy, laser surgery and dilatation in managing obstructive tracheobronchial WG. Methods: Records of eighteen previously-untreated stridulous patients with obstructive tracheobronchial WG, treated between 2004 and 2006 were retrospectively reviewed. Information about patient and lesion characteristics and treatment details were recorded. Treatment progress was illustrated using a timeline plot, and intervention-free intervals were calculated with actuarial analysis. Results: There were nine males and the average age at presentation was 40 ± 16 years (range 13–74). There were thirteen patients with tracheal, and ﬁve patients with tracheal and bronchial lesions. The average tracheal lesion height was 8 ± 3 mm, located 23 ± 9 mm below the glottis. There were 1, 10 and 7 Myer-Cotton grade I, II and III lesions respectively. Intervention-free interval following minimally-invasive treatment was 26 ± 2.8 months. No predictors of treatment durability were identiﬁed on Cox regression. Topical mitomycin application caused one major airway complication. Following endobronchial therapy the median intervention-free interval was 22 months (P > 0.8 vs. tracheal lesions). No patient required a tracheostomy or endoluminal stent. Conclusions: Intralesional steroid therapy and conservative endoluminal surgery is an effective strategy for treating airway compromise due to active tracheal and bronchial WG. It obviates the need for airway bypass or stenting. We recommend the combination of endotracheal dilatation, conservative laser surgery and steroid therapy as the standard of care for treating airway compromise due to obstructive tracheobronchial WG.

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HL 158 Sialolithiasis: diagnosis and treatment Gu¨nther Pabst Kantonsspital Luzern Retrospective analysis of 210 patients after interventional sialendoscopy treated between 2002 and 2006 and 400 patients after extracorporeal shock wave lithotripsy, witch were treated between 1996 and 2006 and the investigation of sialolithiasis of the salivary glands by ultrasound is demonstrated on the basis of ultrasound video. Results: Following extracorporeal shock wave lithotripsy 71% of the patients suffering from parotid lithiasis and 57% suffering from submandibular lithiasis were free of complaints. 210 patients underwent interventional sialendoscopy. Eighty-three percent were treated successfully and remained asymptomatic.Sonography have replaced sialography in the evaluation of patients with sialolithiasis. Discussion: In many cases the diagnosis of sialoitthiasis is easy due to obvious clinical features, but if a treatment is considered ultrasound of the salivary glands is very useful in the evaluation of patients with sialolithiasis. Besides traditional surgical procedures new conservative treatment modalities like extracorporeal shock wave lithotripsy or interventional sialendoscopy have changed the management of salivary gland stones.

Osas HL 159 Sleep disordered breathing events are robustly associated with autonomic activationsin children with OSA G. Pillar, T. Etzioni Sleep laboratory, Meyer Children’s Hospital, Rambam Medical Center and Technion - Israel Institute of Technology, Haifa, Israel Objective: Respiratory cessations in adults with obstructive sleep apnea (OSA) are associated with arousals from sleep. In children, however, this response may be blunted. The Watch_PAT100 device is a tool to detect sleep disordered breathing events predominantly by assessing the autonomic arousals at the termination of events. We have therefore sought to study children with OSA with the Watch_PAT100, to assess whether they experience autonomic activation at the termination of events. We hypothesized that they may not experience cortical arousals, but will demonstrate autonomic activation at the termination of SDB events. Methods: Seventeen children with OSA (11 m/6f) underwent simultaneous recording of in-lab polysomnography and Watch_PAT100 sleep study. PSG was blindly scored for apneas and hypopneas based on common practice for clinical sleep studies in children. WatchPAT100 was automatically scored for respiratory events based predominantly on autonomic activations.

S63 Results: Children’s average age (±SD) was 11.8 ± 3.2 years (range 5–17). Their total sleep time was 408 ± 40 min (range 333–469 min). The AHI based on PSG and Watch_PAT100 were 8.8 ± 7.1 and 7.6 ± 9.5, respectively (P = 0.7). The correlation between PSG AHI and Watch_PAT100 AHI was 8.8 (P < 0.001). The distribution compared to the line of identity is shown in the Figure. Conclusions: We conclude that utilizing autonomic activation index is an accurate tool in diagnosing sleep disordered breathing events in children. We believe that the previously reported blunted arousal response to respiratory stimuli in children with OSA is applicable for cortical arousals or arousals scored by criteria determined for adults, but not for autonomic responses.

HL 160 Cephalometric analysis in patients with obstructive sleep apnea syndrome Ewa Olszewska1, Janusz Rozycki2, Andrzej Sieskiewicz1, Eugeniusz Tarasow2, Marek Rogowski1 1 Department of Otolaryngology Medical University of Bialystok, Poland 2 Department of Radiology Medical University of Bialystok, Poland Objective: The aim of the study was to evaluate the usefulness of cephalometric radiograhs in OSAS patients with the comparison of craniofacial computed tomography as well as to demonstrate the relationship between the severity of sleep-disordered breathing and severity of cephalometric abnormalities. Methods: Twenty-eight randomly selected patients with snoring and varying degrees of sleep-disordered breathing were included in this study. A control group included 22 patients. These patients had no snoring or clinical evidence of sleep–disordered breathing. No patients had prior pharyngeal or maxillomandibular surgery. All patients were evaluated by otolaryngological examination and had polysomnography, cephalometric radiographs and craniofacial CT scans. In study group the evaluation between cephalometric analysis on radiographs and CT scans was made. Results: The cephalometric parameters revealed major differences between controls and patients with OSAS regarding the size and position of soft palate and uvula, volume and position of tongue, hyoid position, mandibulo-maxillary protrusion and size of the pharyngeal airway space. Patients were then classiﬁed to certain procedures according the measurements. Conclusions: Obstructive sleep apnea syndrome is associated with statistically signiﬁcant changes in cephalometric measurements. Lateral cephalometric analysis and craniofacial CT adds further information regarding the anatomical assessment of patients with OSAS. We found craniofacial CT scans easier, more accurate measurements especially applying to soft tissues and more useful for patient classiﬁcation to surgical procedures.

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HL 161 Long and shortterm results: of LAUP for snoring and sleep apnea syndrome Y.-V. Kamami, L. Pandraud, A. Bougara Saint-Cloud Hospital, 3 place Silly, 92, Saint-Cloud, France Dr Yves-Victor Kamami, 43 Boulevard Malesherbes, 75008 Paris, France Objective: The purpose of this study is to report long- and shortterm effects of Laser-Assisted UvulaPalatoplasty (LAUP). Methods: 3,071 patients (491 females, 2,580 males) with symptoms related to snoring or mild sleep apnea were treated in an ofﬁce environment, using a CO2 laser, between December 1988 and July 2006. All subjects completed surveys before and three months after treatment. 644 patients completed long-term surveys ranging from 6 months to 15 years from the date of their procedures. Results: Early evaluation on a Visual Analogic Scale at 3 months demonstrated an complete symptoms improvement on 73.5%, and a partial improvement on 23.5% of patients. Long-term beneﬁt was achieved in 65% of patients satisﬁed initially. The recurrence of snoring was mainly caused by reccurence of nasal obstruction and/or gain of weight. Eighty-two percent of patients would repeat the procedure or recommend it. The daily postoperative visual analogic score for post-operative pain was improved when an intra-muscular injection of a pain-killer was practiced at the end of the procedure. Conclusions: This study demonstrates that LAUP is an effective in-ofﬁce procedure in the treatment of snoring and mild sleep apnea syndrome. Favorable short- and long-term subjective data were reported.

HL 162 Standardization of drug-induced sleep endoscopy in obstructed sleep apnea syndrome and snoring patients Robert Pavelka ENT-Department, General Hospital, Corvinusring 3-5, A-2700 Wiener Neustadt, Austria Objective: Drug-induced sleep endoscopy (DISE) is used to identify the sites of obstructions/vibrations in OSAS and snoring patients in order to improve surgical outcome by a feasible daytime method. Criticism states on differences to natural sleep due to side effects of the drugs like muscle relaxation or central respiratory depression, interaction of the inserted endoscope, etc. Methods: We monitored the depth of sleep during Propofol or Midazolam induced sleep endoscopy using two systems: the Bispectral Index (BIS) from Aspect Medical, USA, analyzing the frontal EEG frequency and the temporal EMG and the Somnoscreen from Somnomedics, GE, recording full polysomnography (PSG) and cardiorespiratory (CR) parameters and events simultaneously to the inserted endoscopic video.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Results and conclusion: In about 400 video sleep endoscopies with and without sleep and CR monitoring we tested the feasibility of the systems. We saw an exact reproducibility in repeated preoperative endoscopies and found esp. the Somnoscreen to be a good tool to make sure that depth of sleep and CR events resemble those known from patients previous sleep lab study. For postoperative control sleep endoscopies it is essential to perform DISE under the same conditions as the preoperative investigation was. Therefore sleep and CR monitoring is mandatory for standardization of DISE.

HL 163 A prospective study comparing ApneaGraph with sleep nasendoscopy and polysomnography in patients with snoring and obstructive sleep apnea Hiba Al-Reefy, Arvind Singh, Richard Hewitt, Bhik Kotecha Royal National Throat Nose Ear Hospital London, UK Objective: The management of sleep apnoea and snoring remains controversial. Our institution provides an excellent level of care for the management and treatment of snoring and OSA and continues to develop this service. ApneaGraph is a new diagnostic method measuring pressure and airﬂow simultaneously at different levels in the pharynx identifying the segment of airway obstruction and providing baseline respiratory parameters. This study aims to evaluate ApneaGraph (AG) and correlate results with both Sleep Nasendoscopy (SNE) and Polysomnography (PSG). Methods: Comparative prospective study of 25 patients with Snoring/OSA. Patients had PSG and ApneaGraph study simultaneously in the Sleep Lab. Patients undergoing SNE had a ten minute ApneaGraph analysis. Results: PSG was used to validate the ApneaGraph system. There are no signiﬁcant differences (Independent t-test, P > 0.15) between AG compared to PSG based on the Apnoea-Hypopnea index, average oxygen saturations and total number of apnoeic/ hypopnoeic events. This suggests that the AG is a reliable tool in assessing OSA. Crude assessment based on an upper or lower level of obstruction shows a 60% concordance between AG and SNE ﬁndings. However, when analysing percentage contribution of site to overall obstruction, less than half the cases agree within 20%. Statistically, there is no correlation between the two groups (Spearman rho, P = 0.3). In the cases of discordance, AG places greater emphasis on a lower pharyngeal contribution. Uniquely, Apneagraph can be performed in drug-induced and natural sleep. Although the two states are entirely different, we will discuss the ﬁndings and limitations in interpretation. Potentially, AG may provide a cost-saving in the evaluation of snoring and OSA but it’s limitation will be discussed. Conclusion: This unique study analyses the ApneaGraph system in the diagnosis of Obstructive Sleep Apnea and Snoring. It demonstrates the beneﬁts of this new system and highlights certain limitations in localising the site and level of pharyngeal obstruction in patients with sleep disorders.

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HL 164 Mild obstructive sleep apnea. Is it worth treating?

HL 166 The annoyance of snoring

J. Seppa¨, J. O. Sahlman, M. Pukkila, H. Tuomilehto Department of Otorhinolaryngology, Kuopio University Hospital and University of Kuopio, Finland

Alfred Dreher, Martin Patscheider, Christine Klemens, Tobias Rader, Caroline Schultheiss, Richard de la Chaux Ludwig-Maximilians-University, Munich, Germany

Objective: To evaluate the evolution of mild obstructive sleep apnea (OSA) after different treatments. Methods: One hundred adult patients with mild OSA were examined at the Department of Otorhinolaryngology in Kuopio University Hospital between 1998 and 2004. In 2005, follow-up studies went through with the same symptom-questionnaire as earlier. Totally 50 of 100 patients also had overnight control polysonography. The patients were devided into three groups according to the treatment they had received after the ﬁrst visit (conventional, CPAP, surgery). The evolution of mild sleep apnea was then estimated by the chance of symptoms and AHI-ﬁndings in relation to different treatments. Results: CPAP and surgery were signiﬁcantly more effective in alleviating subjective daytime sleepiness, restless sleep, snoring and apneas compared to untreated patients. Conventionally treated patients had a statistically signiﬁcant increase in AHI (13.3, SD 18.3) during the follow-up. Half of these patients developed moderate or severe degree of OSA, and only 10% were cured (AHI < 5). In patients who were treated with CPAP the degree of OSA got worse in 64% of cases, and in 27% of patients the AHI turned to normal ( < 5). The degree of OSA in operated patients deteriorated only in 18% of patients, and in 27% AHI turned normal. Conclusions: Even mild OSA merits active measures which can signiﬁcantly improve overall quality of life.

Several surgical and nonsurgical procedures for the treatment of snoring have been developed. Their efﬁcacy is estimated based on the impression of the bedpartner or the measurement of the sound pressure. The impression of the bedpartner is inﬂuenced by a lot of factors which are independent of the snoring sound and the sound pressure doesn’t take in regard the effect of the noise on humans. Therefore a psychoacoustic evaluation of snoring, combining both aspects, was used for the ﬁrst time. Ten patients complaining of loud snoring had polysomnography with recording of their snoring. Typical sections of the snoring sound, lasting 30 s, were presented to three examiners for evaluation (0–100) of their annoyance. The annoyance of all snoring sequences was estimated at 46.9 ± 23.3, the most acceptable snoring sequence at 15 ± 9, the worst at 85 ± 5. The estimations of the examiners concerning a single snoring sequence varied by 8.6 ± 5.0. The psychoacoustic evaluation of snoring seems to be a practicable and promising tool for the measurement of snoring. This new method should make the comparison of different kinds of procedures for the treatment of snoring more reliable and relevant.

HL 165 Weight reduction and lifestyle intervention as a treatment of mild obstructive sleep apnea (OSA) Henri Tuomilehto1, Juha Seppa¨1, Johanna Sahlman1, Markku Partinen2, on behalf of Kuopio Sleep Apnea Group 1 Kuopio University Hospital, Department of Otorhinolaryngology, Kuopio, Finland 2 Skogby Sleep Clinic, Rinnekoti Research, Espoo Introduction: OSA is a highly prevalent disease associated with increased morbidity and mortality. Obesity is one of the most important risk factors for OSA. Objective: To evaluate, if supervised weight reduction and lifestyle intervention improve the ﬁndings of mild OSA in comparison to a conventional dietary counseling. Methods: Prospective, randomized, controlled clinical follow-up study. The study consists of 50 adult patients with mild to moderate obesity and in the polysomnography mild OSA. The patients in the ﬁrst group (N = 25) were given a single dietary counseling. The second group (N = 25) received a 3-months very low-calorie diet followed by regular weight reduction and lifestyle counseling. The ﬁrst control polysomnography and clinical ﬁndings were recorded three months from the randomization. We considered the treatment successful if AHI turned to normal. These results are part of a larger study. Results: In the active group two patients out of three had a normal AHI at the control visit, but in the conventional group only one patient out of four had a normal AHI, (P = 0.004). Conclusions: Weight reduction and lifestyle intervention results not only improved, but turned AHI normal in most patients with mild OSA. The study is in progress and the randomization has ended in September 2006.

HL 167 Esophagopharyngeal pressure measurement in sleep-disordered breathing R. de la Chaux, A. Dreher, C. Klemens, M. Patscheider, N. Feucht, K. Fuge, A. Berghaus ENT-Department, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany Objective: Esophagopharyngeal pressure measurements are helpful in the differentiation of obstructive respiratory events by measuring the esophageal pressure during polysomnography. In addition the localization of snoring and obstructive respiratory events is possible with multichannel pharyngeal pressure measurement. Advantages and limitations of this method will be explained by an experience period of 6 years. Methods: Between 2000 and 2006 esophagopharyngeal pressure measurements were done during nocturnal polysomnography in 100 patients with suspected obstructive sleep apnea syndrome. Only eight patients did not tolerate the pressure probe. A computer-based software allowed us to analyse the data manually and automatically for each separate channel. Results: Without disruption of the physiological sleep architecture an increase of the esophageal pressure was found with increasing depth of sleep. Esophageal pressure correlated well with the respiratory disturbance index. seventy-two patients showed a highfrequent snoring signal with localization in the velar region, multilevel snoring was shown in 63 patients. Analysis of the region of obstruction was sometimes difﬁcult, however a velar region of obstruction was found in 78 patients. Conclusions: The most important value of esophagopharyngeal pressure measurement consists in the preoperative selection of patients with velar snoring or velar obstruction. The method is limited by high ﬁnancial and personal requirements.

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HL 168 Information content of snoring sounds Thomas Ku¨hnel, Sophie Glas, Matthias Huber, Thomas Steffens ORL-Dept., University of Regensburg Objective: Snoring is perceived more annoying by spouses than by the originator. Spouses complain of severe disturbance of sleep which habitual snorers are not affected of. Why does snoring disturb the spouses´ but not the snorers´ sleep? This is matter of this study. We hypothesize that snoring sound transports information relevant for sleep besides its physical properties. Methods: Snoring sounds were recorded under standardized acoustic conditions within a routine polysomnography. Fifteen persons were presented snoring sounds of different sound levels during distinct sleep stages. Frequency of arousals caused by either snoring sound of alien origin or own origin was compared. Results: Snoring sounds of exactly the same physical properties such as loudness, frequency spectrum, acuity and ﬂuctuation strength are percepted unequal. Arousals were recorded more frequently with alien snoring sounds. Results are highly signiﬁcant. Conclusions: Snoring sounds comprise of more than physical properties. There is also the information content of the sound that characterises the sleep disturbing power. There is no alarming information in one´s own, habitual snoring sound whereas external, particularly apnoic snoring causes increased numbers of arousals.

HL 169 Laser surgery of a soft palate at snore and obstructive sleep apnea Alexei Gagauz P.O. Box 1416, MD 2043, Chisinau, Moldova Objective: Investigate the contact and submucosal laser inﬂuence on a soft palate at snore and obstructive sleep apnea. Methods: A retrospective analysis of patients (operated in 1997– 2005 years) in a postoperative period was performed. Two groups each of 272 patients (males and females, the age ranged from 28 to 66 years) underwent a full clinical examination, the settled diagnosis was ‘‘snore and obstructive sleep apnea’’. Surgery was performed with a surgical laser - wavelength 1.06 m km, the feed of energy through quartz-polymeric ﬁber (diameter of 0.2–0.4 mm, pineal shape of a ﬁber’s working part). Two kinds of laser intervention were applied: the ﬁrst group underwent a submucosal inﬂuence, the second—a laser resection of hyperplasia’s parts of the soft palate and palate’s tongue. Results: The quicker cicatrisation of epithelium was noted in the ﬁrst group of patients. The conﬁguration of the soft palate and palate’s tongue remained the same, but with the reduced size.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Discomfort in throat and algesis decreased and ﬁnally disappeared in the shortest terms. The cicatrisation in the second group passed more slowly and the conﬁguration of the soft palate had unnaturally changed. The discomfort and algesis remained longer. Results of snore and obstructive sleep apnea were identical in both groups. Conclusions: Despite of a similar ﬁnal result of snore and obstructive sleep apnea, the method of submucosal destruction of soft palate and palate’s tongue is more preferable. The sparing inﬂuence is more intensive and postoperative period shorter. The discomfort and algesis are less expressed.

HL 170 Prediction of nocturnal obstructive apneas by simulated snoring Michael Herzog1, Thomas Bremert1, Beatrice Herzog2, Werner Hosemann1, Holger Kaftan1 1 Department of Otorhinolaryngology, Head and Neck Surgery, Ernst-Moritz-Arndt University, Greifswald, Germany 2 Institute of Community Medicine, Section Epidemiology of Health Care and Community Health, Ernst-Moritz-Arndt University, Greifswald, Germany Objective: The clinical examination of the upper airway in patients with suspected obstructive sleep apnea syndrome (OSAS) is frequently performed before night time polysomnography. ‘‘Static’’ examination like dorsalization of the tongue base, Malampatti index and Mueller Maneuver are discussed to be of low predictive value. The newly developed ‘‘dynamic’’ examination of the upper airway during simulated snoring in wake patients is analysed in terms of their predictive value for suspected OSAS. Methods: 131 patients with a history of snoring were examined prior to night time polysomnography and the results were correlated to the obtained polysomnographic data. Results: Correlations were detected between an increased dorsalmovement of the tongue base as well as pharyngeal collapse at tongue base level and the AHI. The patient’s body position during simulated snoring did not inﬂuence the results. The ‘‘static’’ examinations like dorsalilzation of the tongue base, Malampatti index and Mueller Maneuver did not correlate with the AHI. Patients with a high degree pharyngeal collapse at tongue base level in combination with a dorsal-movement of the tongue base during simulated snoring revealed a probability of 75% to have an AHI more than 10 and 92% for an AHI more than 5. Conclusion: The ‘‘dynamic’’ examination of the upper airway under simulated snoring in wake patients is an easy to perform method to predict the probability of an OSAS prior to night time polysomnography.

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HL 171 Inﬂammatory biomarkers in mild obstructive sleep apnea

and changes in apnoea-hypopnoea index and Epworth score documented. Visual analogue scores of intensity and duration of discomfort were completed and the extrusion rate documented. Results: The visual analogue snoring score changed from a preoperative median of nine (range 5–9.7) to a postoperative median of six (range 3–9.5). Ladder plots of the change in snoring scores and AHI are demonstrated. Morbidity was minimal. Only one patient required simple analgesia for more than 2 days. Two of 80 implants extruded. Conclusions: The Pillar implant represents an effective advance with low morbidity in the reduction of palatal snoring in simple snorers

Johanna Sahlman1, Keijo Peuhkurinen2 and Henri Tuomilehto1 1 Department of Otorhinolaryngology, Kuopio University Hospital, Kuopio, Finland 2 Department of Cardiology, Kuopio University Hospital, Kuopio, Finland Objective: Atherosclerosis is inﬂammatory disease and obstructive sleep apnea (OSA) is known to elevate the level of some proinﬂammatory cytokines. We evaluated the plasma concentration (pg/ml) of pro-inﬂammatory biomarkers interleukin-6 (IL6), tumor necrosis factor alpha (TNFa), interleukin-1b (IL1b), high sensitivity C-reactive protein (hsCRP) and anti-atherogenic interleukin-10 (IL10) and interleukin-1 receptor antagonist (IL1RA) in untreated mild obstructive sleep apnea patients compared to control patients. Methods: Seventy-eight overweight patients (group A) with newly diagnosed mild OSA (oxygen desaturation index, ODI4 5–15) and 42 overweight snorers (ODI < 5) were enrolled in prospective controlled study. At baseline, cytokines were measured and compared between groups. Results: There were no signiﬁcant differences in BMI, sex, smoking, diabetes-, hyperlipidemia- or hypertension medications between groups. Adjustment for age was performed in statistical analysis because snorers were younger than OSA patients. TNFa (P = 0.002) and hsCRP (P = 0.036) had a signiﬁcantly higher mean concentration in the A-group (1.7, SD 0.9; 2.3, SD 1.7) than in the C-group (1.3, SD 0.5; 1.8, SD 1.8). IL1RA was higher (P = 0.000) in the A-group (528.5, SD 252.1) than the C-group (365.3, SD 230.2). IL1b: group A = 0.19 (SD 0.07), group C = 0.24 (SD 0.07); P = 0.000. IL6 levels didn’t differed from each other. The mean concentration of IL10 was 1.6 (SD 1.8) for A-group and 0.8 (SD 0.4) for C-group; P < 0.05. Conclusions: Both groups had elevated hsCRP levels, which associate with moderate cardiovascular risk. The pro-atherogenic hsCRP and TNFa were higher among mild OSA patients. Results of other cytokines are ambiguous.

HL 172 The pillar implant in simple snoring patients John de Carpentier, Ian Bruce, Zirca Rasul, and Karen Jepson Lancashire Teaching Hospitals NHS Trust, Royal Preston Hospital, UK Objective: To assess the effectiveness of pillar implants in the reduction of snoring in a UK cohort of patients. To assess the morbidity and complication rates of this technique. Methods: Forty patients were recruited from a snoring and sleep disturbance clinic. All had preoperative domiciliary sleep studies to exclude sleep apnoea. Data on age, sex, BMI, witnessed apnoeas and Epworth scores was collected. Each patient had three pillar implants inserted into the soft palate close to the junction of the soft and hard palate under local anaesthetic in an out patient setting. All were assessed at three months with repeat sleep studies. Snoring reduction was assessed on visual analogue scores

HL 173 A prospective randomised clinical trial: laser assisted Uvulopalatoplasty versus Celon Radiofrequency Procut Palatoplasty for snoring and obstructive sleep apnoea Bhik Kotecha, Hesham Khalil Royal National Throat Nose and Ear Hospital, Grays Inn Road, London, UK Objective: Snoring is a common problem affecting approximately 40% of the adult population. Laser-Assisted Uvulopalatoplasty (LAUP), in particularly (Kotecha Technique 2006), was designed to improve outcome and reduce postoperative complications and morbidity. Tatla et al. (2003) investigated the use of bipolar radiofrequency technology (Celon, AG) in treatment of soft palatal snorers which produced signiﬁcant improvement in snoring, and provides advantages including inherent safety, auto-stop energy application and reduced procedure time. In our study we are comparing the effect and morbidity of two techniques, Laser Assisted Uvulopalatoplasty versus our new technique of Celon Radiofrequency Procut Palatoplasty in randomly selected participates, assigned and agreed surgical soft palatal treatment mainly for snoring ± OSA. Methods: A prospective Randomised Clinical Study. Fifty patients fulﬁlling inclusion and exclusion criteria randomly assigned into two groups, the ﬁrst group underwent the Kotecha technique of (LAUP), and the second group underwent Celon Bioplar Interstitial, procut palatoplasty technique. Main outcome measures: Primary: Objective measures on repeated sleep study at 3 months; subjective measures on repeated validated questionnaires, again including visual analogue scoring of snoring, sleep quality and daytime somnolence, but also postoperative pain. Secondary: With each procedure- acceptability, compliance, morbidity, side effects and complications. Results: We observed with the use of both techniques a statistically signiﬁcant (P < 0.05) improvements were observed in snoring loudness, sleep quality and daytime somnolence in participating individuals. Both groups were comparable. Conclusion: Objective improvements in snoring intensity and apnoea-hypopnoea indices were also demonstrated. High patient acceptability of and compliance with RFITT were noted, as was minimal patient morbidity.

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HL 174 A prospective clinical study of simultaneous multi-segmental application of bipolar radiofrequency induced thermotherapy for snoring and obstructive sleep apnoea Hesham M. B. Khalil, Bhik Kotecha Royal National Throat Nose and Ear Hospital, Grays Inn Road, London, UK Objective: Habitual snoring can be a signiﬁcant social issue, affecting upto 40% of adults. Moreover, at times, it may be the only sign of obstructive sleep apnoea (OSA). The problem generally arises from dynamic collapse of one or more segments of the upper airway. Radiofrequency interstitial thermotherapy (RFITT) has recently been developed as a minimally invasive option for snoring and OSA. The study designed to investigate the efﬁcacy and effectiveness of the application of Celon bipolar RFITT to the soft palate and tongue base simultaneously in patients with snoring with or without OSA. Methods: Prospective non-randomised clinical study. Forty consenting patients were recruited, adhering to strict inclusion/ exclusion criteria. Patients completed validated questionnaires preoperatively including visual analogue scoring of snoring, sleep quality and daytime somnolence. Patients received two sessions of RFITT, via a Celon pro sleep generator, to both the soft palate and tongue base, under general anaesthesia. Each session was separated by 6–8 weeks. Main outcome measures: Primary: Objective measures on repeated sleep study at 3 months; subjective measures on repeated validated questionnaires, again including visual analogue scoring of snoring, sleep quality and daytime somnolence, but also postoperative pain. Secondary: Acceptability of and compliance with procedure; side effects and complications. Results: Statistically signiﬁcant (P < 0.05) improvements were observed in snoring loudness, sleep quality and daytime somnolence in participating individuals. Objective improvements in snoring intensity and apnoea-hypopnoea indices were also demonstrated. High patient acceptability of and compliance with RFITT were noted, as was minimal patient morbidity. Conclusion: Bipolar RFITT is both efﬁcacious and effective as either primary multi-segmental treatment or adjunctive treatment for snoring and OSA. Naturally, careful selection of patients is of utmost importance.

HL 175 Lateral hyoid expansion for treatment of obstructive sleep apnea E. Hamans1, B. Stuck2, A. Baisch2, A. Boudewyns1, A. Devolder1, J. Verbraecken1, M. Willemen1, P. Van de Heyning1 1 University Hospital Antwerpen, Belgium 2 University Hospital Mannheim, Germany Objective: Obstructive Sleep Apnea (OSA) can be caused by collaps of the lateral hypopharyngeal wall. The present study addresses the safety and efﬁcacy of a novel implantable device for lateral hyoid bone expansion in patients with OSA. Methods: Twenty-six patients with OSA (apnea-hypopnea-index (AHI) between 15 and 50) and intolerant to CPAP, were en-

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 rolled in a prospective non-randomized study. Standard surgical procedure for the hyoid myotomy was performed and a titanium expansion plate (Air-FrameTM System) was used to expand the hyoid bone, increasing the lateral dimensions of the hyoid bone. Patients were evaluated with polysomnography (PSG), Epworth Sleepiness Score (ESS), Funcional Outcomes of Sleep Questionnaire (FOSQ) and Spouse/bedpartner Survey (SBPS) pre-operative, and again 3, 6 and 12 months post-operative. Results: At 3–12 month evaluations, AHI remained unchanged (26 to 25.9, n = 25) as measured by PSG. At 6–12 months, ESS decreased from 10.7 to 7.3 (n = 22) and FOSQ increased from 16.1 to 18.1 (n = 22). During the same period, SBPS showed a 60% improvement with scores increasing from 25.7 to 41.2 (n = 17). Four patients were cured with an AHI below 5 at 12 months follow-up. There were four adverse events and one serious adverse event, all not device related. Conclusions: These results indicate that the Airframe System is well tolerated with improvements in ESS, FOSQ and SBPS. The AHI however remained unchanged. Further research is required to determine the role of this treatment in the (multilevel) surgical approach of OSA.

Salivary Glands HL 176 Parotid pathology and outcomes of parotidectomies in children Sam Majumdar, Neil Bateman, Peter Bull Shefﬁeld Children’s Hospital NHS Trust, Shefﬁeld, UK Objective: To determine the modes of presentation and spectrum of parotid salivary gland pathology in children and outcomes of surgery. Methods: This is a retrospective review of parotidectomies in children done over a 20 year period. The following data was recorded: age at surgery, diagnosis, facial nerve function and complications. Results: Fifty four patients, 32 girls and 24 boys, were identiﬁed. The mean age at surgery was 6.5 years and the age ranged from 1 month to 15 years. Overall, 40.7% of patients had inﬂammatory or infectious lesions, 14.8% had a congenital anomaly of the ﬁrst branchial cleft with a cervico-aural ﬁstula, 5.5% had benign salivary neoplasms and 14.8% patients had malignant tumours. Two patients presented with facial nerve palsy. Post operatively 52 patients had normal facial function. Two patients were left with a permanent marginal mandibular nerve weakness. The most common complication was development of a hypertrophied scar (12.9%). Other complications were haematoma (1), stitch abscess (1) and great auricular neuroma (1). Two cases were of self limiting Frey’s syndrome. Conclusion: Infectious or inﬂammatory conditions are the most common lesions in this large series of paediatric parotid gland surgery. Parotid neoplasms in children are less common than in adults; but there is a greater proportion of malignant disease. In this series, paediatric parotidectomy is associated with minimal morbidity with low risk of facial nerve damage. We conclude that, in experienced hands, parotidectomy in children is a very safe operation with an acceptable level of morbidity.

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HL 177 Nicotine: a potential risk factor for salivary gland tumors?

extension and thickness of this layer. The aim of this study is to evaluate the presence of the capsule, its histopathological characteristics, and its rilevance in the PA surgery, in terms of oncological radicality and complications. Thirty-three patients with PA were enrolled, 11 male (33%) and 22 female (67%), aging between 22 and 72 years (mean 47.6 years); all subjects were submitted between July 2004–2006 to the surgical procedure of nucleoresection. On the histomorphological examination it was always found capsular integrity of the PA; in the largest tumors it appeared in some points thin (10 lm). These results comﬁrm the hypotesis that the lesion is enclosed by a layer of ﬁbrous tissue of various thickness but evident also on pseudopodes. The capsule is a valid clivage plane in conservative techniques, like nucleoresection; this surgical procedure can guarantee the same possibility of excision and recurrence rate similar to superﬁcial or total parotidectomy, with lesser complicances and functional damage.

Christian Ginzkey, Katja Kampﬁnger, Gudrun Friehs, Rudolf Hagen, Norbert Kleinsasser Otolaryngology, Head & Neck Surgery, Julius-Maximilian-University, Josef-Schneider-Str. 11, 97080 Wu¨rzburg, Germany Nicotine is the major alkaloid in tobacco and causes addiction to smoking. Recently, genotoxic effects of nicotine in human ﬁbroblasts, mucosal cells and lymphocytes were demonstrated. Due to elevated nicotine levels in saliva the cells of salivary glands are exposed more intensely. Hence, the present study focuses on possible genotoxic effects of nicotine on human parotid gland cells in vitro. Separated single cells from parotid glands were exposed to nicotine in rising concentrations and periods. From the same probes, tissue cubes were cultured as miniorgans for one week followed by nicotine exposure as well. Possible genotoxic effects were determined with the single cell gel electrophoresis assay. A dose dependent enhanced DNA-migration induced by nicotine on separated salivary gland cells could be shown. In contrast, minor effects were seen after nicotine exposure of miniorgan cultures. The directly alkylating agent methyl-methane-sulfonate was used as positive control and showed high DNA-migrations in both variations. The present results indicate genotoxic effects of nicotine in human salivary glands. Thus, further studies concerning other steps in xenobiotic induced salivary gland tumorigenesis are warranted. The lower DNA-migration of cells harvested from miniorgans could be due to either a better protection of cells growing in a tissue formation or a superior DNA repair system. The effectiveness of DNA-repair in miniorgans is subject of ongoing studies.

HL 178 Pleomorphic adenoma of parotid gland: signiﬁcance of capsule G. Motta1, G. Colella1, G. Guerra2, R. Iovine1, A. Giudice1, D. Testa1 1 Department of Head and Neck Surgery - Second University of Naples 2 Department of Functional and Biomorphological Sciences University of Naples ‘‘Federico II’’ Pleomorphic adenoma (PA) is the most common tumor of the parotid gland (60–80%).This benign lesion is composed of epithelial and myoepithelial cells, arranged with various morphological patterns and subtypes: the classiﬁcation of this tumor is based on the amount and nature of the stroma (myxomatous, chondroid, mucochondroid, etc.). In literature there are many authors that suggest that PA is enclosed by a layer of ﬁbrous tissue—capsule—but there is disagreement about the form,

HL 179 Parotid function after selective deep lobe parotidectomy G. Colella1, A. Giudice1, D. Testa1 1 Department of Head and Neck Surgery - Second University of Naples Selective deep lobe parotidectomy is a demanding technique, but it preserves healthy glandular tissue, improves cosmetic results and minimises the incidence of Frey’s syndrome. We have evaluated postoperative function of the superﬁcial lobe of the parotid after selective resection of the deep lobe. Fourteen patients who each had a mass involving the deep lobe of the parotid were selected from 127 patients with tumours of the parotid gland who were seen and treated between January 2001 and March 2004. Of the 14, 12 matched the study criteria. The preoperative diagnosis was made using both computed tomography (CT) and ultrasound or ﬁne needle aspiration cytology, and the diagnosis was conﬁrmed by histological analysis. All cases were treated by the same surgeon. At 6 months follow-up all patients had a House– Brackmann test, iodine starch test, and scintigraphy of both parotid glands. Semi-quantitative analysis was done by the same radiologist. After scintigraphy the maximum uptake value and function of the gland were evaluated with the concentration index (CI) and the CI percentage ratio: CI = (Maximum uptake value · background)/ background · CI percentage ratio = CI resected side/CI normal side · 100%. The concentration function of the gland in the resected side of the study group had a mean (SD) CI index of 5.5 (3.6) and a CI percentage ratio of 84%. Selective deep lobe parotidectomy has the following advantages: it minimises the impact of treatment on the facial contour, it does not increase postoperative morbidity and it preserves the function of the gland.

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HL 180 Parotidectomy for benign parotid disease: outcome and risk analysis Orlando Guntinas-Lichius1, C. Wittekindt1, J. Peter Klussmann2 1 ENT-Department, Friedrich-Schiller-University Jena, Germany 2 ENT-Department, University of Cologne, Germany Objective: Analyze outcome after standardized parotidectomy for benign parotid tumours and chronic parotitis. Methods: A retrospective unicentric study in a tertiary university centre of 963 lateral and total parotidectomies treated from 1986 to 2004. Results: Eighty-ﬁve percent of the cases were primary operations (85%) and 15% revision operations. A lateral parotidectomy was necessary in 56% total parotidectomy in 34%, and modiﬁed procedures in 10%. The incidence of transient facial nerve dysfunction, permanent weakness, and relevant Frey’s syndrome was 25, 6, 5%, respectively. Signiﬁcantly more complications were seen after total parotidectomy and in revision cases. Signiﬁcant univariate and multivariate risk factors for a transient facial palsy were age >70 years, operation time >260 min, and a specimen volume >70 cm3. Prior surgery was a signiﬁcant risk factor for development of a permanent palsy. A signiﬁcant risk factor for the development of Frey’s syndrome could not be estimated. For patients treated for recurrent pleomorphic adenoma, the risk of clinically evident re-recurrence after 1 year, 5, 15 years were 16, 42, and 75%, respectively. Female sex, young age at initial treatment, and enucleation instead of parotidectomy for treatment of the ﬁrst recurrence were signiﬁcant risk factors for re-recurrence. Conclusions: Standardized lateral and total parotidectomy for treatment of benign parotid disease is safe, and demonstrates a low perioperative and long-term morbidity. Surgery of recurrent pleomorphic adenoma shows high facial nerve morbidity and a high chance of re-recurrence. Extended parotidectomy seems to be the best approach for the re-operation to reduce the risk of re-recurrence.

HL 181 An analysis of complications following surgical treatment of benign parotid disease S. A. R. Nouraei1, Y. Ismail2, M. S. Ferguson1, N. R. McLean3, R. H. Milner2, P. J. Thomson4, A. R. Welch5 1 Department of Otolaryngology, Charing Cross Hospital, London, UK 2 Department of Plastic Surgery, Royal Victoria Inﬁrmary, Newcastle upon Tyne, UK 3 Institute of Craniofacial Studies, Adelaide, Australia 4 Department of Maxillofacial Surgery, Newcastle General Hospital, Newcastle upon Tyne, UK 5 Department of Otolaryngology, Freeman Hospital, Newcastle upon Tyne, UK Objective: To study the incidence of, and risk factors for developing complications following parotidectomy for benign disease, to improve preoperative patient counselling and surgical management. Methods: An 11-year retrospective review of 162 parotidectomies for benign disease, collecting and analyzing data about presentation, investigations, surgical treatment, postoperative facial nerve function, Frey’s syndrome, and other surgical complications. Results: Mean age at presentation was 58 years. The commonest pathology was benign pleomorphic adenoma (43%), followed by Warthin’s tumor (30%) and chronic sialadenitis (22%). Sialadenitis was a signiﬁcant risk factor for facial nerve palsy, and increased the incidence of salivary ﬁstulae. Parotid duct

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 ligation increased the risk of nerve palsy in the distribution of zygomatic and buccal branches. Operations for Warthin’s tumor were associated with an elevated risk of dysfunction of the cervical branch of the nerve. Half of patients had intraoperative facial nerve stimulation and this did not inﬂuence the likelihood of facial paresis. The recovery of facial nerve function showed a biphasic distribution, with 90% of patients having normal function within 12 months, followed by a slower recovery rate for up to 2 years. Conclusions: The incidence of postoperative complications was inﬂuenced by the pathology, with inﬂammatory lesions signiﬁcantly increasing the risk of facial nerve dysfunction and other complications, but also by variations in surgical practice such as parotid duct ligation. Overall, the incidence of permanent facial paralysis was under 2%, but a temporary nerve palsy was common at 40%, with most patients regaining normal function within one year of the operation.

HL 182 Ultrasound-guided Botulinum toxin type-A (Botox-A) injections for treatment of sialorrhoea in adults: a New Zealand study Subhaschandra Shetty1, Patrick Dawes2, Dean Ruske3, Mohannad Al-qudah4, Brett Lyons5 1 Otolaryngology-Head and Neck Surgeon, Whangarei Base Hospital, Whangarei, New Zealand 2 Senior Clinical Lecturer and Consultant Otolaryngology-Head and Neck Surgeon, Dunedin Public Hospital, Dunedin, New Zealand 3 Consultant Otolaryngology-Head and Neck Surgeon, Dunedin Public Hospital, Dunedin, New Zealand 4 Clinical Fellow in Otolaryngology-Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Dunedin Public Hospital, Dunedin, New Zealand 5 Clinical Leader and Head of the Department of MR Imaging, Southland Hospital, New Zealand Aim: To report our initial experience using ultrasound-guided Botox-A injection to the salivary glands to control sialorrhoea. Methods: Eight adult patients with signiﬁcant sialorrhoea were referred from an inpatient rehabilitation unit, GP referral, and internal medicine department. All subjects underwent bilateral submandibular gland injections and, in addition, one patient (the ﬁrst) also had intraparotid injections. Injections were performed with ultrasound guidance at Dunedin Hospital, New Zealand. Six patients received a total of 30 Units and two patients received 60 Units in the submandibular glands without any complications. Outcome was assessed using a drooling scale and VAS self report of sialorrhoea. Results: Of the eight patients treated, six reported a marked reduction in salivation following treatment, and one patient improved partially. One patient did not ﬁnd the Botox injection helpful in controlling sialorrhoea and was offered escalation of the Botox dose with a subsequent partial response. No serious adverse events occurred, and no procedure-related complications were noted. Conclusions: Our initial experience suggests that injection of Botox-A injected at a relatively low dose to the submandibular glands can be used to achieve desired results for the treatment of sialorrhoea. This is an easily performed procedure with low morbidity and can be recommended as a ﬁrst-line intervention in the treatment of adult sialorrhoea.

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POSTERS HP 1 Customized, defect speciﬁc scaffolds for Tissue Engineering in the means of reconstructive surgery Dr. Staudenmaier Rainer, Blunk Thorsten, Eyrich Daniela, Dr. Maier Gerhard, Wiese Hinrich, Wenzel Magdalene University Regensburg, Pharma Technology Tissue Engineering (TE) of cartilage for reconstructive surgery seems a promising option to gain tissue for 3D structures with a minimal donor site morbidity. A speciﬁc defect needs a customized implant because each tissue requires a speciﬁc scaffold with precisely deﬁned properties which depend on physiological environment. For the creation of a custom-made implant the defect is detected via clinical CT data. Rapid prototyping technologies offer the possibility to fabricate scaffolds accuratley according to these data. Thereto the CT data have to be processed into CAD data and they are turned, e.g. into STL data ﬁles which can be feed into a Rapid Prototyping machine. RP technologies allow to fabricate scaffolds with any geometric complexity, even the inner architecture of the object can be varied in a deﬁned manner and at a deﬁned spot. Most TE srategies rely on the application of resorbable 3D scaffolds to guide the growing tissue. Since there had been no ideal biomaterial for Rapid Prototyping in Tissue Engineering we developed a totally new biomaterial which enables us to create an individual scaffold for Tissue Engineering of cartilage. This two-component material, based on polycaprolacton, builts up an interconnective foam, with a mechanical stability comparable to native cartilage. It shows homogenous 3D-structure, good cell adhaesion and biocompatibility. We evaluated ﬁrst promising preliminary results for Tissue Engineering of cartilage. The combination of Tissue Engineering and Rapid Prototyping presents the basis for the realization of customized implants. Keywords: Rapid prototyping, Tissue engineering, Scaffold, Polyurethane, Polycaprolacton

HP 2 Inhibition of telomerase activity in cancer cells using short hairpin RNA expression vectors Shi-Ming Chen, Ze-Zhang Tao, Hong-Gang Duan, Jie Cheng, Bo-Kui Xiao Department of Otolaryngology-Head and Neck Surgery, Renmin Hospital of Wuhan University, Wuhan 430060 China Objective: Telomerase activity is mainly regulated by the human telomerase reverse transcriptase (hTERT) gene. Our objective was to investigate the effect of short hairpin RNA (shRNA) directed against hTERT mRNA on telomerase activity in laryngeal cancer cells (Hep-2), nasopharyngeal carcinoma cells (NEC) and human bone marrow mesenchyme stem cells (hMSCs). Design Short hairpin RNA expression vectors targeting the messenger RNA of

S71 hTERT were constructed. Cells were treated with shRNA expression vectors directed against hTERT mRNA and control vectors that included mismatched shRNA. Results: We found that treatment of special shRNA expression vectors induced signiﬁcantly decrease in hTERT expression, telomerase activity, and cell viability in Hep-2 and NEC cells. In contrast, the shRNA control showed none of these effects. And none of these effects appeared in hMSCs cells. Conclusions: Our results suggest that shRNA against hTERT mRNA inhibits telomerase activity and cell viability through suppression of the hTERT expression in cancer cells. And this treatment has no side effect on healthy cells lack of telomerase activity. RNA interfering technology may be a promising strategy for the treatment of cancers. Keywords: Telomerase, Human telomerase reverse transcriptase, Short hairpin RNA, Cancer, Stem cells

HP 3 Overexpression of human 27 kDa heat shock protein in laryngeal cancer cells confers chemoresistance associated with cell growth delay Dong-Il Sun, Kwang-Jae Cho, Young-Hoon Joo, Jeong-Hae Cho, Min-Sik Kim, Jeong-Hwa Lee1 Department of Otolaryngology-Head and Neck Surgery, The Catholic University of Korea, College of Medicine, Seoul 137-701, Korea Purpose: HSP70 and HSP27 have been implicated in tumorigenesis and chemoresistance, probably via the prevention of apoptosis. HSP27 levels are frequently increased in large populations of tumors of the head and neck, but the mechanism of its chemoresistance is not yet fully understood. In the present study, the role of HSP27 in the resistance to cytotoxic stress was studied in Hep-2 human laryngeal cancer cells. Method: We established a Hep-2 cell line overexpressing HSP27 and examined whether the expression of HSP27 provides resistance to heat shock and several cytotoxic agents using a MTT colorimetic assay. Cell cycle progression was assessed by ﬂow cytometry and ﬂuorescence staining was performed for F-actin ﬁlaments. Results: HSP27 overexpression induced cellular resistance to heat shock at 45C for 1 h as well as against several cytotoxic agents. However, no difference in sensitivity to irradiation or serum starvation was found. Moreover, HSP27 overexpressing Hep-2 cells showed a delayed cell growth, compared to control cells. The synchronized Hep-2 cells were resistant to cisplatin and H2O2, but not to irradiation or serum starvation, correlating the protection effect shown in HSP27 overexpressing cells. Conclusions: These results suggest that the overexpression of HSP27 in Hep-2 cells confers chemoresistance which is associated with the delay in cell growth.

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HP 4 The prognostic impact of bcl-2 expression on advanced nasopharyngeal carcinomas Mu-Kuan Chen1,2, Jui-Chung Lai1 1 Department of Otorhinolaryngology, Head and Neck Surgery, Changhua Christian Hospital, Changhua, Taiwan 2 Department of Respiratory care, Chang Jung Christian University, Tainan, Taiwan Objective: Nasopharyngeal carcinoma (NPC) is generally sensitive to radiotherapy. However, the prognosis is still poor in advanced cases. The purpose of this study is to evaluate the prognostic impact of bcl-2 expression on patients with advanced NPC. Methods: One hundred and ﬁve advanced NPC treated with high dose radiotherapy with or without chemotherapy were included in this study. The relationship between the bcl-2 expression, TNM stage, and the disease-speciﬁc survival was analyzed. Results: Forty-eight patients were stage III and 16 (33.3%) of them were bcl-2 positive. The disease free survival was similar early after treatment but diverged after 2 years, with the difference favoring the negative bcl-2 expression (P = 0.06). Fiftyseven patients were stage IV and 24 (42.1%) of them were bcl-2 positive with poorer prognosis. The disease free survival of stage IV NPC with negative bcl-2 expression was paradoxically better than that of stage III NPC with positive bcl-2 expression. In the advanced NPC, the disease-free survival of stage III patients was better than that of stage IV patients but the difference was not signiﬁcant (P = 0.06); in contrast, patients with bcl-2 positive tumors had a worse disease-free cumulative 5-year survival (29.9%), and the difference was statistically signiﬁcant (P = 0.02, adjusted for chemotherapy). Conclusions: In advanced staged (III and VI) NPC, bcl-2 expression represented an important prognostic factor of treatment outcome. The 5-year disease-free survival rate of patients with positive bcl-2 expression was only 29.9%. Patients with positive bcl-2 expression should be treated more aggressively.

HP 5 Gene-expression study of putative oncogenes harbouring chromosomal region 3q26-28 in HNSCC Kastner J1,2, Betka J1, Brieger J2, Zima T3, Mann WJ2 1 Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University, Prague, Czech Republic 2 Tumor Biology Laboratory, Department of Otorhinolaryngology and Head and Neck Surgery, Mainz Medical School, Guttenberg University, Mainz, Germany 3 Institute of Clinical Biochemistry, 1st Faculty of Medicine, Charles University, Prague, Czech Republic In our gene expression study we continued our previous molecular studies on head and neck squamous cell carcinoma (HNSCC) which had shown the evidence of ﬁne molecular aberrations of

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 chromosomal region 3q26-3q28 in histologically normal mucosa adjacent to tumor samples, thus conﬁrming the presence of molecular dysplasia and its possible role in early cancerogenesis. Gain of genetic material is frequent in tumorsurrounding mucosa and indicates the overexpression of oncogenes. To evaluate the role of putative oncogenes of early cancerogenesis of HNSCC we applied real-time PCR on a study group of 12 patients with HNSCC. Samples of tumor, nonmalignant mucosa 1 and 2 cm away from the tumor margins and mucosa samples excided more than 10 cm from tumor margins as a reference tissue were proceeded in a realtime PCR.. Five microassays were used, including the following genes: PIK3CA, TP73L(TP63), WIG1, ECT2 and SKIL. The overexpression in tumor samples was shown in all genes investigated, whereas the signiﬁcantly higher expression in tumor adjacent histologically normal tissue samples compared to normal mucosa was evident only in TP73L, thus indicating its possible role in early cancerogenesis in HNSCC. The value for the diagnosis and prognosis will have to be proven in follow-up studies.

HP 6 Expression of metalloproteinases MMP-2 and MMP-9 in salivary gland tumors Nicholas S. Mastronikolis1, Theodoros Papadas1, Panagiota Ravazoula2, Maria Gkermpesi1, Dimitrios Chorianopoulos1, Panos D. Goumas1 1 Department of Otorhinolaryngology, University Hospital of Patras, Patras, Greece 2 Department of Pathology, University Hospital of Patras, Patras, Greece Objective: Matrix metalloproteinase (MMPs) are involved in extracellular matrix turnover. MMPs belong to a family of zincdependent endopeptidases and are classiﬁed according to their substrate speciﬁcity. Although MMPs are among the potential key mediators of cancer invasion, their involvement premalignant lesions is not clariﬁed. The aim of our study were to evaluate the expression of gelatinase A (MMP-2) and gelatinase B (MMP-9) in benign and malignant salivary gland tumors. Methods: We examined immunohistochemically formalin-ﬁxed, parafﬁn-embedded tumor samples from 70 patients with ploemorphic adenoma (48/70), Warthin tumors (17/70), and mucoepidermoid carcinomas (5/70) for MMP-2 and MMP-9. Results: Cytoplasmic MMP-2 staining was detected in epithelial cells of 36 out of 48 pleomorphic adenomas, all Warthin tumors, as well as in ﬁbroblasts and endothelial cells in the tumors. MMP9 cytoplasmic staining was detected in myooepithelial cells of 32 out of 48 pleomorphic adenomas, in epithelial cells of 15 out of 17 Warthin tumors and in inﬂammatory cells of stroma. Nuclear immunostaining for MMP-9 was also detected in epithelial cells of some pleomorphic adenomas. In mucoepidermoid carcinomas MMP-2 and MMP-9 were alsoimmunoexpressed in squamous malignant component. Conclusions: MMP-2 and MMP-9 expression is an early event in salivary gland tumorigenesis suggesting roles of MMPs in tumor initiation in addition to invasion.

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HP 7 Oxidative DNA damage in human cells and the protective potential of vitamin C and zinc

cytotoxicity requires Toll like receptor 7 (TLR7). Increased expression of NK cell TLR7 was shown in response to ss-isRNA. These results suggest ss-isRNA as a potential immunostimularory tool of human NK cells against HNSCC.

P. Baumeister, T. Hu¨bner, C. Matthias, U. Harre´us Department of Otolaryngology/Head and Neck SurgeryLudwigMaximilians-University Munich, Germany Objective: Oxidative DNA damage plays an important role in upper aerodigestive tract carcinogenesis. Reactive oxygen species deriving from cell metabolism and environmental substances cause DNA strands breaks and gene modiﬁcation. Whereas epidemiologic studies suggest, that diets rich in fruits and vegetables lower the risk for head and neck cancer, there is a lack of supporting experimental data. This study provides the evaluation of the DNA protective potential of vitamin C and zinc against oxidative DNA damage. Methods: Miniorgan cultures (MOCs) were cultivated from mucosa specimens of human nasal turbinates. The MOCs were incubated on three consecutive days for 30 min with vitamin C (10, 100 lM) and zinc chloride (10, 100 lM) respectively. On day 3 oxidative DNA damage was introduced to the MOCs by H2O2 (200 lM, 30 min). DNA strand breaks were detected using the formamidopyrimidine glycosylase comet assay, a highly sensitive method for the evaluation of oxidative DNA damage. Results: Pretreatment with vitamin C (10 lM, 100 lM) reduced the H2O2 induced DNA damage by 56 and 60%, respectively. Oxidative DNA damage was diminished by 57 and 60%, when preincubated with zinc chloride (10 lM, 100 lM). Conclusion:Generally a vitamin and trace element rich diet is useful since upper aerodigestive tract cells are constantly affected by oxidative stress. This can not only lead to carcinogenesis but also supports upper aerodigestive tract infections. Based on our results, dietary supplementation with vitamin C and zinc should be recommended for head and neck cancer patients.

HP 8 Up-regulation of NK cell function against head and neck cancer in response to ss-isRNA requires TLR7 Ralph Pries, Sandra Wulff, Rebecca Kesselring, and Barbara Wollenberg Department of Otorhinolaryngology, University of SchleswigHolstein Campus Lu¨beck, Ratzeburger Allee 160, 23538 Lu¨beck, Germany Natural killer (NK) cells play a crucial role in the innate immunity as effectors against tumor cells and pathogen-infected cells. NK mediated host defence against tumor cells is strongly impaired in patients with head and neck squamous cell carcinoma (HNSCC). Tumor secretion of various immune suppressive mediators contributes to massively affected immune functions. Here we demonstrate that NK cell cytotoxicity against tumor cells of HNSCC can be efﬁciently stimulated by single stranded immunostimulatory RNA (ss-isRNA). Stimulation with ss-isRNA results in an increased production of interferon-c (IFN-c) and effector proteins perforin and granzyme B. Our investigations reveal that supernatants of permanent HNSCC cell lines negatively affect the ss-isRNA triggered stimulation of cytolytic NK cell functions. Stimulation of

HP 9 Induction of c-Myc dependent cell proliferation through TLR3 in head and neck cancer Lisa Hogrefe, Ralph Pries, and Barbara Wollenberg Department of Otorhinolaryngology, University of SchleswigHolstein Campus Lu¨beck, Ratzeburger Allee 160, 23538 Lu¨beck, Germany Protein expression of human Toll-like receptors (TLR) 1–10 was measured in cell lines and solid tumors of head and neck squamous cell carcinoma (HNSCC). All HNSCC cell lines and 80% of solid tumors were found to express TLR3 as a predominantly intracellular protein, while no other TLR proteins were expressed. TLR3 has previously been shown to contribute to the activation of NF-jB, a transcription factor which promotes several kinds of human cancers. Signiﬁcantly, NF-kB expression was strongest in protein extracts from carcinoma tissue in which TLR3 was overexpressed. Inhibition of TLR3 expression in permanent HNSCC cell lines resulted in decreased expression of the oncoprotein cMyc resulting in decreased cell proliferation. Correspondingly, overexpression of human TLR3 in mouse ﬁbroblasts resulted in an upregulation of c-Myc and increased sensitivity for PolyI:C induced cell proliferation. Our data suggest that TLR3 contributes to the malignant phenotype leading to invasive carcinoma in HNSCC.

HP 10 Functional alteration of myeloid dendritic cells through head and neck cancer Henning Frenzel, Ralph Pries, Barbara Wollenberg Department of Otorhinolaryngology, University of SchleswigHolstein Campus Lu¨beck, Ratzeburger Allee 160, 23538 Lu¨beck, Germany Background: In head and neck squamous cell carcinoma (HNSCC), the secretion of various immunosuppressive mediators contributes to large-scale effects on the immune functions. The inﬂuence of HNSCC on various cellular functions of human myeloid dendritic cells (MDC) was analyzed in this work. Materials and methods: MDCs were isolated from peripheral blood by ‘magnetic bead separation’. Cellular functions were analyzed using ﬂow cytometry, migration- and ELISPOT assays as well as cytokine detection assays. Results: HNSCC massively affects MDCs to induce effective T-cell responses. Analysis of MDC migration and cytokine secretion revealed that HNSCC triggers the production of tumorpromoting and immunosuppressive cytokines IL-1 and IL-10 and results in an increased MDC migration activity. CpG-ODN is able to act contradictory to HNSCC. Conclusion: HNSCC is able to modulate various functions of human MDCs. CpG-ODN is suggested as a potential immunostimulatory agent of human MDC.

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HP 11 Oxidative stress and tumor grade in HNSCC R. Salzman1, R. Kostrˇ ica1, L. Pa´cal2, K. Kanˇkova´2, J. Tomandl3, Z. Hora´kova´1 1 Clinic of Otorhinolaryngology and Head and Neck Surgery of St. Anne’s University Hospital in Brno 2 Department of Pathological Physiology, Masaryk University, Brno 3 Biochemical Department of Medical School of Masaryk University, Brno Oxidant-antioxidant status is supposed to play an important role in cancer development. The aim of the study was to investigate a relationship among activities and levels of glutathione peroxidase (GPx), malondialdehyde (MDA); Pro197Leu polymorphism in the gene encoding GPx1 and the stage and grade of the head and neck squamous cell carcinoma (HNSCC). Prospective cohort study comprised 88 patients after surgery for HNSCC. Genotypes were detected by PCR-based methodology. Activity of GPx in erythrocytes (GPx-ery) and alveolar macrophages (GPx-AM) and TNFa were determined by ELISA, and MDA concentration by high performance liquid chromatography. Non-parametric Mann–Whitney, Kruskal-Wallis ANOVA, Spearman correlation tests and v2test were used for comparison of parameters. Our study revealed higher activity of GPx-ery in T1-2 patients compared to T3-4 (P = 0.03, Mann-Whitney). Tumor grade negatively correlated with plasmatic GPx level (P = 0.02), MDA (P = 0.05) and positively correlated with GPx-AM (P = 0.001), GPx-ery (0.12, Spearman). The frequencies of GPx alleles were 62.1 and 37.9% (Pro/Pro 45.5%, Pro/Leu 33.3%, Leu/Leu 21.2%). Genotype frequencies were in agreement with HW equilibrium (P > 0.05, v2 test). Genotype and allele frequencies of the Pro197Leu did not differ between groups deﬁned according to the stage of primary disease (TNM). Carriers of Pro/Pro genotype manifested elevated plasmatic level of GPx (P = 0.03) and decreased activity of GPxAM (0.04, Kruskal-Wallis). In conclusion, our results suggest that GPx plays an important role in cancer development and shows correlation with oncologic parameters of HNSCC. The project is supported by grants NR/7996-3 and NR/9200-3 from The Internal Grant Agency of The Ministry of Health of Czech Republic.

HP 12 The comparison of the presence of Epstein–Barr virus derived latent membrane Protein-1 gene In cervical metastatic lymph nodes of patients with head and neck carcinoma Bijan Khademi*, Jalal Mahmoudi*, Ahmad Monabati**, Mohammad J. Ashraf** *From the Department of Otolaryngology, Head and Neck surgery, Khalili Hospital ** Department of Pathology, Shiraz University of Medical Sciences, Shiraz -Iran Background: cervical lymphadenopathy is occasionally of unknown origin and Nasopharyngeal carcinoma (NPC) closely associated with Epstein-Barr Virus which is frequently related with malignant cell transformation through the action of the oncoprotein latent membrane protein -1(LMP -1). Objective: In this retrospective study the presence of EBV-derived LMP-1 gene in nasopharynx and metastatic nodes of nasopharyngeal, oral cavity, laryngeal and skin cancers & non malignant tonsil of patients were compared.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Methods: Eighty-four parafﬁn-embedded tissues of various head and neck specimens including nasopharynx,oral cavity, larynx and skin were examined for the presence of LMP-1 gene, using polymerase chain reaction. Results: Ten of twelve nasopharyngeal biopsies and 8 of 10 specimens from metastatic lymph nodes of the same NPC were positive for LMP-1 gene. The LMP-1 gene was detected in metastatic lymph nodes of NPC with a sensitivity of 80%,speciﬁcity of 100%,positive predictive value of 100% and negative predictive value of 91%. On the contrary after application of PCR,the LMP1 gene was not detected in any samples of other head and neck carcinomas,their metastatic nodes and tonsillar specimens. There was a signiﬁcant association between the presence of LMP-1 gene and tumor location in nasopharynx (P < 0.0001). Conclusion: The study demonstrated that the presence ofLMP-1 gene detected by PCR in metastatic tumor cells is only signiﬁcantly associated with tumor location in nasopharynx and EBV has no essential role in the tumorigenesis of carcinomas arising from other head and neck sites. The polymerase chain reaction method is a potential tool for localizing primary site of a cervical metastatic cacinoma.

HP 13 The correlation of cytokeratin antigens expression in lymph nodes with the morphological features of the tumor front in laryngeal carcionoma—the prognostic signiﬁcance of the Anneroth, Batsakis and Lunas’ classiﬁcation in the presence of micrometastases Katarzyna Starska1, Marek ukomski1, Iwona Lewy-Trenda2 1 Medical University Lodz, Department of Otolaryngology and Laryngeal Oncology, Poland 2 Medical University Lodz, Department of Patomorphology, Poland Introduction: Lymph nodes estimated as pN0 in conventional morphological studies could have focuses of carcinoma cells with a diameter of £2 mm referred to as micrometastases (pN+) which could be cause of nodal recurrence and poorer survival. New clinico-morphological features are still being assessed in order to ﬁnd prognostic factors in laryngeal carcinoma which allow to predict the presence of micrometastases as well. Materials and methods: To presented the direct correlation between the morphological features of tumor acc. to the classiﬁcation of Anneroth, Batsakis and Luna and the probability of micrometastases we have analyzed 22 patients operated for squamous cell carcinoma of the larynx at the ENT Department of the Medical University of Lodz between 1998 and 1999. The total score of classiﬁcation and particular features were analyzed with the presence of micrometastases as assessed by immunohistochemical methods with a panel of cytokeratin antigens (CK 4,6,8,10). Results: Our study showed that the total morphologic score is very useful in the prediction of micrometastases in patients with laryngeal squamous cell carcinoma of the larynx. The statistical analysis has revealed a signiﬁcant correlation between the total score, the mode of invasion and the depth of invasion. Conclusions: The results of our study suggest that it is necessary to extend traditional patomorphologic evaluation by a number of features from the classiﬁcation of Anneroth, Batsakis and Luna which could aid the diagnosis of micrometastases and thus might inﬂuence therapeutic decisions and eventually lead to more appropriate and individualized therapy. Keywords: Laryngeal carcinoma, Anneroth, Batsakis and Lunas’ classiﬁcation, cytokeratin ﬁlaments, micrometastases

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HP 14 Production of cytokines by peripheral blood lymphocytes T under inﬂuence in vitro of squamous cell carcinoma of the larynx Katarzyna Starska1, Marek ukomski1, Henryk Tcho´rzewski2, Ewa Gowacka2 1 Medical University Lodz, Department of Otolaryngology and Laryngeal Oncology, Poland 2 Insitute of Mother’s Health Lodz, Department of Immunology, Poland Introduction: The most important mechanism of host humoral immunity in antitumor response is cytokines activity produced by T lymphocytes. It is well known that peripheral blood lymphocytes from patients with advanced-stage cancer have a poor immune. The aim of this study was estimation of IL-6, IL-8, IL-10 and TNF-a serum concentration in patients with squamous cell laryngeal carcinoma and analysis of indirected inﬂuence of neoplasm cells to the function of T lymphocytes and modiﬁcation of cytokines proﬁle. Materials and methods: For analysis of cytokine secretion the cultures of isolated peripheral blood lymphocytes, isolated centrum and margin neoplasm cells and noncancerous cells were established. Production of cytokines in supernatants was detected by Elisa. In study the serum concentrations was correlated with clinicopathological features of primary tumor. Results: Authors reported that in vitro laryngeal squamous carcinoma cells modiﬁed T lymphocytes activity and production of cytokines. The presence of carcinoma cells in lymphocyte culture may increase concentration of TNF-a especially with margin cells and decrease IL-6 and IL-8 commonly with centrum cells. The serum concentrations of cytokines IL-6, IL-8 were found to be weakly correlated with pathological features of primary tumor. Conclusions: We conclude that cytokines important in proinﬂammatory and proangiogenic responses are detected in tissue specimens and serum from patients with advanced-stage laryngeal cancer and may be useful as biomarkers for therapy.

HP 15 PGE1 makes no complications in post-radiation laryngeal surgery Kiyoto Shiga, Masaru Tateda, Kazuto Matsuura, Shigeru Saijo, Toshimitsu Kobayashi Department of Otolaryngology-Head and Neck Surgery, Tohoku University Hospital, Department of Head and Neck Surgery, Miyagi Cancer Center Hospital Objective: Some of the patients in whom radiation therapy has failed to control the laryngeal cancer, surgery represents a salvage option. However, there is an increased incidence of postoperative complications in such patients compared with those treated with initial surgery. The aim of this study is to examine the usefulness and efﬁcacy of PGE1 administration after laryngeal surgery in patients who were previously treated by radiation therapy. Methods: Our method was retrospective chart review of the 16 patients who underwent partial laryngectomy and 28 patients who underwent total laryngectomy. In these patients, PGE1 at 120 lg/

S75 day was administered intravenously to nine patients after partial laryngectomy and 13 patients after total laryngectomy. Results: Complications were observed in ﬁve out of the seven cases treated by partial laryngectomy without PGE1 administration, while no complications were observed in the nine cases treated with PGE1 postoperatively. On the other hand, complications including major leakage were observed in six out of the 15 patients who underwent total laryngectomy without PGE1 but no complications were observed in the 13 patients who received PGE1 administration. Frequencies of complications of the patients with PGE1 administration were signiﬁcantly lower than that of the patients without it (P = 0.0001). Moreover, duration of hospital stay was signiﬁcantly shorter in the patients treated with PGE1 administration than those treated without it (P = 0.005). Conclusions: PGE1 administration is useful and effective for patients who underwent laryngeal surgery after radiation failure to eliminate the risk of postoperative complications and maintain the quality of life of patients.

HP 16 Study of the polymorphisms genes (SNP), responsible for tobacco metabolism in patients diagnosed with head and neck cancer Jaime Comas Julia1, Marta Amat Soley1, Mariano Monzo2, Xavier Perich Alsina3, Palmira Foro Arnalot4, Angel Gayete Cara3, Joan Fontane Ventura1, Joan Carles Galceran5 1 Hospital del Mar. E.N.T. Department, c/Diagonal 299, 3-1ª 08013 Barcelona, Spain 2 Barcelona University, Biologic Molecular Laboratory, Barcelona, Spain 3 Hospital del Mar, Radiologic Department, Barcelona, Spain 4 Hospital del Mar, Radioterapeutic Department, Barcelona, Spain 5 Hospital del Mar, Oncologic Department, Barcelona, Spain Objectives: The polymorphism genes variations condition the different answer to the treatments, as well as different toxicity. In this study is analysed the importance of these polymorphism genes related with the tobacco in patients with Head and Neck cancer treated with surgery. Methods: A retrospective study achieved in 108 patients with Head and Neck cancer treated with surgery as ﬁrst therapeutic treatment, And analysed different polymorphisms genes changes EPOXH-122, EPOXH-40, NAT-2-1-30, CYP1B1-07 and CYP1B1-58. The alelic discrimination technique was used. Results: Clinic stage: I 33 (39.3), II 14 (16.7), III 17 (20.2), IV 20 (23.8), Location: larynx 20 (23.8), hypopharynx 3 (3.6), oral cavity 35 (41.7), oropharynx 13 (15.5), nasal cavity 5 (6), unknown located 8 (9.5). The genes are: NAT 2-1-30 (CC 27, CT 29, TT 6), NAT 2-2-31 (AA 59), EPOHXI-22 (AA 44, AG 14, GG2), EPOHX-40 (GG 29, GA 33, AA 1), CYP1B1-07 (TT 34, TC 21, CC 8), CYP1B1-58 (AA 32, AG 20, GG 9). Conclusions: No relationship was found among the age of diagnosis in the polymorphisms genes studied. But relationship among cancer time progression and the expression of heterozigotic polymorphisms for the genes NAT-2-1-30, EPOXH-22 and for the CYP1B1-07 (SNP) were reported. No foundings between patient survival and the different polymorphimsgenes.

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HP 17 Current promising molecular markers in head and neck squamous cell cancer Jan Plza´k1, 2, 3, Martin Chovanec1, 2, 3, Zdeneˇk Cˇada1, 2, Jan Betka1, Karel Smetana Jr.2, 3 1 Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University, Faculty Hospital Motol, V U´valu 84, 150 06 Prague 5, Czech Republic 2 Institute of Anatomy, 1st Faculty of Medicine Charles University, Unemocnice 3, 128 00 Prague 2, Czech Republic 3 Center for Cell Therapy and Tissue Repair, 2nd Faculty of Medicine, Charles University, Faculty Hospital Motol, V U´valu 84, 150 06 Prague 5, Czech Republic Objective: Mortality rates of head and neck squamous cell carcinoma (HNSCC) have not changed despite recent advances in surgical treatment, radiotherapy and chemotherapy regimens. Molecular identiﬁcation of tissue biomarkers may not only identify patients at risk for developing HNSCC but may also select patients that may beneﬁt from more aggressive treatment modalities thus improving treatment results. Methods: PubMed survey using keywords ‘‘molecular marker head and neck squamous cell carcinoma’’ in combination with our previous research work in this ﬁeld were performed for analysis of the most promising biomarkers. Results: Sixty-six related papers were found in PubMed database from 1989 till January 2007. A lot of various interesting biomarkers of HNSCC have been so far investigated. The most promising ones seem to be epidermal growth factor receptor, vascular growth factor receptor, p16, p53, cyclin D1, Cox-2 enzyme, matrix metalloproteinases, etc. that could be use for the beneﬁt of HNSCC patients. Conclusions: Some progress has been made with respect to molecular markers and head and neck squamous cell carcinoma. Translational and prospective, hypothesis-driven research must proceed to facilitate the clinical applicability of such results. Acknowledgments: Supported by the National Research Program II No. 2B06106: Novel genomic and biotechnological practice in molecular oncology: Towards early diagnosis and targeted therapy.

HP 18 Effects of drugs on mucus production in homographted rat trachea Masako Ishikawa1, Takeshi Shimizu2, Kazuhiko Takeuchi1 , Yuichi Majima1 1 Department of Otorhinolaryngology-Head & Neck Surgery, Mie University Graduate School of Medicine 2 Department of Otorhinolaryngology, Shiga University of Medical Science Objectives: In order to examine the effect of drugs on mucus, we developed an animal model which produce tracheal mucus in the homografted rat trachea. The effects of clarithromycin (CAM) and glucocorticoid on the mucus production was examined.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Methods: Tracheas of donor rats were removed and the distal end was ligated. LPS or control medium (Ham’s F-12) was instilled into the lumen and the proximal end was ligated. The tracheas were then homografted subcutaneously on the back of recipient rats and maintained for 4 weeks. CAM and dexamethasone was administered orally, or intraperitoneally, respectively, for 4 weeks. The implanted trachea was dissected from recipient rats and the mucus in the homografted trachea was collected and analyzed. Histological examination was performed both in homografted tracheas and tracheas of recipient rats (normal tracheas). Results: The mucus amount was signiﬁcantly higher in the trachea with LPS than that with the control medium. Oral administration of CAM for four weeks signiﬁcantly reduced mucus amount in the LPS administered homografted trachea. Dexamethasone also reduced mucus volume in the LPS treated homografted trachea signiﬁcantly. The spinability of mucus in LPS treated trachea was signiﬁcantly higher than that of mucus in the trachea containing control medium. There was no morphological difference between normal tracheas and the trachea with control medium. On the other hand, goblet cell metaplasia was observed in LPS. Systemic administration of dexamethasone remarkably inhibited the goblet cell metaplasia. Conclusions: This animal model is useful for the study to evaluate the mucus property and to examine the effect of drugs on mucus.

HP 19 Lymphocytes inﬁltrating laryngeal carcinomas overexpress NF-jB Theodoros Papadas1, Konstantinos Kourelis1,2, Georgia Sotiropoulou-Bonikou2, Gerasimos Vandoros2,3, Panos Goumas1 1 Patras University Hospital, Department of Head and Neck Surgery, Rio-Patras 2 Patras Medical School, Department of Anatomy, Rio-Patras 3 Aegion General Hospital, Department of Pathology. Objective: Squamous cell carcinomas (SCCs) of the larynx are commonly surrounded by a mixed population of lymphocytes (Tumor Inﬁltrating Lymphocytes, TILs), which participate in the immune response against tumors, but also seem to promote neoplasms’ aggressiveness. Nuclear Factor-jB (NF-jB) is a fundamental transcription factor involved in lymph cell maturation. Our aim was to assess its presence in laryngeal TILs. Methods: Our clinical material is comprised of biopsy samples from 95 laryngeal cancer patients and 32 controls (normal and premalignant). Parafﬁn-section immunohistochemistry was utilized, to detect the p65 subunit of NF-jB. Results: NF-jB demonstrated intense cytoplasmic immunostaining in the lymphocytic population. Malignant invasion was signiﬁcantly associated with the presence of NF-jB-positive lymphocytes (P < 0.001). However, no correlation was established between SCC Grade and NF-jB expression in TILs. Conclusions: NF-jB overexpression in TILs surrounding laryngeal tumors might account both for their defensive potential as well as their recently described tumor-promoting capacity.

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HP 20 In vitro activity of HPMA-based targeted conjugates against HNSCC J. Boucek1,2, J. Betka1, J. Strohalm3, D. Plocova3, V. Subr3, T.Mrkvan2, O. Hovorka2, K. Ulbrich3, B. Rihova2 1 Department of Otorhinolaryngology, Head and Neck Surgery, The First Medical Faculty, Charles University, University Hospital Motol, V Uvalu 84, 150 06, Prague 5, Czech Republic 2 Institute of Microbiology, ASCR, Videnska 1083, 142 20, Prague 4, Czech Republic 3 Institute of Macromolecular Chemistry, ASCR, Heyrovsky sq. 2, 162 06, Prague 6, Czech Republic Objective: Overexpression of EGFR is typical for head and neck squamous-cell carcinoma (HNSCC). We have chosen EGFR for targeting of polymeric prodrugs in order to improve their efﬁcacy. Water-soluble synthetic polymers based on N-(2-hydroxypropyl)methacrylamide (HPMA) are recognized as useful carriers in targeted drug delivery. As already published by many groups, conjugation of the drug dramatically reduces its adverse effect. Methods: The FaDu cells were used as a model line for head and neck carcinoma. The capacity of the conjugate to bind to the cell surface of the cancer cells expressing EGFR was measured by ﬂow cytometry (FACS). We tried to evaluated the importance of receptor mediated endocytosis for internalization of tested conjugates by ﬂuorescent microscopy, by FACS kinetic measurement and by modiﬁed cytotoxic test. Results: We proved that both conjugates containing antibodies (either speciﬁc mAb or non-speciﬁc HuIg) had the same rate of internalization. We also proved that preincubation with relevant antibody, even in redundancy, did not inﬂuence the uptake of the targeted therapeutics, even though it blocs the speciﬁc bind to the cell surface. Conclusion: Targeted conjugates containing a cytotoxic drug (doxorubicin) bound to a polymeric backbone targeted with antiEGFR monoclonal antibody represent a novel modality in management of cancers. Our recent data indicate that receptor mediated endocytosis is not the main mechanism of the uptake of antibody-targeted polymeric prodrugs. We have been studying the details of the process of internalization. Acknowledgment: The research was supported by CSF 310/03/ H147 and by CSF 305/05/2268.

HP 21 CXCR4 chemokine receptor and SDF-1 chemokine expression in HNSCC A. O´va´ri1, H. Hegyesi2, B. Horva´th3, P. Po´cza2, K. Po´cza4, B. Szabo´1, P. Koltai6, Zs. Balatoni5, G. Re´pa´ssy1, A. Falus2 1 Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Semmelweis University of Medicine, Budapest, Hungary 2 Department of Genetics, Cell and Immunbiology, Semmelweis University of Medicine, Budapest, Hungary 3 Department of Oto-Rhino-Laryngology, Head and Neck Surgery, National Medical Center, Budapest, Hungary 4 Department of Pathology, Uzsoki Teaching Hospital, Budapest, Hungary 5 Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Uzsoki Teaching Hospital, Budapest, Hungary 6 Department of Head and Neck Surgery, National Center of Oncology, Budapest, Hungary Objective: To analyse the expression of the CXCR4 chemokine receptor and its corresponding ligand SDF-1 in head and neck squamous cell carcinoma (HNSCC).

S77 Methods: Quantitative reverse-transcription polymerase chain reaction (Q-RT-PCR) and immunohistological staining (IS) was used to detect CXCR4 and SDF-1 in normal mucosa and lymph nodes, primary tumor and lymphatic metastasis. The tissue samples were collected from previously untreated patients who underwent surgical procedures. We had overall 22 patients, including 19 hypopharyngeal and three laryngeal cancer. 15 patients presented metastatic lymph nodes on the neck (pN+ group), conﬁrmed by histopathological analysis. In seven cases there was no regional spread (pN0 group). Results: CXCR4 was expressed in primary HNSCC and normal mucosa. The strongest expression was in the corresponding metastatic cancer tissue. We found no signiﬁcant correlation between the initial tumor stage and the CXCR4 expression in primary HNSCC tumor. The highest expression level of CXCR4 in primary tumors was found in the cases with advanced neck metastasis (pN2a, b, c), but the difference from pN0 group was not signiﬁcant (P = 0,15 Mann–Whitney test). Expression level of CXCR4 in primary tumors tends to be greater in the pN+ group than in the pN0 group, but the difference was statisticaly not signiﬁcant (P = 0,24). SDF-1 ligand expression of the primary tumor is down-regulated. Conclusions: Primary tumor CXCR4 expression is a possible predictive marker of lymphatic metastasis in patients with HNSCC. Further investigations are needed with a bigger set of patients to clarify the role of CXCR4/SDF-1 chemokine system in the progression of HNSCC.

HP 22 The prognostic value of CYFRA 21-1 in stage II-III squamous cell carcinoma of the larynx and its role in early detection of recurrences A. Eleftheriadou1, T. Chalastras1, I. Yiotakis3, Z. Pappas1, L. Kyriou2, E. Ferekidou3, G. Papacharalampous3, D. Kandiloros3 1 Department of Otolaryngology, G Gennimatas Hospital, Athens 2 Department of Biochemistry, Evangelismos Hospital, Athens 3 Department of Otolaryngology, University of Athens, Hippokration Hospital Objective: To investigate whether assessment of changes in serum CYFRA 21-1 in stage II and III squamous cell carcinoma (SCC)of the larynx patients is correlated with the clinical outcome during prolonged follow up. Methods: Thirty-four patients with SCC of the larynx were included in this study. Fourteen were in stage II and 10 in stage III.13 of them underwent surgical treatment,10 radio/chemotherapy and 11 combined surgery and chemo/radiation. CYFRA 21-1 serum levels were measured before and after treatment and periodically with serial assays during the clinical follow up or until recurrence. The mean time of follow up for all 34 patients was 19 ± 6.2 months. Results: CYFRA 21-1 serum levels presented elevated in 21 (61.76%) patients before treatment. After therapy, serum levels were less than the cut-off value for all but three patients. 15(44.1%) of the 34 patients were diagnosed with recurrent or residual disease during the follow up study and four (11.7%)of them died. The 11 (73.3%) of the 15 patients with recurrence showed signiﬁcant elevation of CYFRA 21-1 levels before the diagnosis of recurrent disease. The mean time between the elevation of the marker and the diagnosis of clinical recurrence was 3 ± 2.8 months The rest 19 patients showed during the follow up period. In 17 of the rest 19 patients with no evidence of recurrence, there was no signiﬁcant elevation of CYFRA 21-1 during follow up. Conclusion: CYFRA 21-1 provides a monitoring tool for early recognition of recurrences in stage II–III SCC of the larynx.

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HP 23 Immunohistochemical and serum cytokeratin expression patterns as a prognostic indicator in oral cancer A. Eleftheriadou1, A. Lazaris4, T. Chalastras3, G. Agrogianis4, I. Yiotakis3, E. Patsouris4, E. Ferekidou3, K. Papadimitriou2, P. Chatzipantelis2, D. Kandiloros3 1 Department of Otolaryngology, G Gennimatas Hospital, Athens, Greece 2 Department of Pathology, Hippokration Hospital, Athens, Greece 3 Department of Otolaryngology, University of Athens, Hippokration Hospital, Athens, Greece 4 Department of Pathology, University of Athens, Athens, Greece Objective: To compare the expression of cytokeratins (CK)8, 18 and 19 in patients with squamous cell carcinoma (SCC) of the oral cavity and to assess whether speciﬁc CK expression could be of predictive value as a marker of disease progression. Methods: Twenty-six patients with (SCC) of the oral cavity stage I to III were enrolled in this study. All tissues were analyzed immunohistochemicallly with monospesiﬁc 8, 18 and 19 anti-keratin monoclonal antibodies. CYFRA 21-1,TPS and TPA-M serum levels were measured before and after treatment and during the clinical follow up or until recurrence. The mean time of follow up for all 26 patients was 12 ± 2.6 months. Results: CYFRA 21-1 presented elevated in 13 patients (50%) before treatment and over-expression of CK19 found in 17 specimens (65.38%) TPS was high in four and TPA-M in seven patients, while CK 8 and 18 staining was only detected sporadically (CK 8 in 5 and CK 18 in 8 specimens). Two months after therapy, all the three markers were decreased to normal cut-off values for all patients. Eight (30.7%) of the 26 patients were diagnosed with recurrent or residual disease during the follow up 6 of these 8 appeared with elevated levels of CYFRA 21-1 before treatment and simultaneous over-expression of CK 19. Conclusion: SCC or the oral cavity giving rise to recurrences, metachronous tumors and distant metastasis were signiﬁcantly associated with CK 19 over-expression in tissue as well as in serum before treatment. Cyfra 21-1 appeared to be promising prognostic tumor marker in oral cancer.

HP 24 Prognostic meaning of cytokeratin and neuroendocrine markers in larynx cancer M. Kursat Gokcan1, Alp Demireller1, Ozden Tulunay2, Cem Meco1, Suha Beton1, Ciler Tezcaner1 1 Ankara University Otorhinolaryngology Head and Neck Surgery Department 2 Ankara University Pathology Department Objective: In this prospective study, expression of distinct cytokeratin (CK) subtypes and neuroendocrine (NE) markers in larynx cancer (LC) were examined by immunohistochemistry (IHC) and results were correlated with known prognostic factors, such as tumor site, local extension, neck metastasis and degree of differentiation. Methods: Thirty LC patients that were operated at Ankara University ORL Department enrolled into study. Pathology and IHC

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 examinations were done at Ankara University Pathology Department. Tumor sections were examined and graded according to Broder’s criteria. For examining the CK and NE properties, low molecular weight CK (LMWCK), high molecular weight CK (HMWCK), CK 18, CK19, neuron speciﬁc enolase (NSE), synaptophysin (SYNF) and chromogrannin A (Chr A) antibodies were applied into tumoral and non-neoplastic mucosa sections with streptavidin-biotin peroxidase technique. Results: Tumors included squamous cell (SC), adenosquamous cell, verrucous, basaloid carcinomas and sarcomatoid carcinoma. Grade II squamous cell cancer was the most prevalent type (63.3%). On IHC, LMWCK and HMWCK’s were found to have diffuse expression that disables any prognostic implication. CK 18 expression seemed to diminish by grade but increase by stage. CK 19 expression had positive correlation with both grade and stage. We found only one case with basaloid cancer to have true NE differentiation with SYNF expression. Conclusions: On prognostic evaluation CK 18 expression was thought to have a positive correlation with neck metastases that would reach to signiﬁcance level with a larger patient series. No larynx SC cancer sample was found to have true NE differentiation.

HP 25 Tumor markers in squamous cell carcinoma of the head and neck: prognostic value Anastasia Konstantinou, Joan Michali ENT Department and Department of Clinical Oncology, GH of Halkis, Greece Objective: Head and neck squamous cell carcinoma (HNSCC) continues to cause signiﬁcant morbidity and mortality. Current management strategies for (HNSCC), rely on the use of prognostic factors to guide selection of appropriate treatment. The aim of the present study was to determine whether a tumor markers panel is associated with such clinicopathological features as the invasive and metastatic potential. Methods: The clinical relevance of the carcinoembryonic antigen (CEA), CA 19-9, CA 125, Ca 15-5, squamous cell carcinoma antigen (SCC), CYFRA, TAT1 and Ferritin as tumor markers in the diagnosis and follow-up treatment of 23 patients with head and neck cancer, is evaluated. Serial serum samples were collected before and at intervals after treatment at the end of the 6th and 12th month. Their serum levels were compared with samples of healthy blood donors, patients with inﬂammatory pathology, and benign tumors. Results: All markers expressed high rates of speciﬁcity over 90%. Their combined sensitivity was raised to 90.6%. Signiﬁcant differences were observed between cancer groups and other patients in the majority of the markers’’ levels examined. In cases with nodal and distal metastases, during the follow-up period, the tumor marker values were elevated signiﬁcantly (10–12%). TAT1, CYFRA 21-1and CEA levels were declined signiﬁcantly after surgical excision and thus could be potentially considered as markers of surgery effectiveness. Conclusions: Patients of high levels of these markers alone or in combination had much lower parameters as cumulating percent surviving relative percent dying and mean survival time than those with normal levels.

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HP 26 Isolation and characterization of mesenchymal stem cells from palatine tonsils Sasa Janjanin1,2, Drago Prgomet1, Rabie M. Shanti2,3, Dolores Baksh2, Rocky S. Tuan2 1 Department of Otorhinolaryngology, Head and Neck Surgery, Zagreb Clinical Hospital Center, Salata 4, 10000 Zagreb, Croatia 2 National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Department of Health and Human Services, 9000 Rockville Pike, Bethesda, MD, 20892, USA 3 Harvard Medical School, Harvard University, 188 Longwood Avenue, Boston, MA, 02115, USA Objective: Mesenchymal stem cells (MSCs) are multipotent cells that have the ability to differentiate into various cell types. Also, they have been determined to have immunomodulatory properties. The purpose of this study was to assess the existence of MSCs in human palatine tonsils and to characterize their stemness potential. Methods: MSCs were isolated using routine cell culture techniques. Cell proliferation assays, limiting dilution and CFU-F assays were performed. Confocal laser scanning microscopy and ﬂow cytometric analysis were employed to proﬁle speciﬁc CD markers. MSCs were induced to undergo adipogenic, osteogenic and chondrogenic differentiation. Multilineage potential was detected by RT-PCR, histology and histochemistry. Results: Using cell culture techniques, MSCs can be successfully isolated from palatine tonsils and expanded in vitro. They possess favorable proliferation characteristics, as well as surface epitope proﬁles. We demonstrated in vitro capacity of these cells to differentiate into multiple mesodermal lineages including fat, bone and cartilage. Conclusions: Owing to their ease of isolation, rapid proliferation in the culture and self-renewal capacity, MSCs are an attractive candidate cell type for the development of novel cell-based therapies. We hypothesized and showed that multipotent MSCs exist in palatine tonsils and can be isolated and expanded in culture. Human palatine tonsils could be source of MCSs for basic research and future clinical applications.

HP 27 TP53 status evaluation in pleomorphic adenoma of the parotid gland Claudia Gedlicka1, Helga Martinek1, Boban M. Erovic1, Chike Item2, Dietmar Thurnher1 1 Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Austria 2 Department of Pediatrics, Medical University of Vienna, Austria Objective: Loss of TP53 function in salivary gland tumours may result in altered cell growth and migration. The aim of this study was to evaluate the expression and mutation proﬁle of different TP53 exons in normal parotid gland tissue, pleomorphic adenoma tissue and carcinomas of the parotid gland. Methods: Genomic DNA was extracted from parafﬁn-embedded tissue and expression status of the exons 2–11 was examined. After total DNA isolation the respective TP53 exons were

S79 ampliﬁed by PCR and mutation analysis was performed using the denaturing gradient gel electrophoresis (DGGE) method. Results and discussion: TP53 mutations in pleomorphic adenomas of the salivary gland may contribute to the assumed progression from a benign adenoma to a squamous cell carcinoma ex pleomorphic adenoma of the parotid gland. The results of the mutation analysis of the TP53 exons and the clinicopathological implications of the currently ongoing study are presented and discussed.

HP 28 Effect of closo-dodecaborate-containing linker on targeting HNSCC xenografts with radioiodinated chimeric monoclonal antibody U36. Dual-isotope comparative biodistribution study Junping Cheng1,2, Mats Engstrom1, Tomas Ekberg1, Marika Nestor1, Matti Anniko1, Vladimir Tolmachev3 1 Department of Oto-Rhino-Laryngology and Head & Neck Surgery, Uppsala University Hospital(Akademiska Sjukhuset), Uppsala, Sweden 2 Department of Oto-Rhino-Laryngology and Head & Neck Surgery, Tianjin First Central Hospital, Tianjin, People’s Republic of China 3 Division of Biomedical Radiation, Department of Oncology, Radiology, and Clinical Immunology, Uppsala University, Uppsala, Sweden Background: Radionuclide targeting to head and neck squamous cell carcinomas (HNSCC) using monoclonal antibodies (MAbs) might contribute to a better diagnosis and staging, thereby making more effective treatment possible. Chimeric monoclonal antibody U36 (cMAb U36), speciﬁc to CD44v6 antigen, is a candidate for targeting of HNSCC. However poor cellular retention of radioactivity might be a problem in the case of conventional direct radioiodination. The use of the charged benzylisothiocyanate derivative of closo-dodecaborate (DABI) as a linker may improve radioiodine retention and thus giving better tumour-to-surrounding tissues contrast. Objective: The aim of the study was to compare the inﬂuence of closo-dodecaborate-based linker (DABI) for radioiodine with directly radioiodinated cMAb U36 on biodistribution of chimeric anti-CD44v6 antibody U36. Method: The study was performed in nude mice bearing UT-SCC7 HNSCC xenografts using dual-label. Inﬂuence of DABI on tumour-to-organ ratio was evaluated. Result: The radioactivity uptake in blood and organs decreased with time, with the exception of tumour and thyroid. A quick blood clearance and an elevated uptake in liver and spleen were characteristic for DABI-labelled cMAb U36. The use of DABI enabled to improve tumour-to-blood and tumour-to-organs ratio 1.5–2 times in comparison with direct radioiodination except liver and spleen. Conclusion: Selective tumour uptake was conﬁrmed in this animal model. These results indicate that DABI might be a promising linker for attachment of radoiodine to HNSCC-targeting conjugates.

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S80 Keywords: Nude mice, Chimeric monoclonal antibody U36, Head and neck squamous cell carcinoma, Tumour transplantation, Radioimmunotherapy, Tumour targeting

HP 29 A pilot phase IIA study for the evaluation of the efﬁcacy of folic acid in the treatment of laryngeal leucoplakia Giovanni Almadori1, Francesco Bussu1, Pierluigi Navarra2, Jacopo Galli1, Mario Rigante1, Bruno Giardina3, Gaetano Paludetti1 1 Institute of Otolaryngology, Universita` Cattolica del Sacro Cuore, Policlinico A. Gemelli, Roma, Italy 2 Institute of Pharmacology, Universita` Cattolica del Sacro Cuore, Policlinico A. Gemelli, Roma, Italy 3 Institute of Clinical Chemistry, Universita` Cattolica del Sacro Cuore, Policlinico A. Gemelli, Roma, Italy Objective: We previously observed that patients with head and neck squamous cell carcinoma or with laryngeal leucoplakia present a signiﬁcant reduction in plasma folate levels. This is a phase IIA pilot study assessing the effectiveness of folic acid as a chemopreventive agent in patients affected by glottic laryngeal leucoplakia. Methods: Forty-three untreated patients affected by glottic laryngeal leucoplakia were enrolled in our ENT department. Glottic leucoplakia was initially diagnosed by indirect laryngoscopy and successively conﬁrmed by diagnostic direct microlaryngoscopy with a biopsy for histological assessment. Folic acid (FolinaR) was administered orally (5 mg every 8 h) for 6 months. Patients were monitored every 30 days by videolaryngoscopy. Results: Twelve patients (28%) had no response, 19 (44%) had a partial response, 12 (28%) had a complete response. The mean increase in serum folate levels (10.06 ± 0.53) and the mean decrease in homocysteine serum (3.65349 ± 0.85526) at the end of the study were highly signiﬁcant (P = 0.0001). Conclusions: The larynx is one of the sites of major interest and a good model for the development of chemopreventive agents but so far proposed agents showed no clear efﬁcacy on precancerous lesions, or on the development of second malignancies. Our results suggested the hypothesis that folate insufﬁciency is a long acting risk factor, which increases along years the rate of carcinogenic progression following the exposure to environmental carcinogens. The present pilot chemopreventive study seems encouraging with a complete response rate of 27% and no clinical or histological progression of leucoplakia after a 6-month treatment.

HP 30 Salivary glutathione and uric acid levels in patients with head and neck squamous cell carcinoma Francesco Bussu, Attilio Limongelli, Mario Rigante, Jacopo Galli, Gaetano Paludetti, Giovanni Almadori Institute of Otolaryngology, Catholic University of Sacred Heart, Rome, Italy Objective: To evaluate the concentrations of glutathione and uric acid, low molecular weight antioxidants, in saliva of patients with head and neck squamous cell carcinoma (HNSCC), in order to identify differences with normal subjects and to obtain informa-

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 tion about biochemical alterations of human saliva during carcinogenesis. Methods: We compared 50 HNSCC patients, divided in two subsets basing upon tumor site, with a control group of 77 subjects, without a previous diagnosis of HNSCC, matched for age, sex, alcohol consumption and smoking status. Results: At tests for equality of means by Welch and BrownForsythe differences between groups resulted probable for salivary levels of glutathione (P = 0.004 and P < 0.001 respectively) but not for salivary levels of uric acid (P = 0.228 and P = 0.122 respectively). Comparing groups by Tamhane test, the patients with oral or pharyngeal cancer have signiﬁcantly higher salivary levels of glutathione than both controls and patients with laryngeal cancer. Conclusions: Salivary glutathione levels might be an index of oxidative stress at the level of the upper airways and in particular of oral cavity and pharynx. Therefore high salivary glutathione may be an epidemiological marker to identify subjects with an increased risk of developing HNSCC, to submit to strict follow up and chemoprevention. Metabolic alterations of saliva could be both an epidemiological marker and a target for chemoprevention of oral and oropharyngeal carcinogenesis.

HP 31 Galectin-7 in sqamous cell epithelia and carcinomas M. Chovanec1,2,3, K. Smetana Jr1,3, B. Dvorˇ a´nkova´1,3, Z. Cˇada1,2, L. Lacina1,4, J. Plza´k1,2,3, J. Betka2, M. Lensch 5, H. Kaltner5, S. Andre´5 1 Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine Charles University 2 Institute of Anatomy, 1st Faculty of Medicine Charles University 4 Department of Dermatovenerology, 1st Faculty of Medicine Charles University 3 Center for cell Therapy and Tissue Repair, Prague Czech Republic 5 Inst. for Physiological Chemistry, Faculty of Veterinary Medicine, Ludwig-Maxmillians-University, Munich, Germany Objective: Galectin-7 is member of b-galactoside-binding lectins (galectins) expressed characteristically in all keratinocytes. Galectins display multiple biological roles, e.g. in information transfer, proliferation/differentiation and apoptosis control, and pre-mRNA splicing. Methods: Expression of galectin-7 was studied in situ in squamous cell epithelia (epidermis, epithelium of oropharynx and larynx), squamous cell carcinomas and their lymph node metastases), basal cell carcinomas, and in vitro (epidermal keratinocytes, FaDu). Simultaneous double labeling studies were performed to asses level of differentiation (cytokeratin 10, cytokretain 14), proliferation (Ki67) and basal lamina formation (collagen IV). Imunohistochemical features were correlated with clinical and pathological ﬁndings. Results: In nontransformed cells galectin-7 was detected throughout the depth of epithelia. Basal cell carcinomas were devoid of its signal. Different pattern of expression was seen in squamous cell carcinomas which correlated with pattern of basal lamina formation, keratinization and differentiation level. Expression of galectin-7 reﬂected stratiﬁcation of epidermal keratinocytes culture not observed in FaDu cells. Conclusions: Monitoring of galectin-7 represent promising parameter in pathology of tumors originating from sqamous epithelia with expected clinical application in head and neck oncology.

Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 The study was supported by the IGA MZ CˇR, project No. NR 9049-3 and by and by EC Marie Curie Research Training Network grant (contract No. MRTN-CT-2005-019561)

HP 32 Analysis of human telomerase reverse transcriptase protein in laryngeal cancer* Pietruszewska Wioletta1, Wicher Anna1, Durko Marcin1, Gryczyn´ski Maciej1, Kobos Jo´zef2 1 Department of Otolaryngology, Medical University of Lodz, Poland 2 Department of Pathology, Medical University of Lodz, Poland Objective: Human telomerase reverse transcriptase (hTERT), a catalytic subunit of telomerase, has been known as an almost universal tumour marker but its predictive value has been found in only a limited number of malignant tumour types. The aim of this study was to detect hTERT protein in laryngeal cancer and study the relationship of hTERT expression with clinical and histological features. Methods: The subject were 41 patients with laryngeal cancer surgically treated. Immunohistochemical staining of parafﬁn specimens was supervised by the use of monoclonal antibody (NCLhTERT, Novocastra). The results were compared with clinical and histological staging. Results: Intensity of hTERT protein expression in laryngeal cancer was signiﬁcantly correlated with primary tumour size (T) and the more advanced tumours were related to higher hTERT protein expression (P = 0.01). We also perceived correlation between presence of nodal metastases (N), local recurrences and primary tumours occurrence in investigated patients and hTERT expression. In those cases hTERT level was higher but the differences were not signiﬁcant (P = 0.05). Although it was signed, that hTERT expression was signiﬁcantly higher in case of nodal recurrence (P = 0.04). There were no signiﬁcant dependence between the level of hTERT protein and localization of tumour in larynx, overall and disease free survival of the patients and histological grading (P > 0.05). Conclusions: Detection of telomerase may help to diagnose and determine the malignant grade of cancer. Therefore, this may indicate the feasibility of IHC detection of hTERT protein in laryngeal cancer as a potential diagnostic or prognostic marker. *This study was supported by grant No 502-11-453 from Medical University of Lodz

HP 33 Gene expression proﬁle in laryngeal cancer by oligonucleotide microarrays analysis Jaroslaw Markowski1, Tatiana Gierek1, Malgorzata Oczko-Wojciechowska2, Jaroslaw Paluch1, Michal Jarzab3, Malgorzata Kowalska2, Zoﬁa Wygoda2, Piotr Wardas1, Barbara Jarzab2, Dariusz Lange4 1 ENT Department, Silesian Medical University, Katowice, Poland 2 Department of Nuclear Medicine and Oncologic Endocrinology, Oncology Centre, Gliwice, Poland 3 Department of Neoplasm Biology, Oncology Centre, Gliwice, Poland 4 Department of Neoplasm Pathology, Oncology Centre, Gliwice, Poland

S81 The aim of the study is the analysis of gene expression proﬁle in laryngeal carcinoma. Materials and methods: The study comprised 14 patients suffering from squamous cell laryngeal carcinoma. Total RNA was isolated both from squamous larynx cancer tissue and from healthy larynx tissue, collected from the same patient. After 16-h hybridisation on high density microarrays Human Genome U 133 Plus 2.0 (Affymetrix) read-out was performed, followed by data analysis. Results: Analysis was performed by means of non-parametric U Mann–Whitney test, with the assessment of percentage of false positive results (FDR) applying the method of Benjamini-Hochberg, as well as the Holm method. Using Mann–Whitney test, 1241 transcripts were singled out, differentiating between both groups at FDR < 5%. In the next stage that group was narrowed down to 398 genes, meeting the criteria assumed, analysing by means of parametric test. Two genes, agiopoietin like transcript (231773_at, ANGPTL1, angiopoietin-like 1) and undeﬁned protein CGI-115 (219037_at) revealed a very substantial difference in expression, as well as complied with very rigorous criteria of error risk assessment for group of genes (FWER) applying Holm method. Conclusions: Analysis of gene expression proﬁle in laryngeal carcinoma allows to pick out new genes, which in future may become molecular markers of that carcinoma. Project ﬁnanced by a grant of Polish Ministry of Education and Science (MeiN) No. 3 PO5B 112 25.

HP 34 The diagnostic value of EBV detection using PCR in metastatic carcinoma to cervical lymph nodes Azza M. Rizk1, Soheir M. Hamam1, Shwikar M. Abd El-Salam1 Faculty of Medicine, Alexandria University Objective: In nasopharyngeal carcinoma, the primary lesion is difﬁcult to ﬁnd. Metastasis occurs frequently to neck nodes and is difﬁcult to distinguish form other head and neck tumours. The conducted study comprised 40 cases of metastatic tumours to neck nodes, 20 of which were NPC and 20 were other head and neck carcinomas. Twenty more cases were controls Methods: As EBV has been implicated in the etiology of NPC, the aim of the present work was to identify the viral genome of the EBV in the cells of this carcinoma by PCR assay in an attempts to differentiate it from other metastatic head and neck tumours.. Results: It was found that all cases of nasopharyngeal carcinoma were EBV positive and monoclonal, while the other metastatic head and neck carcinomas showed positive EBV in only 60% of cases, and these cases were all polyclonal. Also 45% of the control cases were EBV positive and also polyclonal. Conclusion: PCR, through ampliﬁcation of the EBV genome, is a reliable technique in differentiating NPC metastatic to neck nodes form other metastatic head and neck tumours.

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HP 35 Immunohistochemy (EGFR and CD44) in hypertrophic laryngeal lesions Elena Ionita˘*, Florin Anghelina*, Iulica˘ Ionita˘**, Carmen Mogoanta˘*, Sorin Ciolofan**, Carmen Popescu**, Laurentiu Mogoanta˘*** *ENT Department, University of Medicine and Pharmacy of Craiova **Emergency Hospital of Craiova ***Histology Department, University of Medicine and Pharmacy of Craiova Objective: We determinate expression of CD44 and EGFR in 57 cases of hypertrophic laryngeal lesions and we correlated with clinic and morphologic aspects. Materials and methods: The present paper represents a retrospective study on 45 cases of laryngeal epidermoid carcinomas, and 12 cases of laryngeal dysplasia, over a period of 5 years, 2001–2005. The material consisted of laryngeal biopsies and specimens resulted from the laryngectomies performed in the ENT Clinic of Craiova. The hystologic study has been made with colored solutions of hematoxiline-eozine, tricrome and with green light, while for the immunohistochimic study the LSAB has been used. The following markers of cellular proliferation have been used: CD44 and EGFR Results: The histologic study allowed us the reﬂection on the varied degrees dysplasia lesions: mild dysplasia: seven Cases(58%), moderate dysplasia: three Cases(26%) severe dysplasia: two Cases(16%).The histopathological forms of laryngeal cancer that we encountered were: 7 epidermoid carcinomas well differentiated (15%), 14 moderate differentiated(15%) and 24 poorly differentiated (54%).The TNM staging was as follows: three patients in stage I (7%), ﬁve patients in stage II (11%) 15 patients in stage IV (33%), 22 patients in stage IV (49%). A correlation was established between the presence of EGFR expression and the degree of differentiation. EGFR was substantially present in the epithelium of well differentiated carcinomas, and also in the moderate and poorly differentiated ones. Conclusion: The expression of CD44 and EGFR established a correlation with the degree of malignancy of the laryngeal cancer, and CD44 with the presence of lymph node metastases.

HP 36 Signiﬁcance of anti-HPV VLP-16, E6 and E7 in detection of the oral/oropharyngeal SCC Michal Zabrodsky1, Eva Hamsikova2, Ruth Tachezy2, Jana Smahelova2, Martina Salakova2, Jan Klozar1, Viera Ludvikova2, Jan Betka1 1 Department of Otolaryngology and Head and Neck Surgery, 1st Medical Faculty Charles University, Prague, Czech Republic 2 Department of Experimental Virology, National Reference Laboratory for Papillomaviruses, Institute of Hematology and Blood Transfusion, Prague, Czech Republic Objective: To evaluate the signiﬁcance of HPV-speciﬁc seropositivity for the early detection of the HPV DNA+ tumours. Methods: Patients surgically treated oral/oropharyngeal SCC and age and gender matched controls willing to participate in the study were enrolled. By the end of 2006 a complete set of data

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 from 86 patients and 124 controls was available. Tumour tissue from cases and exfoliated cells from oral rinses of both cases and controls were examined for the presence of HPV DNA using PCR with GP5+/6+BIO primers and reverse blot assay for typing of the positive samples. Sera were tested by ELISA for presence of HPV-speciﬁc antibodies using HPV 6, 11, 16, 18, 31, and 33 VLPs and HPV16 E6 and E7 recombinant proteins as antigens. Results: Patients with oropharyngeal SCC had signiﬁcantly higher prevalence of anti-HPV16 VLP antibodies when compared to control group (58.7% vs. 29.8%, P < 0.0001). The prevalence of anti-E6 and E7 antibodies in patients with oropharyngeal SCC was 73.2 and 29.9%, while only 1.0 and 2.9% in the control group. There was highly signiﬁcant correlation between the presence of anti-E6 and E7 antibodies and of HPV DNA in the tumour. Conclusions: The strong correlation between the presence of HPVspeciﬁc antibodies and the HPV DNA positivity in a subgroup of oropharyngeal SCC suggests the causal role of HPV viruses in the development of HNSCC and indicates the possibility to use serology for early detection of tumours.

HP 37 EMMPRIN expression in oral squamous cell carcinoma Matti Pukkila, Antti-Pekka Siljander, Ari Kosunen, Jukka Virtaniemi, Risto Johansson, Henri Tuomilehto, Juha Seppa¨, Juhani Nuutinen, Veli-Matti Kosma Institute of Clinical Medicine, Otorhinolaryngology, Head and Neck Surgery, Pathology and Forensic Medicine, and Oncology, University of Kuopio and Kuopio University Hospital, P.O. Box 1777, 70211 Kuopio, Finland Objective: To investigate the expression of EMMPRIN and its associations with clinicopathological variables as well as prognosis in oral squamous cell carcinoma (OSCC). Methods: Immunohistochemistry was used to study EMMPRIN expression in 119 OSCCs. All pertinent clinical data were collected retrospectively from the hospital records. Results: EMMPRIN was expressed on the tumour cell plasma membranes but not in the tumour stroma. The median tumour cell expression percentage was 60. EMMPRIN expression was statistically signiﬁcantly more active in bigger tumours (T1 vs. T2-4; P = 0.04) and in more advanced cases (SI vs. SII-IV; P = 0.01). EMMPRIN expression did not associate with other clinicopathological factors; i.e., sex, age, general condition, N-class or histological differentiation of the tumour. In univariate analyses higher risk for disease recurrence did not associate with EMMPRIN expression or any other clinicopathological variable. In univariate analysis of disease-speciﬁc survival (DSS) factors suggesting better prognosis were low T-class (P < 0.001), low Nclass (P < 0.001) and low stage (P < 0.001). EMMPRIN expression did not affect prognosis. In multivariate disease-speciﬁc survival (DSS) analysis, only high T-class (P = 0.005) and high N-class (P < 0.001) remained as independent predictors for poorer disease outcome. Conclusions: In the present study EMMPRIN was more actively expressed in larger and in more advanced tumours. However, it was not a prognostic factor in OSCC.

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HP 38 Rheological measurements in dysphagia K. Me´sza´ros1, Zs. Varga2, P.Ka´rpa´ti3, A´. A´bra´nyi4, T. Hacki5 1 National Medical Center, 1135. Budapest, Szabolcs u.33-35, Hungary 2 SOTE, Budapest, Hungary 3 Anton Paar Firma Hungary 4 BME 5 University of Regensburg Viscosity is a fundamental rheological property both of the foods used for feeding, and the test foods applied in endoscopic and Xray swallowing studies. The aim of this study was to determine the viscosities of the test foods and that of the foods used for everyday feeding, to compare and standardize them. The measures were taken with a rotational viscometer, an UDS200 air-bearing supported rotation/oscillation rheometer, at standard temperatures of 40 and 20C using US200 operating software and a PP50 plate/ plate measurement system. We prepared an increasing concentration series of the test food (jelly, pudding, puree, mush) by adding water to Resource Thicken Up of corn-starch content, and determined the viscosities. We also measured the viscosities of commercial available foods as well as of self-prepared foods.

HP 39 Cervical hyperostosis (Forestier disease) as a rare cause of dyspnea, aspiration, vocal cord immobilisation and extreme dysphagia G. Psychogios, C. Alexiou, F. Waldfahrer, I. Vlastos*, A. Karatzanis*, H. Iro Department of Otorhinolaryngology, Head and Neck Surgery, University Erlangen-Nurnberg, Waldstrasse 1, 91054 Erlangen, Germany *Department of Otorhinolarygology-Head and Neck Surgery, University of Crete, Heraklion, Crete, Greece. Introduction: Cervical hyperostosis also known as a diffuse idiopathic skeletan hyperostosis (DISH) is a rare but well known cause of dysphagia. Aspiration and dyspnea appear extreme rare as a clinical manifestation. We present a case of an 82-year-old man with dyspnea, aspiration, pneumonia and an emergency tracheotomy after a microlaryngoscopy. Case report: The laryngoscopy showed a severe bulging of the posterior oropharyngeal and hypopharyngeal wall which left a thin cleft to the epiglottis. The view to the glottis was limited and immobilisation of the right vocal cord could be seen. The computed tomography demonstrated large anterior osteophytes and ossiﬁcation of the posterior longitudinal ligament from C2 to C5. Barium swallow demonstrated massive aspiration. The patient underwent a panendoscopy to explore the upper aerodigestive area and received a percutaneous gastrostomy to secure the nutrition. An intraoperative electromyography of the intrinsic laryngeal muscle on both sides showed normal action potentials.

S83 After the ﬁrst operation he developed laryngeal edema requiring an emergency tracheotomy. In cooperation with the orthopedic department the patient underwent excision of osteophytes through an anterior lateral approach. Three months postoperatively the patient had no difﬁculty to breath and was tolerating regular nutrition without complaints, so the tracheostoma could be closed. Conclusion: Cervical hyperostosis is commonly in the older patients and usually asymptomatic, therefore most patients will be treated nonsurgically. Nevertheless it can be a source of considerable morbidity and potential life-threatening airway obstruction. The respective physician should be able to recognise this clinical entity in order to initiate the appropriate treatment.

HP 40 Pharyngo–esophageal dysphagia caused by large osteophytes in the cervical spinal tract A. Chatziavramidis1, E. Kyrodimos2, I. Delis1, D. Gennadiou1, Th. Sidiras2 1 Department of Otolaryngology-Head and Neck Surgery, General Hospital ‘‘Gianitsa’’, Greece 2 Department of Otolaryngology-Head and Neck Surgery ‘‘Theagenio’’ Cancer Hospital, Thessaloniki, Greece Introduction: Cervical osteophytes in the spinal tract are rather common especially in the elderly population. The Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a situation which is characterized by calciﬁcation and ossiﬁcation of the attached soft tissues of the spinal column and in some instances can compromise the function of the upper aero digestive tract. In this report we present three different cases with DISH causing dysphagia. Case reports: Case 1: A 63 year old male was presented in the outpatient department because of an acute episode of dysphagia. Endoscopy revealed a partial obstruction of the lumen of hypopharynx due to osteophytes. No surgical excision of osteophytes was performed. Supportive measures (speciﬁc deglutition maneuvers) were applied to relief some of the symptoms. Case 2: A 72 year old male was presented in the outpatient department because of episodes of intermittent dysphagia. Observation of pharynx-larynx with a rigid endoscope revealed a projection of the posterior pharyngeal wall due to osteophytes. Speciﬁc deglutition maneuvers were applied to eliminate possible aspiration hazards. Case 3: A 65 year old male was complained of dysphagia in solid food. Laryngoscopy with a rigid endoscope and barium shallow revealed no pathology present. X-rays reveled osteophytes in the anterior portion of C3 to C7 vertebras. Proton pumps inhibitors and anti inﬂammatory drugs were administrated with some encouraging results. Conclusions: The osteophyte-related dysphagia should raze the suspicion to the physician especially when radiologic or functional modalities reveal the presence of thick osteophytes in the spinal tract.

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HP 41 Detection of Helicobacter pylori in oropharyngeal diseases 1

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Petr Lukes , Jaromir Astl , Jan Plzak , Emil Pavlik , Bela Potuznikova2, Ivan Sterzl2, Jan Betka1 1 Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University, Faculty Hospital Motol, V U´valu 84, 150 06 Prague 5, Czech Republic 2 Institute of Immunology and Microbiology of the 1st Faculty of Medicine, Charles University, Studnicˇkova 7, 128 00 Praha 2, Czech Republic 3 Institute of Anatomy, 1st Faculty of Medicine Charles University, Unemocnice 3, 128 00 Prague 2, Czech Republic Objective: Helicobacter pylori (HP) plays a major role in the pathogenesis of miscellaneous diseases (gastric ulcers, adenocarcinoma, lymphoma). Recent studies have explored the relationship between HP and the oral cavity diseases. HP infection could cause the same immunological changes in the gastric and oropharyngeal mucosa. HP can induce production of different cytokines and regulatory molecules, which could promote carcinogenesis of the oropharynx. Preliminary results of HP detection in tonsillar tissue are presented. Methods: The tissue specimens obtained from 16 patients with tonsillar cancer, 22 patients with chronic tonsillitis and 12 patients with obstructive sleep apnea syndrom (OSAS) were examined for presence of HP by culture. Seven of them were examined by PCR. Anti HP antibody levels were detected by commercial imunoassay in venous blood. Results: Serum antibodies were positive in 15 patients with cancer, 8 with chronic tonsilitis and 9 with OSAS. HP was detected in one cancer specimen and one chronic tonsillitis specimen by culture. We found HP in 6 of 7 specimens by PCR. Conclusion: Detection of tonsillar HP is mostly difﬁcult. Serology is very sensitive method, but it is not speciﬁc for oral infection. Culture is speciﬁc and sensitive method for HP diagnosis in gastric specimens but it could have high level of false negative results when investigating oral specimens. The most promissing method seems to be PCR, which is both sensitive and speciﬁc for HP in oral specimens. Our preliminary results show that HP can be detected in tonsillar tissue. Acknowledgments: This poster was supported by the IGA MZ CˇR NR 9077-3.

HP 42 Laryngopharyngeal Reﬂux in patients with laryngeal cancer Jetmira Bulaj*, Pjerin Radovani*, Anila Kavaja**, Ilir Peposhi**, Floreta Kurti *** *Tirana University Hospital ‘‘Mother Teresa’’ ENT DepartmentDibra street, Tirana, Albania **Tirana Hospital of Pulmonary Disease Sanatorium, Sauk, Tirana, Albania

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***Tirana University Hospital ‘‘Mother Teresa’’ Gastroenterology Department, Dibra street, Tirana, Albania Objective: Laryngopharyngeal reﬂux may play a role in the etiology of laryngeal squamous cell carcinoma. Methods: In this prospective study to investigate the incidence of laryngopharyngeal and gastroesophageal reﬂux in 48 untreated patients with histologically proven laryngeal squamous cell carcinoma and in the control group, video gastroscopy and 24-h double-probe pH monitoring was performed. The control group consisted of 40 patients with typical manifestation of Gastroesophageal Reﬂux (Pirosis and dyspepsia). Results: Thirty-eight of the laryngeal cancer patients (79%) and 30 patients of the control group (75%) revealed Gastroesophageal Reﬂux (GER). On the other hand 30 patients with laryngeal cancer (62%) and only four control patients (10%) revealed Laryngopharyngeal Reﬂux(LPR). Sixty percent of the laryngeal cancer patients (29/48) were smokers. The rate of gastroesophageal reﬂux was close among the two groups, but the laryngopharyngeal reﬂux rate was much higher in the cancer group. Conclusions: Both groups revealed Gastroesophageal Reﬂux (GER) in similar rates but the Laryngopharyngeal Reﬂux (LPR) rate was much higher in cancer patients than in the control group. LPR can be a factor in the development of the laryngeal cancer.

HP 43 Helicobacter pylori colonizes the palatine tonsil but not the adenoid E. Labropoulou1, C. Labropoulou1, G. Charalambopoulou2, M. K. Gerolymos1, C. Tzamalis1, P. Morfaki2 General Hospital of Messolonghi1, Messolonghi, Greece General Hospital of Agrinio2, Agrinio, Greece Objective:H. pylori has been associated with the development of gastritis, peptic ulcer and gastric cancer. Although H. pylori infects up to >50% of the world’s population, to date the precise modes of transmission has not been fully understood yet. The presence of H. pylori in palatine tonsil and the adenoid has recently been reported. However, it has not been conﬁrmed by immunohistochemistry. Method: Formalin-ﬁxed and parafﬁn-embedded tissues from 31 tonsillectomy, 3 adenoidectomy and 2 adenotonsillectomy were studied. Immunohistochemistry using a polyclonal antibody directed against H. pylori was performed. Results: H. pylori was present in 24 of the 33 tonsillectomy specimens (72.72%) whereas all adenoidectomy specimens were negative. In H. pylori positive cases, both helical and coccoid forms were found in high numbers, in the superﬁcial mucous layer, attached to the surface epithelium of the tonsillar crypts. Conclusions: H. pylori colonizes the palatine tonsil, and thus may represent a risk factor for oro-oral route of transmission or, alternatively, for gastrointestinal re-infection and ulcer relapse after cessation of antibiotic therapy. To the best of our knowledge, this is the ﬁrst study by immunohistochemistry with results positive for colonization of the palatine tonsil by H. pylori.

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HP 44 Relation of E.N.T patients complains for atypical symptoms to Reﬂux

gia. Thirty six patients (49%) were already receiving acid suppression treatment. Laryngopharyngeal reﬂux was the most common clinical ﬁnding. Barium swallow was normal in 39 patients (53%) and in the remaining cases benign pathologies were documented such as GERD, hiatus hernia and cricopharyngeal spasm. Conclusion: None of the patients was found to have any malignancy on Barium swallow. Statistically, there was no correlation between the clinical ﬁndings and BS result. The benign ﬁndings seen in 47% of patients could all potentially play an aetiological role in their symptoms. Barium swallow is helpful, not only to exclude malignancy but also to delineate the benign pathologies in globus pharyngeus.

S. Triantos, S. Vlachou, G. Terzakis, D. Andrianopoulos, G Dritsas, G. Mireas, G. Papazoglou ENT Department, Red Cross Hospital, Athens, Greece Objective: The scope of this study was to evaluate the percentage of patients with atypical symptoms like chronic cough, throat clearing, mucous sensation in the throat, globus sensation and hoarseness suffering from reﬂux. Methods: One hundered and ten patients were examined at the outpatient clinic suffering from the above mentioned symptoms. There were 42 men and 68 women. The patients were submitted to complete clinical head and neck examination and indirect laryngoscopy. All of them were referred to the gastroenterology clinic for evaluation. Results: Thirty-eight out of 110 (34%) patients were found to suffer from various severity of reﬂux. The prevailing symptoms of these patients were mucus and globus sensation in the throat and throat clearing. The main endoscopic ﬁndings were interarytenoid space oedema and inﬂammation of the area, but they are not pathognomonic ﬁndings. Conclusion: Reﬂux may present with atypical gastrointestinal symptoms that may be typical ENT symptoms. The otolaryngologist should always consider reﬂux in the differential diagnosis of atypical laryngopharyngeal symptoms

HP 45 Role of barium swallow in patients with FOSIT Muhammad Shakeel, Amanjot Dhaliwal, Andrew Evans, Kim W. Ah-See Department of Otolaryngology, Aberdeen Royal Inﬁrmary, Aberdeen, Scotland, UK, AB25 2ZN Objective: A feeling of something in the throat (FOSIT) is a common presentation of globus pharyngeus syndrome. The chance of any sinister pathology presenting as FOSIT is extremely rare with Barium swallow (BS) providing a quick screening tool. We carried out a retrospective review to investigate any correlation between clinical ﬁndings and BS result in this group of patients. Method: We reviewed the case notes of all patients undergoing BS between January 2002 and December 2004 under our care. A total of 119 patients were identiﬁed. FOSIT was the only or the principle complaint in 79 patients. Five of the 79 patients were excluded. Data was collected and analysed using SPSS. Results: Out of 74 patients, 30 were male and 44 female (mean age 57 years). FOSIT was the only complaint in 21 patients while others had associated symptoms such as hoarseness and dyspha-

HP 46 Structural displacements during the swallow in patients with early primary cancers of the head and neck S. H. Vyas, S. Ford, S. Gollins, P. Hobson, North Wales Cancer Treatment Centre, Glan Clwyd Hospital, Rhyl, UK Objective: To assess the baseline swallowing of T1 larynx and small head and neck cancer patients, in terms of spatial movements of the pharyngeal structure during the swallow. Further,more assess other factors that affect the swallow such as gender, age, and body mass index. This is then compared to reported results of swallows in normal, healthy individuals. Method: Swallows of 48 patients (with small head and neck cancers) were assessed, using videoﬂuroscopy, prior to deﬁnitive curative treatment. Twenty-four patients were T1 carcinoma of the larynx, and the other 24 were early cancers in other head and neck locations. Results: Measurements were generally consistent with previously reported results in healthy volunteers with normal swallows. There were no signiﬁcant differences between T1 larynx and other small cancers. On univariate analysis, patients >70 versus < 70 years old, had a signiﬁcantly greater hyoid-laryngeal distance and pharyngeal area at rest. Patients with BMI >26 versus < 26 demonstrated a signiﬁcantly greater maximal width of the PES in the lateral view. On multiple regression analysis, greater hyoid-laryngeal distance at rest and at the point of maximal approximation were the signiﬁcant predictors of male versus female gender at the exclusion of all other variables, accounting for 59% of the variance seen. In no patient did contrast touch the vocal cords during the swallow. Conclusions: This study forms a baseline for future prospective studies of swallows in patients with early cancers of the head and neck cancer post-treatment.

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HP 47 Swallowing disorders: proposal of a method for forensic medicine assessment Bruno Fattori1, Andrea Nacci1, Francesco Ursino1, Fabio Matteucci1, Valentina Mancini1, Vito Mallardi2 1 3rd Otorhinolaringology Unit, Department of Neurosciences, University of Pisa, Italy 2 Institute of Odontostomatology, Marche Region Polytechnic University, Ancona, Italy Objective: For a correct classiﬁcation of dysphagia, morphologic instrumental investigations capable of analysing the anatomical structures of the digestive tract, are undoubtedly essential, but the most important investigations are the functional ones, such as videoﬂuoroscopy, ﬁberoptic endoscopic evaluation of swallowing (FEES), oro-pharyngo-oesophageal scintigraphy (OPES), manometry and pH-metry. The results of these exams enable us to identify, in patient with dysphagia, the extent of permanent damage as a consequence of injury to the structures designated to swallowing must be such that it at least minimally impairs and diminishes the relative function, but to a degree that can be detected and, in some manner, measured. Methods and results: From a penal point of view, alterations in swallowing caused by damage to structures belonging to the respiratory-digestive can be found in crimes against persons and particularly in those involving body injury. In the case of civil and also in private or social insurance proceedings, it is necessary to distinguish which parameters are to be used as reference for evaluating and quantifying the injury in terms of reimbursement. With the introduction of complete biological well-being, injury is considered as an impairment of his worth and of his right to enjoy psychological-physical integrity as a quality of his life. The criteria internationally used at the moment take into account the conception of psychological-physical efﬁciency, nevertheless, in Italian forensic medicine there is no table that can give a thorough quantiﬁcation of swallowing modiﬁcations, if one excludes oesophageal disorders. Conclusions: We propose an evaluation table dividing oro-pharyngo-esophageal dysphagia into ﬁve, progressively serious classes.

HP 48 Chronic aspiration Dayse Manrique UNIFESP-Universidade Federal de Sa˜o Paulo, AACD (Associac¸a˜o de Assisteˆncia a` Crianc¸a Deﬁciente- Disabled Child Assistance Association), Rua Cana´rio, 1112-61, Sa˜o Paulo, Brazil, CEP 04521-005 Objective: Described the methods to diagnose chronic pulmonary aspiration (CPA) and level of aspiration and the clinical repercussions resulting from it indicating the type of treatment to be proposed. Methods: Almost two thousand patients with oropharyngeal deglutition disorders (dysphagia) and CPA were selected and the methods that demonstrated the disorders in airway protection, in the period of 1998 to 2006, at AACD (Disabled Child Assistance Association). Speciﬁc clinical presentation of chronic aspiration were included like: choking, fever, dyspnea, dysphonia, frequent throat clearing, chest pain, disphagia, odynophagia, wheezing, regurgitation of feedings and emesis. Nonspeciﬁc clinical presentation were: choking, fever, dyspnea, dysphonia, frequent throat clearing, chest pain, disphagia, odynophagia,

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 wheezing, regurgitation of feedings and emesis. The diagnostic methods employed were discussed by sensibility and speciﬁcity: videoendoscopy of deglutition (VED), videoﬂuoroscopy or modiﬁed barium swallowing: Is considered standard in the study of swallowing function, radionuclide scintigraphy, bronchoalveolar lavage (BAL) to calculate the lipid-laden macrophage index (LLMI), thorax CT scan with high resolution provides clinically helpful information. Results: Two hundred ten patients have been undergone to surgical procedure to control chronic aspiration, and age and etiological disease had no impact in limitating the surgical management, but the level and clinical repercussions of CPA. The procedures more frequently performed were classiﬁed in minimally invasive as vocal fold medialization, cricopharyngeal myotomy, saliva reduction (local injecton of botulinum toxin in salivary glands)or bilateral submandibular gland excision and parotid duct ligation as a surgical procedure to long-term saliva reduction. Procedures more invasive were tracheotomy, and laryngotracheal separation (LTS). This technique (Lindeman modiﬁed) could be control aspiration in 56 patients, specially children with severe motor disease. Conclusion: Chronic pulmonary aspiration is a not rare syndrome, specially in patients with craniofacial malformations, neurological diseases, neurosurgical postoperative periods, vascular diseases of central nervous system, and the suspect of the CPA is the most important tool to employ the most effective method diagnostic and the speciﬁc treatment. The treatment is capable of avoiding the most important cause of morbidity and deaths in patients with neurological diseases.

HP 49 Efﬁcacy of once-daily Esomeprazole treatment in patients with laryngopharyngeal reﬂux evaluated by 24-h pH-monitoring O. Reichel*, G. Rasp**, A. Berghaus* * Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilians University, Marchioninistraße 15, 81377 Munich, Germany ** Department of Otorhinolaryngology, Head and Neck Surgery, Katharinenhospital, Kriegsbergstraße 60, 70174 Stuttgart Objective: Laryngopharyngeal reﬂux (LPR) is generally treated with twice-daily (BID) proton-pump inhibitor (PPI) therapy. In this study the efﬁcacy of esomeprazole 40 mg once-daily (QD) together with lifestyle modiﬁcations was determined by repeated 24-h pH-monitoring. Method: Prospective study. Forty-nine patients with suspected LPR underwent 24-h pH-monitoring. Twenty-seven of 49 patients with measurable abnormal proximal reﬂux reﬂected by a reﬂux area index (RAI) >6.3 were treated with esomeprazole 40 mg QD and a second pH-study was performed. Results: In 22 of 27 patients QD PPI treatment reduced the RAI. Four of 5 patients with no RAI reduction reported on symptomatic relief. Conclusions: In a considerable number of patients with suspected LPR pH-monitoring reveals no abnormal proximal reﬂux. Esomeprazole 40 mg QD together with lifestyle modiﬁcations could reach adequate acid suppression in a large number of patients. Symptom improvement is also reported by patients without measurable effects of therapy.

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HP 50 Microbiological colonization of tracheal tubes after tracheostomy and its impact on colonization of the lower respiratory tract Michaela Zumtobel1, Alexander M. Hirschl2, Ulrike Holzinger3, Andja Bojic3, Mariam Nikfardjam3, Joanna Warszawska3, Berit Schneider1 1 Department of Otorhinolaryngology, Medical University of Vienna, Austria 2 Department of Clinical Microbiology, Medical University of Vienna, Austria 3 Department of Internal Medicine, Intensive Care Units, Medical University of Vienna, Austria Objective: Mechanically ventilated patients are at increased risk to develop pneumonia (‘‘ventilator associated pneumonia’’, VAP). Pneumonia incidence due to oro- or nasotracheal intubation has been studied extensively, but little information is available on the impact of tracheostomy on VAP incidence under prolonged tube use. Goal of this study was to investigate the dynamics of microbiological colonization of tracheal tubes and the lower respiratory tract during the ﬁrst two postoperative weeks. Methods: Consecutively 50 patients were tracheotomized because of prolonged mechanical ventilation (on average 14 days prior to tracheostomy) under intensive care conditions. Tracheal swabs were taken intraoperatively as well as on predeﬁned postoperative days (3rd, 5th, 7th, 10th and 14th days). Additionally rinses of the tracheal tube were performed on the same days of follow-up. Results: At the day of surgery the tracheal mucosa was already colonized in 47 of 50 patients; after 7 days all patients had a microbiologically colonized trachea. The maximum concentration of microorganisms on tracheal mucosa was measured after 3 days, on tracheal tubes after 5 days. However, no VAP was diagnosed after tracheostomy in the observation period. Conclusion: Tracheostomy is not associated with increased VAP incidence. However, high prevalence of colonization of the tube as well as the trachea with microorganisms affords special surveillance and care. This study was approved by the Ethical Commission of the Medical University of Vienna. (Nr: 331/2004)

HP 51 Vocal cord paralysis as the presenting sign of aortic arch aneurysm Amit Kotecha, Yujay Ramakrishnan, Anna Leslie, Alwyn D’souza New Cross Hospital, Wolverhampton Recurrent laryngeal nerve palsy (RLNP) secondary to cardiovascular disease is a well recognised but uncommon complication. Vocal cord paralysis (VCP) secondary to RLNP is a common clinical condition. The most common causes worldwide are carcinoma lung and tuberculosis, but many pathologies, benign and malignant can cause this condition. Cardiovascular disease is a well recognised but uncommon cause of RLNP. When it does occur it has been described as the cardio vocal syndrome, also known as Otner’s syndrome. RLNP has been reported to occur in patients with pulmonary artery dilatation (secondary to mitral stenosis, valve replacement, septal defects, patent ductus arteriosus) and aortic arch aneurysm and repair. RLNP may be idiopathic or it is also seen in patients of thyroid tumour, lung carcinoma, oesophageal carcinoma and postoperative complication. The importance of knowing aortic arch aneurysms as a cause of causing RLNP is that but can resolve following treatment of aneurysm. RLNP in these

S87 patients also affects quality of life due to hoarseness and risk of aspiration. RLNP has also been suggested as an important predictor of need of need for surgery in thoracic aortic aneurysm Also size, shape, and rate of growth of aneurysm are important. RLNP in severe trauma cases has been suggested as an early sign of aortic injury and need prompt further management. We describe two cases of left RLNP secondary to aortic arch aneurysm.

HP 52 Laryngeal fracture following shrapnel injury: case report Neil Sharma, Mriganka De, Paul Pracy Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Birmingham NHS Trust, Edgbaston, Birmingham, UK, B15 2TH Objective: To present a case of laryngeal fracture in a soldier due to shrapnel injury. Case report: A 26-year-old soldier was involved in an explosion whilst serving in Afghanistan. He sustained a shrapnel injury to his neck. A cricothyroidotomy was performed followed by a surgical tracheostomy at the ﬁeld hospital. He was transferred to the UK where imaging revealed a disrupted left thyroid cartilage. He underwent neck exploration, laryngoﬁssure and reconstruction of his larynx. Post operatively he made a good recovery. Following decannulation his swallow and phonation were good. Discussion: Penetrating laryngeal injuries should be dealt with by emergency cricothyroidotomy or surgical tracheostomy. Full assessment of the patient accompanied by CT scanning of the neck will delineate the extent of injury. This should be complimented by laryngeal framework surgery. The best outcome should be a patient with a near normal voice and good swallowing.

HP 53 The comparison study of results endo- and extralaryngeal methods of surgery bilateral paralytic laryngeal stenoses Mikhail Melnikov Novosibirsk State Medical University, Russian Federation It is known and is described with literature main Methods surgical treatment laryngeal paralyses after thyreodectomy: microsurgical endolaryngeal lateroﬁxation of vocal cords, reconstructive laryngoplasty with external approach, reinnervation etc. The trials of the study was a comparison result using of these methods. The methods: Endoscopic study of the larynx, spirometry, CTscan of neck. Under our observation there were 21 patients with paralysis vocal cords after thyreodectomy, divided into two groups. The ﬁrst group consisted of 8 patients, treated endolaryngeal microsurgery method.The second group consisted of 13 patients, treated by extalaryngel method. Results: In the ﬁrst group of patients time improvement of function of breath during the ﬁrst month after operation was marked. The basic parameters of spirometry have slightly improved. In the second group all patients on 14 day is made decanulation, satisfactory condition. Spirometric factors to external respiratory function vastly increased. In 5 cases from patients ﬁrst group is in the same way made extralaryngeal lateroﬁxation of vocal cords. In the same way either as in the second group all sick were decanulated and in the following social are adapted. Conclusion: The extralaryngeal lateroﬁxation of vocal cord is an most efﬁcient method of the surgical treatment paralytic stenosis of the larynx, restoring respiratory function for satisfaction results.

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HP 54 Measurement and comparison of in vitro air-ﬂow characteristics of the most frequently used European indwelling voice prostheses types P. Kress1, P. Schaefer 1, F.-P. Schwerdtfeger1, S. Roesler2 1 Klinikum Mutterhaus der Borroma¨erinnen gGmbH, Feldstr. 16, 54290 Trier, Germany 2 University of applied sciences Esslingen Recently underpressure related valve opening in indwelling voice prostheses with a ﬂap valve has been described as a frequent reason for early device failure similar to bioﬁlm formation. Anyway until today there were no objective aerodynamic proﬁles in SI-Units of the different types of indwelling voice prostheses available. In cooperation with the University of applied sciences Esslingen we performed in vitro air ﬂow measurements of the most frequently used types of indwelling voice prostheses in Europe. Pressure-ﬂow charts from nine prosthesis types were taken with a laminar ﬂowmeter HST LAM-ES 25-10 that is optimized for measurements of low pressure differences in a laminar ﬂow system. Special focus was paid to asses the exact opening pressure of each valve type to enable the user to choose the valve according to the patients individual needs of valve resistance. A Second aim was to check differences in aerodynamic characteristics due to production of the valves. For this purpose ten valves of each design were examined and signiﬁcant differences were found. Further measurements will be performed to evaluate the changes in resistance and opening pressure of the valves after long term use in vitro and in vivo.

HP 55 Preoperative clinical prediction of difﬁcult laryngeal exposure Ercan Pinar*, Caglar Calli*, Semih Oncel*, Burcu Selek*, Bekir Tatar* *Ataturk Training and Research Hospital, Izmir, Turkey Objective: We investigated clinical predictors of difﬁcult laryngeal exposure(DLE) in patients undergoing microlaryngosurgery. Methods: Ninety-three patients were included in this study. Twelve clinic and physical parameters were carried out for all patients preoperatively. During suspension laryngoscopy laryngeal exposure scores were obtained for each patients and compared with the parameters. Patients were divided into two groups according to the laryngeal exposure score: DLE group and non-DLE group. Results: The patients’ age ranged from 22 to 85 years (mean age 52.70 ± 13.01). 22 of 93 patients had DLE. Relationship between DLE score and parameters was analyzed with Spearman’s correlation coefﬁcient. Of all parameters Cormack-Lehane score, neck circumference, body mass index, full mouth opening, modiﬁed mallampati index, hyoid-mental, thyroid-mental, vertical thyroidmental and sternum-mental distance in full extension showed signiﬁcant correlation in patients with DLE (P < 0.05). All the signiﬁcant variables in univariate analyses were included in the multivariate logistic regression model with enter method. Only neck circumference >40 cm (P < 0.05; OR:12.82), hyoid-mental distance < 6.05 cm (P < 0.05; OR:6.80) and sternum-mental distance < 13.9 cm (P < 0.05; OR:23.04) in full extension were independently associated with DLE.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Conclusion: This results indicates the necessity of preoperative measurement of the predictors may be useful to estimate patients with DLE.

HP 56 Reconstruction of the larynx and trachea in case of chronic stenosis associated with laryngopharyngeal reﬂux disease Kokorina Victoria, Deragin Nikolai The Far Eastern State Medical University, ENT Department, 680000 Khabarovsk, Russia, Myravieva-Amurskogo str.35 Purpose: Chronic laryngeal and trachea stenosis is one of the most challenging problems for ENT specialist in Russia. In recent years this pathology is increasing as a result of prolong intubation and laryngeal trauma. Laryngopharyngeal reﬂux (LPR) and acid exposure after laryngeal cane damage perichondrium and subglottic injury progress to a recurrent stenosing lesion. So, in most cases decanulation is impossible because of malformation of the larynx and tracheal cartilage. In case of breathlessness as a result of cartilage malformation and tracheal wall collapse we need to install stents or implants to reconstruct laryngeal and tracheal wall and to close tracheotomy hole. The purpose of our research was to estimate the result of implantation of new type of material- micro perforated Ni-Titanium (Ni-Ti) for the reconstruction of trachea and laryngeal wall. To analyze inﬂuence of correction of a reﬂux on frequency of postoperative complications Methods: Our patient were followed over a 2-year period from 2004 to 2006, during which there were 19 admissions. All these patients got stenosis as a result of intensive therapy and prolong intubations. 16 patients (84, 2%) with subglottic stenosis had positive pH probe studies (pH below 4 in the pharyngeal probe). This ﬁnding was noted in 13 patients despite therapy with proton pump inhibitors at the time after operation during 3 months. For the same 13 patients we use Ni-Ti ﬂap for laryngeal and tracheal implantation. Six patients with using auto cartilage implant, was taken as a control group, and three patient from these group reject to use proton pump inhibitors Results: After visualization of stenosis area, the granulation and scar tissue are removed. For reconstruction the trachea and laryngeal wall Ni-Ti ﬂap were implanted in the anterior wall with using coated Vicryl 3-0 for it ﬁxation. Because of micro perforated structure and biological conformity Ni-Ti implants, we cane decanulat 12 patients. After 2 months implant were perforated with ﬁbrin a built-in tracheal tissue. In 1 case decanulation was impossible because of repeated growth of scar tissue as a result of postoperative inﬂammatory complications. In control group in 5 cases decunulation was impossible because of malformation of cartilage implant and collapse of tracheal wall. Postoperative inﬂammatory complications were detecting in three cases (50%) in this group. Conclusion: This research have showed the advantage of using new material- micro perforated Ni-Titanium (Ni-Ti) for the reconstruction of trachea and laryngeal wall in case of chronic laryngeal and trachea stenosis. In 2 months it was built-in tracheal tissue and we close laryngeal and tracheotomy hole with perfect cosmetic result. The association of LPR and chronic subglottic stenosis acts as a synergistic factor that stimulates inﬂammatory process after laryngeal reconstruction and recurrent stenosis.

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HP 57 Chondronecrosis of the thyroid cartilage after combined chemotherapy and radiation therapy M. Hernando, C. Perez, V. Garcı´ a, G. Plaza Department of Otolaryngology, Hospital de Fuenlabrada, Madrid, Spain Objective: Describe a case of serious complication after combined chemotherapy and radiation therapy. Methods: Case report. Literature review. Results: We present a 63 year-old woman with chondronecrosis of the thyroid cartilage after chemotherapy and radiotherapy. This patient presented with many risk factors (diabetes, chest distress and cardiovascular disease) which could have inﬂuenced the development of the chondroradionecrosis after radiation therapy, especially concurrent chemotherapy. It is important to rule out the recurrence or persistence of the primary tumour in the cases where chondronecrosis is suspected. This differential diagnosis may not be easy, as imaging by MRI or CT scans are not always useful, in our case tridimentional reconstructions of the laryngeal CT and surgical specimen photographs are shown. Our patient ﬁnally required a total laryngectomy due to frequent aspirations and pneumonias. Diagnosis and treatment of this entity are discussed. Conclusions: Even though the combination of chemotherapy and radiation therapy is increasing for laryngeal cancer treatment, the presence of chondroradionecrosis of the larynx is a complication to keep in mind when following this therapy.

HP 58 Laryngotracheal NonHodgkin’s lymphoma M. D. Cobzeanu*, V. Costinescu*, Carmen Daniela Rusu*, I. Hantescu*, A. Arama**, Sultana Mihailovici***, Delia Ciobanu***, M. Grigoras****, L.Miron***** *ENT Clinic, ‘‘Sf. Spiridon’’ Hospital, Iasi, Romania **Pneumology Hospital, Iasi, Romania ***Histopathology Department,‘‘Sf. Spiridon’’ Hospital, Iasi, Romania ****Radiodiagnostic Department, ‘‘Sf. Spiridon’’ Hospital, Iasi, Romania *****Oncology Department, ‘‘Sf. Spiridon’’ Hospital, Iasi, Romania Objective: Malignant lymphomas of larynx and trachea are rare tumors and require special diagnostic and therapeutic attention. The authors present an unexpected case of nonHodgkin Lymphoma localized in the subglottic larynx and upper cervical trachea. The clinical presentation, diagnostic and therapeutic approach, evolution and prognosis are discussed. Methods: We report a case of 25-year-old man patient, with anamnestic progressive dyspnea, presented in our ENT Depart-

S89 ment with severe airway obstruction caused by a large subglottic tumoral mass migrated in glottic space during an accidental fall of pacient. An emergency tracheotomy was performed. The ﬂexible endoscopy and CT-scan revealed a large pedunculated mass arising from the subglottic larynx and anterior wall of upper cervical trachea with the obstruction of 2/3 from laryngotracheal lumen. Results: After a complex assessment, the tumor was excised by external approach (median thyrotomy). The histopathologic exam of surgical specimen showed malignant nonHodgkin lymphoma and the immunohistochemical proﬁles were evaluated in order to establish the therapeutic strategy including combination chemotherapy in the Department of Oncology. Conclusions: Involvement of the subglottic larynx and trachea by lymphoma is an uncommon problem which can cause severe airway obstruction and requires multidisciplinary approach (ENT, pneumology, oncology/hematology). The clinicopathologic features of this case have been described and compared with previously reported cases.

HP 59 Spindle cell carcinoma of the larynx-inicial case report Zorica Novakovic1, Predrag Spiric1, Sanja Spiric1, Dalibor Vranjes1, Radoslav Gajanin2 1 ENT clinic, Clinic center Banja Luka, Bosnia and Herzegovina 2 Department of Pathology, Clinic center Banja Luka, Bosnia and Herzegovina Objecitves: Spindle cell carcinoma of the larynx is a very uncommon neoplasm. It takes less than 1% of all laryngeal malignancies. Proper diagnosis and understanding of tumor nature is essential for planning the treatment strategy. Methods: Case report of a 70-years-old man with three months symptoms of hoarseness and one month difﬁculties with breathing. Results: We performed biopsy in MLS. Pathohistology diagnosis with imunohistochemistry was:chondrosarcoma gradus III. Clinicali anterior commisurae and anterior parts of vocal codrs were involved. 5 mm subglottic spreading was noticed.We performed total laryngectomy wthout neck dissection (it was difﬁcult to choose side for elective neck dissection so we decided to ’’wait and see‘‘). Final pathohistology and immunohistochemistry diagnosis was Spindle cell carcinoma. Four months after surgery there is no signs of local recurrency or metastasis. Conclusions: Spindle cell carcinoma in our case was recognized as chondrosarcoma at moment of biopsy. With examination of all parts of tumor we found epithelial cells with squamous differentiation and spindle cells with elements of chondrosarcoma and osteosarcoma. Total laryngectomy was our choice although we perform partial laryngectomy in similar cases with SCC.

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HP 60 Development of newer dilatating stents made from poly (HEMA) based biopolymers for treatment of laryngo-tracheal stenoses in chidren. P. Janousˇ ek1, M. Prˇ a´dny´2, J. Vacı´ k2, A. Banˇasova´3, Z. Kabelka1 1 Paediatric ENT Departement, ENT Clinic of the 2nd Medical School, Charles University, Motol, Prague, Czech Republic 2 Institute of Macromolecular Chemistry, Academy of Sciences of the Prague, Czech Republic 3 Departement of Physiology Medical School, Charles University, Prague, Czech Republic Objective: In treating chronic stenosis of larynx and trachea, an unequivocal, generally-accepted approach has not been established. The predominant method of treatment is surgical. Other Methods applied include endoscopic (laservaporation, stents) and external procedures (split, graft). Methods: We have worked on the development of stents suitable for clinical use that exhibit a combination of useful properties (rigidity, absorbability, biocompatibility, microbial inactivity). The stents were developed by polymerisation of 2-hydroxyethylmethacrylate. Tests of physical properties included traction and pressure trials. Biological evaluation involved microbiological testing and testing the reactivity of the polymer in the subcutaneous tissue and airways of laboratory rats and rabbits. Implantation into the airways and ventilation function tests were practised. Results: Animal tests evinced that the implant evoked a minimal inﬂammatory reaction in the subcutaneous tissue and trachea. In addition, through measuring with a plethysmograph, it was proven that parameters of ventilatory function in animals were satisfactory after stent implantation. Conclusions: Stents produced on the basis of co-polymers of HEMA exhibit sufﬁcient properties of biocompatability and biological inertness.

HP 61 Cervico-mediastinal Hibernoma presenting with vocal cord paresis E. Kyrodimos1, N. Barbetakis2, A. Varsamis1, I. Thomaides1, Th. Sidiras1 1 Department of Otolaryngology-Head and Neck Surgery, ‘‘Theagenio’’ Cancer Hospital, Thessaloniki, Greece 2 Department of Thoracic Surgery, ‘‘Theagenio’’ Cancer Hospital, Thessaloniki, Greece Objective: Hibernoma is a rare benign tumor usually derived from vestigial remnants of brown adipose cells. The location of these tumors usually parallels the normal anatomical distribution of brown fat in humans. Head and neck locations are rarer and

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 usually asymptomatic. We report a case presented with vocal cord paresis. Case report: A 52-year-old male was presented in the outpatient department with symptoms of coughing and slowly worsening hoarseness. No other symptoms were present. A right true vocal cord paresis was revealed on the ﬁberoptic examination. A soft encapsulated mass was identiﬁed in the right tracheosophagyal groove during the neck and mediastinal exploration. The mass was dissected inferiorly to the level of the aortic arch and removed through the neck. The location of the tumor in the anterior aspect of the neck was compressing the trachea and resulting with symptoms of hoarseness. The macroscopic and microscopic ﬁndings were suggestive of a cervico-mediastinal hibernoma. The patient made an uneventful recovery and after one year follow up period there has been no recurrence. Conclusion: The hibernoma is a rare benign tumor and in our case, although it originated from the mediastinum, resulted in functional abnormality causing neuropraxia (vocal cord paresis) due to compression. The removal of the tumor relieved patient’s symptoms but close follow up is needed to prevent local recurrence.

HP 62 Simple suture’s optimal position for glottis widening. Experimental sutdy on cadaversnves L Szaka´cs, G Smeha´k, A Torkos, L Rovo´ ENT Department, University of Szeged, Hungary, Tisza L. Krt. 111 Szeged, Hungary Objective: Attention to vocal cord lateroﬁxation by a ‘‘simple’’ suture was drawn by the feasibility of glottis widening. The authors used cadaver larynges for examining the optimal position of the suture(s), because it may determine both short and long term results. Methods: Three Methods were examined with the use of digital area measuring on 60 cadaver larynges: vocal chord lateroﬁxation (VL) where one lateroﬁxing suture was positioned on the vocal process and one in front of it; arytenoid lateroﬁxation (AL) where the lateroﬁxing suture was positioned with consideration of the physiological rocking mechanism of arytenoid cartilage; and King-Schobel method (KS). Results: The average unilateral glottic area (measured from the glottic midline to the edge of the vocal cord) gained by VL was 80.66 mm2 ; by AL was 124.11 mm2; and by KS was 107.73 mm2. AL produced signiﬁcantly better results than VL (P < 0.01). Also signiﬁcant difference was measured between KS and VL, odd to the ﬁrst (P < 0.01). The difference wasn’t signiﬁcant between AL and KS (P = 0.12). Conclusion: The results support the clinical observation of the authors, that the ideal place of ﬁxating sutures is the one, which provides physiological abduction position of the arytenoid cartilages.

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HP 63 Videostroboscopy and the management of laryngeal oncocytic cyst

HP 65 Results of hemilaryngectomy in treatment of laryngeal carcinoma

Scott L. Lee1, Sara C. Scheid2 1 Albany Medical College, Division of Otolaryngology Head & Neck Surgery, 35 Hackett Blvd, MC-41, Albany NY 12208, USA 2 Capital Region Otolaryngology Head and Neck Group, 6 Executive Park Dr., Entrance C, Albany, NY 12203, USA

Jovica Milovanovic1, Vojko Djukic1, Ivan Baljosevic2, Predrag Stankovic1, Vladimir Djordjevic1, Zeljko Petrovic1, Bojan Pavlovic1 1 Institute of Otorhinolaryngology and Maxillofacial Surgery, Pasterova 2, 11000 Belgrade, Serbia 2 Institute for Health Care of Child and Mother, Belgrade, Serbia

Objective: Oncocytic cysts of the larynx are a subgroup of laryngeal cysts that typically originate in the ventricle and present later in life. These are rare lesions and may be solitary or multiple. Symptoms range from mild and nonspeciﬁc, to airway obstruction necessitating emergent management. We present a case report of an oncocytic cyst of the larynx, review the histopathology, and the pre and postoperative videostroboscopic images. Methods: Case report. Results: A preoperative videostroboscopic examination demonstrated a cystic laryngeal lesion at the right anterior ventricle. The mass impinges on the vocal fold, limiting its mobility with noted aperiodicity in vibration. The patient proceeded with a mucosal preserving excision under suspension microlaryngoscopy. Postoperatively, mild Renke’s edema persisted, but an improvement in mucosal waves was demonstrated on videostroboscopy, There was no evidence of recurrence. Conclusions: Oncocytic cysts are rare lesions of the larynx characterized by oncocytic epithelial proliferation. These lesions are benign and complete excision is the treatment of choice. Advances in laryngoscopic evaluation, such as by videostroboscopy in the ofﬁce setting, aid in the preoperative diagnosis, assessment of mucosal wave impairment, and postoperative follow up for patients with laryngeal pathologies.

HP 64 Voice prosthesis in voice restoration after total laryngectomy-complications Predrag Spiric, Zorica Novakovic, Sanja Spiric, Dalibor Vranjes ENT clinic, Clinic center Banja Luka, Bosnia and Herzegovina Objective: TE puncture with voice prosthesis is widely accepted as good, fast and safe procedure. Anyway it is followed by different complicationes. Some of them can be serious. All precautions should be applied during and after surgical procedure in order to minimize risk. Among other criteria social, economical, educational level of candidate must be considered as well as individual habits. With this overview of complications that we experienced we wanted to stress in what one can stuck if underestimate chalenges of inserting the voice prosthesis. Methods: We analized 25 patients with PROVOX 1 and 13 PROVOX 2 prosthesis inserted in six years peroid. All complicationes were conunted and succes rate was expressed in percentage. Each complication was individualy described. Results: In 6 years period we had 25 patients with PROVOX 1 and 13 with PROVOX 2 prosthesis. We had patients with one or multiple reinsertions with PROVOX 2. Wide range of complication were described. All are devided in three groups, ﬁrst due to anesthesia, second during or immediately after surgery and third were late complications. Different reasons and therapeutic strategies were discussed. Conclusions: TE with voice prosthesis insertion is safe procedure and method of choice in selected patients. Not all laryngectomized patients are candidates for voice prosthesis. Complications are inevitable but can be minimazed if you follow certain procedures and therapeutic protocols.

Objective: To assess postoperative results of hemilaryngectomy in patients with T2 carcinoma of larynx, including appearance and treatment of local and regional reccurences, and assessment of functional status after treatment. Methods: We present a retrospective study of 438 patients with glottic carcinoma, treated with hemilaryngectomy, at the Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia between 1988 and 1997. Results: The patients with positive margins (19.4% of all) were postoperatively irradiated. Local recurrences of carcinoma were found in 17.3% of subjects, and regional recurrences in 16.4% of subjects. Those patients were treated with total laryngectomy or radical neck dissection, and with radiotherapy. 5-years survival rate in our patients was 79%. Conclusions: Hemilaryngectomy provided acceptable percent of local and regional recurrences, and good functional results: respiration, swallowing and voice quality. Therefore it could be the ﬁrst choice surgery technique in treatment of T2 laryngeal carcinoma.

HP 66 Low grade chondrosarcoma of the cricoid cartilage. A case presentation C. Ikonomidis, P. Konu, E. Stauffer, D. Meier. Clinic of Oto-Rhino-Laryngology, Head and Neck and Maxillofacial Surgery, Hoˆpital Cantonal of Fribourg, Switzerland Objective: A case of a low grade chondrosarcoma of the cricoid cartilage is presented, underlying the importance of conservative surgery as treatment of choice. Methods: A 52-year old man presented with persistent hoarseness, which had developed progressively in a 6 months period. The investigations by nasoﬁbroscopy, CT scanner, MRI and endoscopy, revealed a low grade chondrosarcoma of the cricoid. (mass of about 4 · 3 cm situated in the cricoid’s postero-lateral right part.) Results: The patient was treated with conservative surgery by external approach (thyrotomy). The anatomopathologic image showed an invasive and good differenciated (G1) chondrosarcome of the cricoid cartilage.No indication for radiotherapy was posed for this case and the decision for a clinical and radiological follow-up was taken. One year later, this patient presents no recurrence. Conclusions: Chondrosarcomas of the larynx are rare tumors that present a slow and progressive evolution. They have a low metastatic potential but local recurrence is common. They represent less than 1% of cartilaginous tumors of the body and less than 0.2% of laryngeal tumors. Approximately 300 cases have been documented in the literature since 1900.Conservative surgery is the treatement of choice. Radiotherapy is indicated in speciﬁc cases.

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HP 67 Results of extended supraglottic laryngectomies Zeljko Petrovic, Vladimir Djordjevic, Vladimir Nesic, Vojko Djukic, Aleksandar Trivic, Jovica Milovanovic, Sead Ljajic Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Centre of Serbia, Belgrade Objective: The objective of the study was to analyze the success of the extended supraglottic laryngectomy in relation to classical supraglottic laryngectomy in indicated cases. Method: The study was retrospective and included the patients with evidenced and patohistologically veriﬁed carcinoma of the supraglottis diagnosed and treated in our Institute, during the period 1976–2001. The total of 461 patients with supraglottic laryngeal cancer were primary treated by surgery using the method of supraglottic laryngectomy. Classical supraglottic laryngectomy was performed in 401 patients, while 60 underwent extended supraglottic laryngectomy. Results: T1 tumor was found in 193 (41.9%) patients, T2 in 240 (52.1%), while T3 was found in 28 (6.0%) cases. Local recurrence developed in 3 out of 60 patients operated by the extended supraglottic laryngectomy, and in 19 out of 401 operated by classical supraglottic laryngectomy (v2 = 0.008, DF = 1, P = 0.929; Yates = 0.000, P = 1.00). Five-year survival of patients operated by the extended supraglottic laryngectomy was reported in 45 out of 60 patients, while survival of patients operated by classical supraglottic laryngectomy was noted in 305 out of 401 cases (v2 = 0.032, DF = 1, P = 0.858; Yates = 0.000, P = 0.986). Conclusion: There was no signiﬁcant difference of local recurrence and ﬁve-year survival between patients treated by classical and extended supraglottic laryngectomy.

Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 stage T1 and T2 for cure, with oncologic and functional results superior to those of conventional surgical procedures when the indications, contraindications, general principles and technique of endoscopic CO2 laser surgery are correctly applied.

HP 69 Larynx Pacing: a new minimal invasive approach for electrode insertion via cricoids cartilage G. Fo¨rster, A. Mu¨ller Klinik fu¨r HNO-Heilkunde/Plastische Operationen, SRH Waldklinikum Gera, Straße des Friedens 122, 07548 Gera, Germany Objective: In 2003 Zealear et al. showed for the ﬁrst time that laynx pacing in humans with recurrent laryngeal nerve palsy is possible. As part of our own efforts to improve the concept of larynx pacing we thought of new ways to insert the stimulation electrodes with the least possible surgical trauma. Methods: The method was tested during total laryngectomy procedures due to advanced laryngeal carcinoma. Results: Electrical stimulation caused an opening of the vocal fold. The required current was in the same dimension as is needed for an excitation of nerve ﬁbres. The project was sponsored by the German Federal Ministry of Education and Research (Project No. 01EZ0335).

HP 70 Voice quality after laser and open neck surgery for T2 glottic carcinoma

HP 68 Our experience in the endoscopic LASER surgery of glottic cancer

F. Palonta, M. Bussi, R. Teggi, F. Lira Luce, L.Giordano San Raffaele Hospital- Vita e Salute University, Via Olgettina 6020132 Milano

Caius Doros, Stan Cotulbea, Stelian Lupescu, Marioara Poenaru, Cristian Sarau ENT Department, Cardiology Department University of Medicine and Pharmacy ‘‘Victor Babes’’ Timisoara

Objective: The T2 vocal fold tumor therapy allow the preservation of respiration and deglutition. The quality of phonation is the most important criterion for the patient. The aim of the study is to retrospectively compare vocal function after treatment of T2 glottic tumors by endoscopic surgery and open neck supracrycoid laryngectomy. Methods: Twenty patients, having very similar oncological conditions, but different treatment, were included in the study: 10 underwent supracricoid laryngectomy using an external approach, and 10 underwent an endoscopic laser surgery. Videolaryngoscopy and laryngostroboscopy were performed for each subject. We performed an objective and subjective evaluation of speech. Voices were perceptually reated by an experienced phoniatrician using the GRBAS scale and by subjective Voice Handicap Index. We evaluated hospitalization time, need for and duration of feeding tube and tracheotomy, and complications. Results: Laser surgery had signiﬁcantly better conditions concerning time of hospitalization, peri and post operative complications. Open neck surgery had a long stay in the hospital and more intra and postoperative complications, scar tissue impairment, bad compliance. But from a functional point of view, after a 2 year period of follow up, they showed a slightly better voice. Conclusions: Post treatment voice results can have signiﬁcant impact on the patient’s quality of life and his ability to maintain employment. Even though a slightly better voice was found after open surgery, no statistically signiﬁcant difference was measured in the two groups.

Objective: The CO2 laser surgery is a modern method in the treatment of laryngeal glottic cancer. In the ENT Department Timisoara during a period 01.01.1997–31.12.2006 were operated 261 patients with laryngeal glottic cancer stage T1a (56 patients), T1b (28 patients), T2 (160 patients) and T3 (17 patients) by endoscopic CO2 laser surgery. The purpose of the study was to analyze the surgical, functional and oncologic results. Methods: Endoscopic laser CO2 microsurgery was the primary and solitary management for curative resection of the glottic cancer performing four types of cordectomies (Type I, II, III, IV) depending of the stage of tumor. All operations were performed under general anesthesia with orotrachel intubation; tracheotomy was not necessary. Preoperative evaluation of carcinoma and postoperative control examination included modern videoendoscopical procedures and CT-scan or sonography of the neck. The mean follow-up was 36 months. Results: We obtained the following oncologic results: no reccurence of disease in 94.3% (246 patients), local recurrence in the larynx in 5.7% (15 patients). The functional results obtained in our series were very good and good in 73.9% (193 patients) of cases. Conclusions: The endoscopic CO2 laser surgery is in our view the elective and preferable surgical method in laryngeal glottic cancer

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HP 71 The management of laryngo-tracheal rupture and separation A´kos Reme´nyi, Gyo¨rgy Lichtenberger Szent Ro´kus Hospital, Dept of ORL-HNS, Budapest, H-1085, Gyulai P. u. 2, Hungary Objective: The authors describe the case of a patient whose trachea has been separated off from the larynx after self-hanging. Methods: The patient undervent urgent tracheotomy and transmitted to the department of the authors. In the course of admission it has been seen that a gap of continuity of several centimetres was present between the cricoid cartilage and the broken-off trachea. In this area the vaulting of the trachea was conspicuous. Based on indirect examination, the vocal cords were in paramedian position. After excision of the wound edges the continuity of the larynx and trachea was restored by end to end anasthomosis. After healing of the wound, some months later partial arytenoidectomy and submucosal cordectomy was performed with laser, preserving and lateralizing the medial mucous part of the vocal cord according to Lichtenberger. Than the patient was decannulated. Result: Five years have passed since the performed operations and the closing of the tracheostoma. The breathing of the patient is satisfactory, the voice is slightly weaker than normal, but can be well accepted for every day conversation. Conclusions: This case represents, that also combined laryngotracheal injuries could be managed with satisfactory result performing adequate techniques in appropriate time.

HP 72 Solitary plasmocytoma of the epiglottis. Presentation of a clinical case and review of the literature J. Urbancic, J. Fischinger, A. Zupevc University Department for Otorhinolaryngology and Cervicofacial Surgery, Ljubljana, Slovenia Solitary plasmocytoma is very rare tumor of the head and neck. It represents less than 1% of the malignancies in this region. Although difﬁcult it has to be differentiated from multiple myeloma early. Since this determines the initial treatment. We describe a female patient with solitary plasmocytoma of the laryngeal part of epiglottis with surgery as primary treatment modality. Characteristics of disease, diagnostic criteria and therapeutic possibilities are reviewed.

HP 73 Laryngeal dysplasia: a management conundrum Khushnood Alam, Philip Michael, Andrew Batch City Hospital, Birmingham, UK Objective: Laryngeal dysplasia presents a management conundrum. There is a risk of progression from dysplasia to invasive carcinoma. The management of dysplastic changes is controversial. There are no clear guidelines as to the length of follow-up time for this patient group. Early detection can be difﬁcult but is

S93 essential in reducing the chance of disease progression. Studies have concluded that patients with laryngopharyngeal reﬂux have a high incidence of laryngeal carcinomas or dysplasia. This should be considered with smoking and alcohol consumption as risk factors for laryngeal cancer. Methods: Our three patients had evidence of laryngeal dysplasia on laryngoscopic examination. There was a high index of suspicion of laryngopharyngeal reﬂux after ﬂexible gastroscopic examination in all three cases. These patients were commenced on high-dose anti-reﬂux medication in the form of proton-pump inhibitors and followed up with nasendoscopic examination to assess disease progression. Results: Our patient group had a variable outcome. During the follow-up period our ﬁrst patient demonstrated regression of dysplastic changes. The second patient had no real change. The third patient did unfortunately progress to a T2 N0 M0 squamous cell carcinoma during the course of follow-up. He was managed with external beam radiotherapy. Conclusions: We conclude that the ﬁndings demonstrate the importance of considering the role of laryngopharyngeal reﬂux in the management laryngeal dysplasia. Oesophagogastroscopy and repeat biopsy in the conﬁnes of long-term, close, follow-up should be a key part of the management of these patients.

HP 74 Tuberculosis: a rare differential diagnosis of laryngeal lesions Khushnood Alam, Heather Beaumont, Philip Michael, Andrew Batch City Hospital, Birmingham, UK Objective: Laryngeal tuberculosis (TB) is a rare disease usually associated with pulmonary TB and accounting for less than 1% of all TB cases. The variable clinical presentation of laryngeal TB may generate diagnostic confusion with other laryngeal diseases such as chronic laryngitis and laryngeal carcinoma. Laryngeal TB is the commonest ENT manifestation of tuberculosis and is readily treatable with anti-tuberculous therapy. Methods: We present the case of a 49-year old Vietnamese gentleman. He was a smoker of 20 years and had been resident in the United Kingdom for the past 26 years. He complained of a 2-week history of sore throat associated with haemoptysis and a 3-kg weight loss over the preceding week. Results: An initial referral was made to the otolaryngologist from the respiratory physicians who noted an inﬂamed and swollen epiglottis on bronchoscopic examination. Clinical endoscopic appearances at a subsequent microlaryngoscopy were thought highly suggestive of a carcinoma but subsequent histological and microbacterial investigations indicated a tuberculous aetiology. Conclusions: With the United Kingdom population becoming increasingly multicultural and foreign travel becoming more widespread, the rates of tuberculous disease are rising. Therefore, while the index of suspicion of an underlying mycobacterial pathology was high in this case, the otolaryngologist should elevate the consideration of tuberculous infection in the differential diagnosis of laryngeal lesions in order to institute swift therapy and counsel contacts.

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HP 75 Apneic anaesthesia with intermittent ventilation (AAIV) under propofol, in laryngeal microsurgery Anastasia Konstantinou, Antelina Kotsa, Errika Dermitzaki, George Banos ENT and Department of Anaesthesiology, GH of Halkis, Greece Objective: Apneic anaesthesia with intermittent ventilation (AAIV) has been reported to provide a good visualization and immobile ﬁeld for microscopic laryngeal surgery. Methods: We evaluated AAIV using total intravenous anaesthesia with propofol and fentanyl instead of inhalational anaesthesia on respiration and circulation in 34 patients undergoing microsurgery of the larynx. As the technique is considered potentially hazardous in those patients with upper airway obstruction, such patients were excluded in this study. Anaesthesia was started and maintained with infusion of propofol and intermittent administration of fentanyl and intravenously. The patients were ventilated with 100% oxygen and the period of intermittent apnea, guided by pulse oximetry and periodic measurement of end-tidal carbon dioxide (CO2) levels, the endotracheal tube was removed. Results: The number of periods of apnea (mean ± SD) was 3.2 ± 1, and the duration of apnea was 265 ± 43 s. Neither blood pressure nor heart rate changed during the apneic periods. No signiﬁcant complications have occurred with AAIV. Contraindications to AAIV are age less than 2 years, signiﬁcant cardiopulmonary disease, and any hypermetabolic state. Conclusions: We conclude that AAIV using total intravenous anaesthesia, under constant monitoring of Spo2 is a useful and safe technique.

HP 76 Subglottic neuroﬁbroma associated with von Recklinghausen disease (Casereport and review of the literature) Anastasia Konstantinou, George Banos, Athanasios Sakellaridis ENT Department, GH of Halkis, Greece Objective: Neuroﬁbromas of the larynx are extremely rare especially in the subglottic part. They occur in association with neuroﬁbromatosis less frequently than solitary neuroﬁbromas Methods: We describe a 24-year-old man with neuroﬁbromatosis, presented to our department of otolaryngology with a 10-month history of slight exertional dyspnea, without pain or dysphagia. The patient was diagnosed as having neuroﬁbromatosis type 1 (von Recklinghausen’s disease (NF1), by the established criteria. NF1 is known as peripheral NF with cardinal ﬁndings, including peripheral neuroﬁbromas, cafe´ au lait spots, freckles, and Lisch nodules. Fiberoptic laryngocopy revealed a round smooth surfaced submucosal subglottic mass.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Results: The tumor was removed completely using an endolaryngeal approach without an external incision. A deﬁnitive diagnosis of a laryngeal neuroﬁbroma was based on the histopathologic demonstration of the characteristic spindle cells, and a positive result in immunohistochemical staining for S-100 protein. There has been no recurrence after a follow-up of 2 years. Conclusions: In the literature, a total number of 16 cases, laryngeal neuroﬁbromas were documented in patients with NF1. Neuroﬁbromas of larynx occur most commonly in supraglottic area (arytenoids and aryepiglottic fold), due to the abundance of sensory nerves at that location, as motor ﬁbers are less involved. Due to their slow growth nature, laryngeal neuroﬁbromas can remain symptom free for years or become pathogenic since birth, depend on their location and size. A change in voice, dysphagia, or respiratory difﬁculty can constitute the spectrum of symptoms. Surgical excision is the treatment of choice.

HP 77 Radiosurgery application in the larynx through ﬂexible endoscope Jose´ M. Colio*, Valentı´ n Madrid**, Fe´lix Ruiz de la Cuesta*, Luis Cambra* *ENT Department, Marina Alta Hospital, Denia, Spain **Anaesthesia Department, Marina Alta Hospital, Denia, Spain Objective: Presentation of a new technique which combines 4.0 MHz radiofrequency and the ﬂexible endoscope for removal of benign laryngeal lesions. Method: Laryngeal lesions for which this technique is indicated are benigns. Malignant lesions would be excluded from this indication. Topical anaesthesia is applied, ﬁrst by nebulisation and then directly (as you go) onto the lesion. Light sedation can be used in nervous patients. The ﬁberscopes used are an OLYMPUS with an external diameter of 4.8 mm and a working channel of 2.2 mm and a STORZ with an external diameter of 3.7 mm and a working channel of 1.5 mm. As the source of the radiowaves we use a SURGITRON DUAL 4.0 MHz unit manufactured by Ellman International. The energy is applied to the lesion by means of a microﬁber electrode (from the same manufacturer) through the working channel. Results: Lesions removed include polyps, angiomas, nodules and a granuloma of 16 mm diameter. The patients remained awake and cooperative and the tolerance was excellent in 9 of 10 cases operated. There was no abnormal scarring or oedema in the post-operative period. Early discharge in 3–4 h is also an important factor. Conclusions: The radiosurgery to the larynx through the ﬂexible endoscope is a safe and efﬁcient method for the treatment of benign lesions of the larynx. In those patients in whom general anaesthesia would be a major risk, this technique would be the method of choice.

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HP 78 Pharyngocutaneous ﬁstula following total laryngectomy

HP 80 Control of haemorrhage by transoral removal of laryngeal haemangioma

Cem Ozer*, Erdinc Aydin*, Fulya Ozer*, Haluk Yavuz*, Cuneyt Yilmazer*, Levent Naci Ozluoglu* *Baskent University Faculty of Medicine, Department of Otorhinolaryngology Head and Neck Surgery, Ankara, Turkey

A. Bihari, A´. Reme´nyi, S. Leitersdorfer, G. Lichtenberger Szent Ro´kus Hosp. and Inst., Department of ORL-HNS, 1085 Budapest, Gyulai Pa´l u. 2., Hungary

Objective: The objective of this study was to investigate the incidence and predisposing factors of pharyngocutaneous ﬁstula (PCF) following total laryngectomy. Methods: In this retrospective study, the medical records of 75 patients who underwent total laryngectomy were reviewed. Age, sex, smoking and drinking habits, presence of systemic diseases, preoperative tracheotomy, previous radiotherapy, duration of general anesthesia, concurrent neck dissection, partial pharyngectomy, type of pharyngeal closure (T versus horizontal), size and site of origin of the tumor, clinical stage of the tumor, status of surgical margins, histologic grade, perioperative transfusion, postoperative Hb level and time of postoperative oral feeding were analyzed as potential risk factors in ﬁstula formation. Results: A pharyngocutaneous ﬁstula was observed in nine (12%) patients. Among the possible risk factors investigated, preoperative radiotherapy was signiﬁcantly associated with PCF. Also, a signiﬁcant decrease in the rate of ﬁstula formation was found in patients orally fed on or before the ﬁfth postoperative day compared to those orally fed on or after the seventh postoperative day. Other factors were failed to show statistical signiﬁcance. Conclusions: Evaluation of the risk factors for PCF in our series indicates that early postoperative oral feeding signiﬁcantly decreases the rate of ﬁstula formation which was emerged for the ﬁrst time in the literature. The time after which it is safe to initiate oral feeding is still a topic of debate and further controlled prospective multicenter studies are needed to conﬁrm our ﬁndings.

HP 79 Laryngocele: an unusual late complication of subtotal laryngectomy Dimitrios Lefantzis, Chrysa Lyra, Minas Artopoulos, Kostantinos Christidis ENT Department, The Red Cross Hospital, Athens, Greece Objective: Laryngoceles usually have a congenital origin or coexist with laryngeal carcinoma. Laryngocele is the result of the dilation of saccule due to functional or true anatomic obstruction of the laryngeal ventricle.There also must be an important association with laryngeal carcinoma because while the incidence of laryngoceles in normal larynx was found to be about 2%, laryngoceles occurred in 18% of specimens when carcinoma was present.However laryngocele can be a late complication of partial laryngectomy. Methods: We present an unusual case of laryngocele occurring to a 49-year-old man who underwent a partial laryngectomy due to laryngeal carcinoma. Results: The main symptom of our patient, persistent hoarseness, and the endoscopic documentation of a laryngeal mass indicated the recidivation of the disease. Conclusions: The purpose of this presentation is to increase doctors’ alertness in facing postoperative laryngoceles.

Objective: Laryngeal haemangioma in adults is a rare condition. It may cause hoarsness, coughing and dysphagia. Nowadays laser surgery is the most common procedure, to treat these patients. Patients and methods: We present three cases of laryngeal and hypopharyngeal haemangioma in adult patients. Theirs complaints were: hoarsness, dysphagia, and coughing. The location of the lesions were in one case on the ary-region and on the false vocal cord, and in the other two cases at the postcricoid region. After check-up all patients were treated surgically, using CO2 laser endoscopically. In two patients after removing of the haemangioma, the coagulation of bleeding area was sufﬁcient. In one patient, who had a larger lesion at the postcricoid region, the coagulation was not sufﬁcient to control haemorrhage. There we had to adapt the mucosal edges around the wound bed and suture them using the ligature-suture technique and instrument by Lichtenberger. Results: There were no complications. Histology proved to be in all three cases cavernuos type haemangioma. All patients have remained free of recurrence, and have no complaint. Conclusion: These cases present, that most laryngeal haemangiomas (under a reasonable size) can be safely managed with endoscopic laser surgery. At larger lesions the bleeding may cause difﬁculties. The ligature-suture technique by Lichtenberger helps us to overcome this problem.

HP 81 HO:YAG and KTP lasers in the microsurgery of the larynx D. M. Mustafaev, Z. M. Ashurov, E. V. Osipenko Ruusia, Moscow Objective: The aim of the research is the increase of the efﬁciency of surgical treatment of the patients suffered from benign lesions using the endolaryngeal microsurgery with the help of Ho: YAG and KTP of the lasers in the conditions of the transcatheter highfrequency artiﬁcial ventilation of the lungs (THFAVL). Materials: One hundred and ninety-eight patients examined from 6 to 75 years suffered from papillomas and polypus of the larynx (2003–2007). The efﬁciency of the microsurgery Ho:YAG and KTP using the lasers has been controlled by the measurement of the acoustic parameters of the voice and the research of the function of external breath (FEB) and bodyplethysmography. Results: before the operation 100% of the patients have dysphonia. The changes of permeability of the out of pectoral department of the respiratory ways of the ﬁrst degree was typical of 12.12% After the operation the voice has recovered at 78.1% of the patients, the improvement of the voice was typical of 18.8%, there were no changes in the health conditions at 3.1%. The restoration of permeability out of pectoral of the department of the respiratory ways was typical of 93.4% of the patients. Conclusion: (1) The use of Ho:YAG and KTP of lasers in microsurgical treatment benign lesions provides exsanguinity, smaller inﬂammatory reaction in comparison with instrumental methods of the endolaryngeal microsurgery; (2) THFAVL produces maximum convenient and safe conditions for surgeon’s actions in the terms of microsurgery of the larynx using the lasers.

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HP 82 Basaloid squamous cell carcinoma of the larynx: a case-report S. Vlachou1, A. Karageorgopoulos1, G. Plessas1, G. Terzakis1, C. Barbatis2, G. Papazoglou1 1 ENT Department, Red Cross Hospital, Athens, Greece 2 Department of Pathology, Red Cross Hospital, Athens, Greece Objective: Basaloid squamous cell carcinoma (BSCC) is a recently introduced subtype of laryngeal cancer, with less than 50 cases presented since 1986. We report such a case diagnosed and treated in our Department. Method: The patient presented 4 years ago because of odynophagia. The clinical examination revealed leukoplacia of the oropharynx, and a suspiscious foci on the tonsil. Biopsies taken showed a non keratinized squamous cell carcinoma, grade III. The patient was submitted to radiotherapy. One year later, in a follow up visit, there was a lesion in the right glottis and adjacent arytenoid. Direct laryngoscopy and biopsy revealed laryngeal cancer. The patient was operated on and had a total laryngectomy. The tumor invaded the right glottis, the thyroid cartilage, the laryngeal walls, extending to the right thyroid lobe. The ﬁnal histology was that of a BSCC. The tumor tested positive for CEA and high molecular weight cytoceratines, while vimentin, CK 29 and a-sma were negative. Results: The patient passed away 1 year ago. Conclusion: BSCC is a comparatively new type of SCC, with a more aggressive clinical course.

HP 83 Rare laryngeal tumors. Presentation of 46 cases G. Dritsas, G. Mireas, A. Karageorgopoulos, E. Nikolaidis, M.-F. Graikou, S. Triantos, G. Papazoglou ENT Department, Red Cross Hospital, Athens, Greece Objective: The purpose of the present study was to present our data on rare laryngeal tumors.. Methods: We report 46 consecutive cases diagnosed and treated in our Department within 7 years (1998–2004). The patients were 7 women and 39 men, 25 to 72 years old, who presented mainly with hoarseness, and some of them with odynophagia, neck swelling and dyspnea. All patients were admitted, clinically examined, and submitted to laboratory workup, including neck CT with contrast scan and underwent direct laryngoscopy and biopsy. Results: The histological examination revealed the following tumor types. A: benign tumors. 1 neurilemmoma, 1 hemangioma, 1 chondroma, 1 paraganglioma, 1 rabdomyoma. B: Malignant tumors 25 verrucous Ca, 5 mucoepidermoid Ca, 3 oat cell, 1 basaloid, 1 adenoid cystic, 2 neuroendocrines, 2 spindle cell carcinomas and 2 sarcomas.Depending on the histological type and tumor staging the patients underwent different type of management including laryngectomy, neck dissection, radiation therapy or chemotherapy. Conclusion: The knowledge of the histological type along with the tumor staging determines the treatment in each since it is related to the biological behavior of the tumors.

HP 84 High resolution magnifyng endoscopy: a new diagnostic tool also fu¨r laryngeal examination? Claudio Parrilla, Mario Rigante, Giovanni Cammarota*, Eugenio De Corso, Luigi Corina, Giovanni Almadori, Gaetano Paludetti, Jacopo Galli Institute of Otolaryngology and Gastroenterology; *Catholic University of Sacred Heart, Rome, Italy

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Objective: To introduce the use of new high resolution magnifyng endoscope in the endoscopic examination of the upper aerodigestive tract and discuss the usefulness of this tool in the diagnosis of laryngeal lesions. Study design: Comparison between traditional electronic videoendoscopy and new high resolution magnifyng endoscopy. Methods: Twenty-six patients presenting different laryngeal pathologies were examinated by means of an electronic videoendoscope and a high resolution magnifyng endoscope. The images obtained were examinated and compared. Results: In the 26 patients observed, the clinical diagnosis was changed with high magniﬁcation and digital image processing in four patients. In 22 patients the high magniﬁcation examination allowed a better description of the laryngeal lesions without leading to a signiﬁcant switch in the diagnosis. In the cases of leukoplakia there were a more detailed examination of colour, extension and thickness of the lesion, surface and borders irregularities, with easy characterisation of aspect of neighbour laryngeal mucosa. Furthermore the optical magnifying zoom does not require a close approach to the laryngeal mucosa to well characterize the lesions so less local anaesthesia is required. Conclusions: The high resolution magniﬁed images obtained with this new tool provide precious information on the color of the lesions, on their tridimentional aspects and precise extension in the laryngeal structures. This new endoscopic technology, as already happen in gastric, esophageal and colorectal pathologies, can be also improved by using chromoedoscopy and other vital stain techniques in order to provide precious information about pre-neoplastic lesions of the larynx.

HP 85 Solution of dyspnoe due to paradoxical vocal cord movement Judit Falvai, Krisztina Me´sza´ros*, Gyo¨rgy Lichtenberger Szent Ro´kus Hospital and Institutions, Department of Otorhinolaryngology, Head and Neck Surgery, 1085 Budapest, Gyulai Pa´l u. 2., Hungary *National Medical Center, 1135 Budapest, Szabolcs u. 35., Hungary Objective: Paradoxical vocal cord movement is a very rare condition. It is characterized by the abnormal, conﬂicting adduction of the vocal cords during inspiration and abduction during exspiration. The treatment is complex: speech therapy, pharmacological therapy, psychotherapy, and/or surgical intervention, depending on the causative factors. Paradoxical vocal cord motion can imitate upper airway obstruction. It is a serious condition that requires prompt diagnosis and treatment. Case history: We report a young female patient presenting with inspiratory dyspnoe, stridor and dysphonia after upper airway infection. Examinations demonstrated paradoxical vocal cord motion without laryngological organic disorder. The patient underwent an endoscopic reversible endo-extralaryngeal lateralisation by Lichtenberger in general anaesthesia with high frecvency JET ventilation. Results: Postoperative control examination, lung function tests and phoniatric checking proved, that the patient’s breathing and voice became normal again. Probably the surgical thread-loop pressed the vocal cords to perform near physiological motion. Conclusion: This procedure may open a new way in solution of dyspnoe and acut respiratory distress due to paradoxical vocal cord movement.

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HP 86 Chondroma and chondrosarcoma of the larynx. Two case reports Sotirios Papouliakos1, Georgios Peristerakis1, Stamatios Fergadis1, Dimitrios Aggeletos1, Eyaggelia Zacharioudaki1, Spyros Kavvadias2, Zisis Pappas1 1 ENT Department, General Hospital of Athens ‘‘G.Gennimatas’’ 2 Radiology Department, General Hospital of Athens ‘‘G. Gennimatas’’ Objective: Cartilaginous tumours of the larynx represent less than 1% of laryngeal tumours, chondroma and chondrosarcoma being the most common. Laryngeal chondromas are rare benign tumours originating from the cartilagenous framework of the larynx (mainly from the cricoid cartilage). Chondrosarcomas are usually diagnosed with signiﬁcant delay due to nonspeciﬁc symptoms. We present two cases with cartilaginous tumours of the larynx that were diagnosed and treated to our department. Methods: The ﬁrst patient presented with hoarseness, progressive dyspnea, dysphagia and aspiration. Direct laryngoscopy revealed a glottic mass, while barium swallow was normal. CT scanning displayed a mass arising from the cricoid cartilage. The second patient presented with a neck mass. CT scan of the neck displayed a mass involving the cricoid cartilage. A biopsy was obtained revealing a chondrosarcoma. Results: On the ﬁrst patient total laryngectomy was performed and the histopathologic diagnosis was chondroma. Vertical partial laryngectomy was performed on the second patient and the histopathologic diagnosis revealed a low-grade chondrosarcoma of the cricoid cartilage. Conclusions: The clinical presentation of chondromas and chondrosarcomas of the larynx is varied and dependent on their size and location. The most common symptoms are hoarseness, dyspnea or a neck mass. CT scanning is necessary due to its ability to delineate tumour’s size and invasion into surrounding structures.Direct laryngoscopy and biopsy may be useful regarding diagnosis although it is not always easy to obtain a biopsy sample because of the tumour’s submucosal location. Surgical treatment is the standard therapy. Depending on the tumours extend wide excision or laryngectomy may be performed.

HP 87 Assessment of laryngeal epithelial hyperplastic lesions in the Ljubljana classiﬁcation* Pietruszewska Wioletta1, Bojanowska-Poz´niak Katarzyna1, Gryczyn´ski Maciej1, Durko Marcin1, Kobos Jo´zef2, 1 Department of Otolaryngology, Medical University of Lodz, Poland 2 Department of Pathology, Medical University of Lodz, Poland Objective: Diagnosis and treatment of laryngeal epithelial hyperplastic lesions have been frustrated because of failure to deﬁne the histologic changes that may predict the potential for progression to invasive carcinoma. To validate criteria for the grading of hyperplastic epithelial laryngeal lesion, we used a Ljubljana classiﬁcation.

S97 Methods: In a retrospective study, 68 biopsies of laryngeal hyperplastic lesions were classiﬁed according to the Ljubljana classiﬁcation comprising simple hyperplasia (benign spinous layer augmentation), abnormal hyperplasia (benign basal and parabasal layer augmentation), atypical hyperplasia (with a high risk for malignancy) and carcinoma in situ. Sixty-eight biopsies with preneoplastic changes were classiﬁed according to Ljubljana classiﬁcation. Results: We found 25 cases (36.8%) which showed simple, 23 (33.8%) abnormal, 18 (26.5%) atypical hyperplasia and 2 (2.9%) carcinoma in situ. Two cases of atypical hyperplasia (2.9% of all investigated cases) progressed to invasive carcinoma during the observation ranging from 5 to 9 years. None of the cases classiﬁed as simple or abnormal hyperplasia showed progression to malignancy. Conclusion: The Ljubljana classiﬁcation focuses on the important clinical decision involving benign lesion that do not require strict follow-up (simple and abnormal hyperplasia); and ‘‘risky’’ epithelium that require close follow-up with repeated histologic assessment (atypical hyperplasia); and carcinoma in situ that requires fast, complete treatment. We suggest that the Ljubljana classiﬁcation can be reliably applied for classifying all hyperplastic laryngeal lesions, may be essential for planning treatment and prognosis in those patients. *This study was supported by grant No 502-11-453 from Medical University of Lodz

HP 88 Laryngitis and anabolic steroids Shalina Ray, Ajmal Masood, John Pickles, Ioannis Moumoulidis Department of Otolaryngology, Luton and Dunstable Hospital, Luton, UK Objective: The effects of anabolic steroids on the quality of voice have been well documented; however, no study has established signiﬁcant structural changes in the larynx as a direct result of anabolic steroid use. We present a unique case of stridor due to severe laryngitis in a patient who regularly used anabolic steroids as a part of his body building training. Method: A 47-year-old male smoker and professional bodybuilder presented with progressive dyspnoea, stridor and hoarseness. He was a professional body builder and admitted abusing anabolic steroids regularly as a part of his routine training. Microlaryngoscopy revealed hyperaemic laryngeal mucosa, markedly congested and swollen supraglottis along with irregularly oedematous vocal cords Biopsy showed polypoid lesions with hyperkeratotic and hyperplastic epithelium. Results:Conservative management failed to resolve his symptoms and a planned tracheostomy was performed to secure his airway. Subsequently he was treated with multiple laser resections, and eventually decannulated. Conclusion: No previous cases found describing airway impairment due to laryngeal changes associated with chronic anabolic steroid use. The changes noted in the larynx were similar but more ﬂorid to those found in experimental animal studies. These changes in the human larynx have not been reported previously.

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HP 89 ‘‘Morphometric estimation of laryngeal cancer tissue’’ Tatiana Gierek1, Jaroslaw Paluch1, Jaroslaw Markowski1, Jacek Chraponski2, Jan Cwajna2, Marian Malin´ski2, Maciej Kajor3, Ewa Zielinska – Pajak3, Lucyna Klimczak-Golab1 1 ENT Department, Silesian Medical University, Katowice, Poland 2 University of Technical Science, Katowice, Poland 3 Department of Pathology, Silesian Medical University, Katowice, Poland The purpose of study was to determine the degree of differentiation of laryngeal squamous carcinoma, applying morphometric methods. The following research aims have been deﬁned; (1) determination of morphometric parameters of nuclei and nucleoli of laryngeal carcinoma cells, (2) performance of mathematical analysis of obtained size parameters of nuclei and nucleoli of laryngeal carcinoma cells, (3) comparison of investigation results in relation to speciﬁc degrees of pathomorphologic malignancy of laryngeal carcinoma and control group. Material: The investigation comprised 67 patients suffering from squamous laryngeal carcinoma, malignancy degree between G1 and G3, undergoing surgical treatment. Methods; The material for studies consisted of laryngeal carcinoma tissues, while the objects of studies were the nuclei and nucleoli of cells. The control group consisted of healthy laryngeal tissues. For morphometric assessment was used microscope Olympus AX70-PROVIS. Surface and circumference of the cellular nuclei and nucleoli of laryngeal carcinoma have been assessed. The images of objects underwent mathematic examination using the specialist computer programme VISILOG 4.1 by NOESIS. Results: Morphometric measurements of the surface of ﬂat crosssection of nuclei and nucleoli as well as ﬂat circumference of cellular nuclei and nucleoli of laryngeal carcinoma have been shown statistically signiﬁcant differences, depending on the malignancy degree of neoplasms; G1–G3. Conclusion: Size features of nuclei and nucleoli of cells as circumference and diameter of ﬂat cross-section determined by means of morphometric method, may be use in diagnosis of malignancy degree of squamous laryngeal carcinoma.

HP 90 Endoscopic laser surgery for laryngeal malignancy Sachin Gandhi, Vasant Oswal* Voice disorder Clinic, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India *James Cook University Hospital, Cleveland, UK Objective: To assess the laser management of Tis, T1, T2 tumors of the larynx, and debulking of large tumors for palliation and avoiding tracheostomy. Methods: This is a review of 25 cases of laryngeal malignancy operated between 2001 and 2006 with CO2 and diode laser.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Thirteen cases were of early glottic carcinoma for whom cordectomy was done. Seven cases came in respiratory distress and endoscopic laser debulking was done to avoid tracheostomy. In ﬁve cases debulking was done as a palliative measure. Results: In nine cases of T1a, one case of T1b and three cases of T2a laser cordectomy was done. All 13 patients are under observation. Three of them were given radiotherapy on follow up. Patients have good postoperative voice and have shown no recurrence till date. Three patients came with respiratory distress due to obstructive supraglottic mass. Debulking was carried out with diode laser and tracheostomy was avoided. Histopathology revealed evidence of malignancy in all three cases. Conclusion: In carefully selected patients of early glottic carcinoma endoscopy laser surgery has given excellent control rates. This procedure avoids morbidity and side effects associated with radiotherapy and gives one session therapy as compared to four to six weeks therapy with radiation. Endoscopic laser surgery for early glottic carcinoma is a good treatment alternative in terms of oncological as well as functional results.

HP 91 Amyloidosis of the larynx Su¨ha Beton1, Hu¨nkar Batikhan1, Hilal Erinc¸2, O¨zden Tulunay2, Gu¨rsel Dursun1 1 Department of Pathology, Medical School of Ankara University, Ankara, Turkey 2 Department of Otorhinolaryngology, Medical School of Ankara University, Ankara, Turkey Objective: Amyloidosis is an acquired or inherited disorder associated with deposition of extracellular, insoluble, ﬁbrillar protein. Laryngeal amyloidosis (LA) is an uncommon form of amyloidosis with limited long-term clinicopathologic knowledge in the literature. LA represents 0.5–1% of benign laryngeal disease, increasing with age but occasionally affecting young adults, We discussed our experience in laryngeal amyloidosis. Methods: A 75-year-old female presented with a 1 month of hoarseness and a foreign body sensation in her throat. Direct laryngoscopy showed yellow, hyperemic mass on the left false fold and laryngeal ventricle. Results: Microlaryngoscopic removal of the tissue (7 · 3 · 3 mm) was performed. Because of recurrence, 3 months later a mass (5 · 3 · 3 mm) was removed. The histopathology revealed an subepithelial, extracellular, acellular, amorphous, eosinophilic matrix deposition that is often accentuated around minor seromucous glands and vessels. A sparse inﬂammatory inﬁltrate predominantly made up of lymphocytes and plasma cells was noted, particularly at the leading edge of amyloid. There was no evidence of neoplasm. Patient was followed up 3 years without recurrence. Conclusions: The prognosis for patients with localized LA is excellent if the lesion is completely excised with safe margins. Long-term monitoring for local recurrences or subsequent development of systemic disease is important. There has been no report of malignant transformation in amyloid tumor.

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HP 92 Actinomycosis and osteochondroradionecrosis of hyoid bone and thyroid cartilage Danic Hadzibegovic Ana, Danic Davorin, Prgomet Drago* Department of Otorhinolaringology and Head and Neck Suregery, General Hospital Slavonski Brod, Andrije Stampara 42, 35000 Slavonski Brod, Croatia *Clinic of Otorhinolaringology and Head and Neck Surgery, University Clinical Center Zagreb, Salata 3, 10000 Zagreb, Croatia Osteoradionecrosis of hyoid bone and thyroid cartilage is rare and severe complication of combined head and neck carcinoma therapy, and it is known that irradiated bone is highly susceptible to infections. Today, head and neck actinomycosis is a rare clinical entity, and laryngeal actinomycosis is even more unusual. Primary actinomycosis occurs in immunocompromised patients with no head and neck lesions, whereas secondary actinomycosis occurs after trauma, operative procedures and/or radiotherapy, or concurrently with malignant lesions, or other infectious diseases. To this date, no cases describing actinomycosis and osteoradionecrosis of the hyoid bone and chondroradionecrosis of the laryngeal cartilage were found. We present a case of osteoradionecrosis of hyoid bone and chondroradionecrosis of laryngeal cartilage, both accompanied by actinomycosis, in a 54 year old patient following oropharyngeal carcinoma resection, reconstruction surgery, and postoperative radiotherapy. Clinical manifestations, diagnostic dilemmas and therapeutic options are discussed.

HP 93 Ionizing radiation and laryngeal carcinoma T. Antoniv, A. Mickonas Russian People‘s Friendship University The quantity of oncological patients is still constantly growing. In spite of the fact that tumour of such localization is easy to examine the majority of the patients are admitted to the hospital in III, IV stages. Objective: We analyzed the results of examination and treatment of 490 patients with larynx cancer with were treated in our clinic last 12 years. From 490, 165 patients had contact ionizing radiation (main group) and (or) radionucleeds (atomic physicists, sailors of atomic icebreakers and submarines, workers of atomic stations, liquidates in accident at Chernobyl AES). Methods: The tumour of upper larynx part according to research manifests by dysphagia. Dysphonia appears late in patients with primary upper laryngeal part tumour. The tumour of middle part of larynx characterized by the other chronology of symptoms. The ﬁrst appeared sign is dysphonia that transmit to hoarseness and then to aphonia. The ﬁrst sign of low part tumour is dyspnoea (respiratory failure), stenosis and apnoea. Conclusions: The growth of tumour is fast (30–60 days) the low differentiated form of cancer prevail more than 20% of patients of main group had primary multiply form of cancer, majority of them (78%) died during the ﬁrst year after treatment (surgery) radio treatment as well as chemotherapy is not successful but contraindicated

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HP 94 Laryngeal stenosis in epidermolysis bullosa dystrophia Takuo Haruyama, Masayuki Furukawa, Fumihiko Matsumoto, Kenji Kawano, Katsuhisa Ikeda Department of Otorhinolaryngology, Juntendo University School of Medicine, Tokyo, Japan Epidermolysis bullosa dystrophia is a rare hereditary skin disease of infancy in which minor trauma causes blister formation. We report a rare case of epidermolysis bullosa dystrophia (recessive) with a stenosis of the larynx due to epiglotic deformity. We performed a tracheotomy followed by a long-term observation of tracheostoma. Although it has been suggested that a biological nature of the disease results in the erosion on a trachea mucous membrane by non-speciﬁc stimulation such as ttacheal intubation or tracheostomy, the postoperative course in the present case was uneventful.

HP 95 EBV associated smooth muscle tumour mimicking bilateral vocal process granuloma Eng Cern Gan1, David P. C. Lau1, Khoon Leong Chuah2 1 Department of Otolaryngology, Singapore General Hospital 2 Department of Pathology, Singapore General Hospital Objective: (1) To increase awareness that Epstein Barr virus associated smooth muscle tumour (EBVASMT) may mimic bilateral vocal process granuloma, especially in immunocompromised patients. (2) To understand the prevalence, pathogenesis, clinical behavior and treatment of EBVASMT in immunosuppressed patients or organ transplant recipients. (3) To review the literature concerning the differential diagnosis of polypoid vocal process lesions. Methods: A case is presented of a 36-year-old Chinese lady with a renal transplant for end-stage renal failure due to Goodpasture’s Syndrome. She presented with a year’s history of throat discomfort and acid regurgitation into her throat. Videolaryngoscopy revealed bilateral vocal process granulomas. These were presumed to be due to gastroesophageal reﬂux and she received four weeks of high-dose Omeprazole. However on follow up a month later, the granulomas had enlarged, and laser excision was undertaken. Histological and immunohistochemical stains were consistent with EBVASMT. Results: EBV has been linked to conditions such as nasopharyngeal carcinoma, Burkitt’s lymphoma and post-transplantation lymphoproliferative disorders. EBVASMT has been reported in the lungs, kidney, liver, spleen, dura and skull base. Little is known of the pathogenesis of this rare disorder but the condition seems to improve with modiﬁcation and reduction of the immunotherapy dose. This is believed to be the ﬁrst reported case in the English literature of EBVASMT affecting the vocal process. Conclusions: Clinical awareness of this condition is important especially in immunocompromised patients to facilitate early diagnosis and institution of appropriate treatment.

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HP 96 Homocysteine, folate and vitamin B12 plasma levels in laryngeal cancer A. Nacci1, I. Dallan2, L. Bruschini2, F. Matteucci1, P. Bruschini2, V. Mancini1, F. Ursino1, B. Fattori1. 1 3rd Otorhinolaringology Unit, Department of Neurosciences, University of Pisa, Italy 2 2nd Otorhinolaryngology Unit, Azienda Ospedaliero-Universitaria Pisana, Italy. Objectives: Metabolic alterations, often non-speciﬁc, are common in cancer patients. An association between folate and homocysteine levels and head and neck squamous cell carcinoma (HNSCC) has been described. Methods: We described our experience about homocysteine, folate and vitamin B12 plasma levels in laryngeal cancer. Serum levels of homocysteine, folate and vitamin B12 have been measured in 25 patients with histologically conﬁrmed laryngeal carcinoma. The control group was composed of 80 subjects (subdivided into smokers and non-smokers and into drinkers and non-drinkers). Results: The mean level of total homocysteine in patients was 21 ± 12 versus 7.3 ± 1.8 SD lM/l in the control group (P < 0.001). The mean folate plasma level in patients was 4.3 ± 2.2 versus 7.9 ± 2.4 SD ng/ml in the control group (P < 0.001). Conclusions: We believe that these metabolic alterations (especially hypofolatemia) could predispose, in association with other factors, either environmental or genetic, to laryngeal cancer. Lengthier follow-up studies and larger groups of patients will help us to understand the real value of these metabolic alterations.

HP 97 Hyoid chondroma presenting an external neck mass I. Ozcan*, K. M. Ozcan*, A. Selcuk*, G. Ergul**, H. Dere* *Ankara Numune Education and Research Hospital 4th ENT Clinic, Turkey **Ankara Numune Education and Research Hospital Pathology Clinic, Turkey Objective: Chondromas of the larynx are rare neoplasms, only a few examples of cartilaginous tumors affecting hyoid bone have been reported. Methods: A 33-year-old woman patient presented with a history of neck mass on the left carotid triangle. The patient’s computerized tomography and magnetic resonance imaging revealed a heterogenous mass which seemed to originate from the left greater cornu of hyoid.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Results: The mass was excised using a transcervical approach with left greater cornu of hyoid bone. The pathologic diagnosis was chondroma of hyoid. Conclusions: Expert radiologic and pathologic review is mandatory in cartilaginous neoplasms of the larynx. Cartilaginous neoplasms of the hyoid should be included in the differential diagnosis of neck masses at the carotid triangle.

HP 98 Morphological aspects in laryngeal premalign lesions Florin Anghelina*, Elena Ionita˘*, Carmen Mogoanta˘*, Iulica˘ Ionita˘**, Sorin Ciolofan**, Carmen Popescu**, Laurentiu Mogoanta˘*** *ENT Department, University of Medicine and Pharmacy of Craiova **Emergency Hospital of Craiova ***Histology Department, University of Medicine and Pharmacy of Craiova Objective: We investigated the proliferative activities in premalignant laryngeal vocal chord lesions treated by epithelial stripping in microlaryngoscopy, using immunohistochemical staining with anti p-53, anti-PCNA and anti-Ki-67 monoclonal antibody and we correlated with clinic and morphologic aspects. Materials and methods: The study was made on 32 patients hospitalized in Craiova ENT Clinic in 2005 presenting lesions precursor to vocal cord malignity. The lesion’s aspect was observed using suspended microlaryngoscopy, a biopsy was performed and biological tests were examined from a pathological and immunohistochemical point of view, with the investigation of the following immunohistochemical markers: Ki-67, PCNA and p53. Results: Thirteen cases (41%) presented red hypertroﬁc cronic laryngitis, 7 cases (22%) presented white hypertroﬁc cronic laryngitis, 12 cases(37%) presented papillomas with with simple, moderate, severe dysplasia and in situ carcinoma in 62.5, 22, 12.5% and, respectively, 3% of the cases. All the dysplasic lesions, no matter the dysplasic degree, have presented alteration of both surface eplitelium and chorion. The expression of Ki67, PCNA and p53 was correlated with the dysplasia’s degree in various proportion. Conclusion: In clinical practice, morphological grading of dysplasia is difﬁcult to evaluate. The Ki-67 and PCNA markers were correlated with the dysplasia degree; the expression of p53 was present only in 28% cases with moderate dysplasia and in one case with in situ carcinoma.

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HP 99 Autoﬂuorescent diagnostics of laryngeal precancerosis and cancer Nenad Baletic1, Hidajet Malicevic2, Zeljko Petrovic3, Jelena Sotirovic1 1 Military Medical Academy, Clinic for Otorhinolaryngology, Belgrade, Serbia 2 Hospital Center Bezanijska Kosa, Pulmology Department, Belgrade, Serbia 3 Clinical Centre of Serbia, Institute for otorhinolaryngology and maxillofacial surgery, Belgrade, Serbia Introduction: Autoﬂuorescent endoscopy (AFE) is based on natural ability of coenzyme ﬂavin-mononucleotide (FMN) contained in healthy tissue to emit green ﬂuorescence when is exposed to blue light (435 nm). In precancerous and malignant tissue anaerobic glycolytic pathway without FMN dominates, hence do not emit green ﬂuorescence. Objectives: To estimate diagnostic efﬁcacy of AFE in patients with precancerous and malignant lesions of the larynx. Methods: In this prospective, descriptive analytic study we compared sensitivity (SN) and speciﬁcity (SP) of Pentax System of Autoﬂuorescent Endoscopy (SAFE) and microlaryngoscopy (MLS) in 21 patient with laryngeal cancer and 16 patients with precancerous conditions, with pathohistology veriﬁcation as a ’’golden standard’’. Results: In diagnostics of laryngeal cancer SAFE had SN 95%, and SP 71%, while MLS achieved 71 and 98%, respectivelly. In cases with precancerosis SAFE achieved SN and SP 94% and 71%, respectivelly, while these parameters in MLS were 75 and 100%. In both lesions SAFE had better sensitivity than MLS, but this difference was statistically signiﬁcant only in cases with laryngeal carcinoma (Fisher’s test P = 0.047). Speciﬁcity of SAFE was lower than MLS, mainly due to absorption of emited green ﬂuorescence by haemoglobin in hyperaemic chronically inﬂammed laryngeal mucosa. Keratosis of laryngeal epithelium with its increased autoﬂuorescent signal could mask underlying more important lesions like carcinoma or precancerous lesion. Conclusions: Safe has great potential in detection and extent determination of premalignant and malignant lesions of larynx, but can not completelly replace MLS as standard diagnostic method, mainly due to low speciﬁcity.

HP 100 Endoscopic arytenoid lateralisation of scarry ﬁxed vocal cords B. Sztano´, L. Rovo´, G. Smeha´k, J. Czigner, J. Jo´ri ENT Department, University of Szeged, Hungary; Tisza L. Krt. 111 Szeged, Hungary Objective: In severe cases of scarry ﬁxation of cricoarytenoid joints (CAJ) only the external surgical interventions were proven

S101 to be successful and endoscopic methods are generally suggested for only mild types of stenosis. The aim of this study was to introduce an endoscopic method that can solve suffocation without tracheostomy even in difﬁcult cases. Methods: Thirty-three patients were enrolled with minimum two year follow-up. The interarytenoid scar was completely excised, and the intracapsular ﬁxing scar was transsected by a special blade designed by the authors. After this the arytenoid cartilages were ﬁxed in abducted position by endoscopically inserted suture. The peak inspiratory ﬂow (PIF) was measured before (I), in the ﬁrst days after the procedure (II), and at the end of the ﬁrst postoperative year (III) Results: Average PIF I: 1.22 l/s; avg. PIF II: 2.56 l/s; avg. PIF III: 2.53 l/s. Good postoperative vocal cord function is proven by objective voice analysis. Conclusion: The minimally invasive method we suggest provides immediate and stable signiﬁcant increase of breathing with good laryngeal function even in difﬁcult cases of scarry ﬁxation of vocal cords.

HP 101 Voice and speech after laryngectomy Smiljana Sˇtajner Katusˇ ic´1, Maja Musˇ ura 1, Damir Horga2, Dubravka Globlek1 1 ENT Department, Sestre milosrdnice University Hospital, Zagreb 2 Department of Phonetics, Faculty of Philosophy, University of Zagreb, Zagreb, Croatia Objective: To compare voice quality in three groups of patients with electroacoustical (EASA), esophageal (ESOS) and tracheoesophageal (TESS) speech. Methods: A short story was recorded in the sound-proof booth. The speech samples were analyzed subjectively by programs for acoustical speech analysis. Results: Voice quality, spech intelligibility and temporal organization of speech were analyzed. The results showed that average frequency of voice of TESS speakers is nearer to voice frequency of normal subjects (71 Hz vs. 57 Hz) while EASA patients can regulate frequency of the aid. TESS speakers are better in voice variables than ESOS speakers but EASA speakers are the best (jitter: 0.95%, shimmer: 1.15 dB). In variables of temporal organization of speech TESS speakers are better than the other two groups: speech rate (TESS – 4.61 syl/ s, ESOS – 1.39 syl/s, EASA – 2.56 syl/s), duration of phonetic block (TESS – 2.30 s, ESOS – 0.71 s, EASA – 1.39 s), number of syllables in the phonetic block (TESS – 10.93, ESOS – 2.63, EASA – 4.97), speech rate in the longest phonetic block (TESS – 4.81 syl/s, ESOS – 3.21 syl/s, EASA – 4.53 syl/s). Conclusion: Air-stream source (lungs) in speech production of TESS contributes to speech quality of alaryngeal speakers.

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HP 102 Management of juvenile recurrent laryngeal papillomatosis Marioara Poenaru, Stan Cotulbea, Caius Doros, Gabriela Doros, Delia Horhat ENT Department, University of Medicine and Pharmacy ‘‘Victor Babes’’ Timisoara, III-rd Pediatric Clinic, University of Medicine and Pharmacy ‘‘Victor Babes’’ Timisoara Objective: Juvenile recurrent laryngeal papillomatosis (RLP) is a viral disease characterized by multiple recurrences of benign tumours of the larynx mucosa and signiﬁcant morbidity on paediatric patient and strain on their families. The aim of this study was to evaluate the results of combined treatment with CO2 laser microsurgery and interferon (IFN) alpha 2b in children suffering from laryngeal papillomatosis. Methods: During a 5 years period (2001–2006) 11 patients aged from 2.9 to 5.2 years (mean age 4.1 years) diagnosed with laryngeal papillomatosis were included in the study. Case management consisted of CO2 laser microsurgery followed by adjuvant therapy with IFN. All patients underwent microsurgical excision and progressive vaporization of papillomas with the CO2 laser under general anesthesia and good exposure. Tracheotomy was not necessary in any of the cases. The follow-up time was 14 months on average. Results: Clinical examination revealed regression of papillomas in all patients. Seven patients had complete regression after primary CO2 laser microsurgery and additional interferon treatment. Four patients had partial response to the combined treatment. In these cases second intervention was needed. No perioperative or postoperative complications and no severe side-effects were noted. Conclusions: This combined treatment is a method of choice in laryngeal papillomatosis in children, causing longer remission of the disease. Surgical ablation with laser CO2 is the elective treatment and its combination with IFN improved the prognosis of this recurrent viral disease. Reachable functional results, good tumour control, short hospitalization makes it a favourable treatment in paediatric patients.

HP 103 Surgical treatement of T3 and T4 laryngeal carcinoma Vladimir Djordjevic, Jovica Milovanovic, Zeljko Petrovic, Zoran Dudvarski, Vladimir Nesic, Anton Mikic Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Centre of Serbia, Belgrade Objective: The aim of the study was to establish today’s results of the surgical treatement of patients with T3 and T4 laryngeal malignoma. Method: The study was retrospective and included the group of 1,054 patients who had total laryngectomy during the eight years period (1994–2001) at our institution. Results: The postoperative complications were: faryngocutaneous ﬁstulas (16%), haemorrhage (7%), tracheal stenosis in 6 and oesophageal stenosis in six cases. The ﬁve-years survival rate established in the group of patients who had primary total laryngectomy is 308/794 (39%); in the patients group where total laryngectomy was salvage surgery after radiotherapy, the 5-years survival rate is 47/172 (27%); in the group where total laryngec-

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 tomy was salvage surgery after conservative or reconstructive surgery, the 5-years survival rate is 28/84 (33%). Conclusion: Despite diagnostical and therapeutical achievements, prognosis for T3 and T4 malignoma of the larynx was not signiﬁcantly approved in the last few decades.

HP 104 Failures after laryngopharyngeal reconstruction in caustic stenosis Irina Achim1, V. Costinescu2, Gina Stegaru3 1 Medical center ‘‘MEDAS’’ Bucharest, Romania 2 Univesity of Medicine and Pharmacy ‘‘Gr. T.Popa’’, Iasi, Romania 3 University hospital ‘‘Sf. Spiridon’’, Iasi, Romania Objective: The authors describe some of the difﬁculties and failures after the reconstruction of the pharynx, larynx, and cervical esophagus with cutaneous tube, due to caustic ingestion. Methods: We analyze the causes which have determined the appearance of the difﬁculties and even the failures occurred in 69 patients with laryngo-pharyngo-esophageal stenosis between 1996 and 2005. Results: After surgical reconstruction 15 patients presented digestive and/or respiratory problems. In three patients (4.3%) we could not re-establish the continuity of the digestive and respiratory tract. Conclusions: The failures after the reconstruction with cutaneous tube depend on the complexity of the lesions, the status of the connective tissue, optimal time for the surgical treatment and also on the surgical techniques that have been used.

HP 105 Assessment of voice in patients with Reinke’s oedemas after laser microsurgery A. Szkiekowska1,2, B. Mias´ kiewicz1, E. Wodarczyk1, H. Skar_zyn´ski1,2 1 Foniatric Clinic of Institute of Physiology and Pathology of Hearing, Warsaw, Poland 2 Academy of Music, Warsaw, Poland Objective: This investigation was undertaken for perceptual and acoustic analysis of voice in patients with Reinke’s oedema treated with laser microsurgery. Material: Material of the study included 45 patients at the age of 23 to 65 presenting to Foniatric Clinic with dysphonia in Reinke’s oedema. Patients were divided into three groups according to the Remacle’s classiﬁcation of Reinke’s oedema. All patients were treated with the CO2 laser microsurgery. Voice assessment was made subjectively with the GRBAS scale and objectively, using multidimensional voice parameters analysis (MDVP). The examination was undertaken preoperatively, 1 week after operation and four weeks after an operation. Results: The results of our study show relationship between quality of voice after surgery and the stage of evolution of Reinke’s oedema according to the applied classiﬁcation. The best quality of voice was presented by young patients (up to the age of 30) with 1st stage of Reinke’s oedema.

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HP 106 Predisposing factors, management, and outcomes of major anastomotic dehiscence after crico-tracheal resection and anastomosis C. Piazza, G. Peretti, P. Nicolai Department of Otolaryngology, University of Brescia, Spedali Civili, Piazza Spedali Civili 1, 25123 Brescia, Italy Objective: Crico-tracheal resection and anastomosis (CTRA) is applied to benign and neoplastic stenoses of the crico-tracheal junction. Aim of this paper is to describe predisposing factors, management, and outcomes of major anastomotic dehiscence (MAD), the most feared CTRA’s complications. Methods: Between 1996 and 2007, 92 patients received CTRA for inﬂammatory (61) or neoplastic (31) stenoses. A charts review identiﬁed eight (9%) MAD: four after CTRA for post-intubation and four for neoplastic stenoses. Results: MAD occurred 2–20 days after surgery (mean, 8). Extent of resection was considered the main predisposing factor in two patients (5 and 5.5 cm resections). In one patient, an epileptic crisis caused anastomotic rupture, while emesis was encountered in two. Concomitant thyroidectomy with central compartment neck dissection in three, tracheo-oesophageal ﬁstula closure in two, and preoperative RT in two were responsible for MAD in the others (three patients had an association of two or more predisposing factors). Univariate analysis by Fisher or Pearson Chi Squared test showed statistically signiﬁcant association between MAD and length of resection equal or superior to 5 cm (P = 0.007), preoperative RT (P = 0.02), and postoperative emesis (P = 0.007). MAD required total laryngectomy with forearm free ﬂap for oesophageal closure in one case and permanent tracheostomy in another (both neoplastic stenoses after RT); 75% achieved a patent airway (after redo-CTRA in ﬁve and Dumon prosthesis insertion in one). Overall decannulation rate was 97%. Conclusions: Besides length of resection, other factors predispose to MAD. Preoperative RT should be considered a contraindication to CTRA for neoplastic stenoses. Management of these patients must include aggressive anti-emetic therapy in the postoperative course.

HP 107 Endoscopic guided cerclage sphincter pharyngoplasty: a new technique for velopharyngeal insufﬁciency Ahmed Ragab* ORL Department, Menouﬁya University Hospital, Egypt Objective: Several surgical techniques are available for the treatment of velopharyngeal insufﬁciency (VFI). Each method has its own complications and non-dynamic roles. The aim of this study was to present a novel physiological surgical technique designed by the author for reconstruction of the velopharyngeal sphincter in VFI. Methods: This prospective study included six patients with VFI (two males and four females) with ages from 5 to 20 years (mean 12.50 years). Speeches, nasopharyngeal and oral endoscopies for velopharyngeal valve closure were measured according to a 5point scale where 0 was equivalent to normal and 4 meant a severe (constant) deviation. They were scheduled for cerclage sphincter pharyngoplasty after failure of appropriate speech therapy. Under general anaesthesia and the patient in semiFowler’s position; two level cerclages (1-0 polypropylene suture materials) were inserted behind the muscles of the velopharyn-

S103 geal sphincter. The ﬁrst at the level of junction of posterior and middle one-third of the soft palate passing through soft palate left lateral pharyngeal wall, posterior pharyngeal wall, right lateral pharyngeal wall and the soft palate. The second was at 3 mm in front of the latter. The surgical technique was described in details. Results: Before surgery ﬁve patients (83.3%) had severe hypernasality (rating scale 3). After the cerclage operation and speech therapy four patients (66.6%) signiﬁcantly improved to normal nasality (rating scale 0) and the remaining two patients improved to mild and moderate hypernasality (rating scale 1 and 2), respectively (P-value = 0.02). By endoscopy the closing activity was (rating scale 3) in ﬁve patients (83.3%) and (rating scale 2) in one patient (18%). After the cerclage operation and speech therapy ﬁve patients (83.3%) changed signiﬁcantly to complete closure (rating scale 0) and to (rating scale 1) in one patient (Pvalue = 0.01). Conclusions: Endoscopic guided Cerclage sphincter pharyngoplasty is a new procedure designed by the author in VFI. It helps the velopharynx to function physiologically in 3D patterns without dependency on the type of closure. Also it is an easy technique; without tissue ﬂaps transfer, upper airway obstruction or hyponasality.

HP 108 Endolaryngeal/-tracheal surgery in tubeless superimposed high frequency jet ventilation (SHFJV) Doris-Maria Denk-Linnert1, A. Rezaie-Majd2, M. Burian3, W. Bigenzahn1, A. Aloy2 1 Division of Phoniatrics and Speech Pathology, ENT Department, Medical University of Vienna, Wa¨hringer Gu¨rtel 18-20, A-1090 Vienna, Austria 2 Department of Anesthesiology and Intensive Care Medicine, Medical University of Vienna, Austria 3 Division of General ENT, ENT Department, Medical University of Vienna, Austria Objective: In endolaryngeal and -tracheal surgery, the translaryngeal tube interferes with a free operating ﬁeld. Therefore, the supraglottic tubeless superimposed high frequency jet ventilation (SHFJV) was developed by Aloy et al. 1990 and has since been used and studied prospectively in our department. Methods: In 1,515 consecutive patients transoral laryngotracheal surgery was performed in SHFJV. 158 of the patients operated were children (newborn to 14 years), 139 suffered from a laryngeal / tracheal stenosis, and in 312 patients transoral laser surgery was carried out. For ventilation an air/oxygen mix was used. Anesthesia was administered intravenously. The larynx was exposed by the ENT surgeon using a specially designed jet laryngoscope. Results: In 1,512 patients (99.8%) an adequate ventilation and oxygenation was achieved so that SHFJV was successfully performed without any complications. Three patients suffering from severe obesitas and laryngeal stenosis or pulmonary disease needed tracheal intubation for anesthesiological reasons. An important beneﬁt of the studied technique is the avoidance of tracheostomy in the management of patients with severe laryngeal/tracheal stenosis. Due to it´s minor invasiveness, SHFJV proved especially useful in children. Limitations were insufﬁcient exposure of the airway with the jet laryngoscope, systemic infectious diseases, severe obesitas and endolaryngeal bleeding. Conclusions: SHFJV offers a free access to the operating ﬁeld as well as an adequate ventilation and oxygenation. Our experiences show that SHFJV is a safe, effective and useful method for endolaryngeal/tracheal surgery.

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HP 109 Cervical actinomycosis: a review of the literature and description of a case

HP 111 The use of ligasure in otolaryngology: head and neck surgery

Ja´nos Szikszai, Csongor Gyo¨rgy Lengyel, Judit Bakk, Ibolya Elek, Erzse´bet Fu¨le Department of Otolaryngology Head & Neck Surgery, Jo´sa Andra´s County Hospital, Nyı´ regyha´za, H-4400, Szent. I. u. 68., Nyı´ regyha´za, Hungary

Emmanuel Prokopakis, Vassilios Lachanas, Nikolaos Hadzakis, Alexander Karatzanis, Emmanuel Helidonis, George Velegrakis Department of Otolaryngology, University of Crete School of Medicine, 7110 Heraklion, Crete, Greece

Objective: Cervicofacial actinomycosis usually presents as a submandibular mass. The aim of the article is to report of our case and review of the literature. Methods: Boy, 9, previously well, reported a painful mass in the left neck of 5-day duration. A tender, hard mass measuring 3 · 4 cm was present in the region of the thyroid and multiple smaller, nontender nodes both side in the supraclavicular and axillary regions. Ultrasound revealed a conglomerate in continuity with the left thyroid lobe (3 · 3 · 3.5 cm). His laboratory ﬁndings were normal. Aspiration of the mass suggested autoimmune thyreoiditis, later bacterial thyreoiditis. Parenteral antibiotic therapy was iniciated (augmented Amoxicillin and Metronidazole, later Tazobactam) but during the ﬁrst weeks the conglomerate largely increased in size (7 · 5 · 4.5 cm). A CT scan revealed an enormous mass compressing and displacing the whole length of the pharynx and extending to the mediastinum suggesting an inﬂammation or a malignant lymphoma. After 3 weeks, the mass decreased in size, and was excised by surgery. Histology revealed actinomyces ﬁlaments. Results: A 3-week parenteral, followed by a postoperative 5-week of oral treatment could eradicate the organism. The patient remained completely symptom-free. Conclusions: Surgery for actinomycosis is considered mainly of diagnostic use, because Actinomyces is not known to be resistant to penicillin. In this case, needle aspiration did not facilitate the diagnosis. Our case illustrates that despite the antibiotic treatment, the mass was capable of enormous increase in size.

HP 110 Trends in ENT surgery in the UK: are we operating less than we used to? Samuel MacKeith, David D. Pothier ENT Department, Royal United Hospital, Combe Park, Bath, UK, BA1 3NG Objective: To analyse trends in Otorhinolaryngological surgery in the National Health Service (NHS) Hospital Episode Statistics (HES) from 1998 to 2005. Methods: HES statistics were downloaded from the Department of Health website. Data were imported into SPSS and trends were analysed. Results: Rates of insertion of ventilation tubes and tonsillectomy have decreased by 38.9 and 24.5%, respectively over the 7 year period. Rates of septoplasty and turbinate surgery have decreased by 10.6 and 25.6%, respectively. Not only were absolutes numbers of operations reduced, but the frequency ranking of the procedures has dropped consistently over the time period when compared to procedures performed by other specialties. Despite a 6.6% reduction in diagnostic laryngoscopies, levels of major laryngeal surgery have increased by 0.9%. Rates of major otological procedures have dropped. Conclusions: The volume of simple ‘bread and butter ENT surgery seems to be decreasing rapidly, but rates of more complex laryngeal and otological surgeries remain constant. This will have a signiﬁcant effect on service provision and training within the NHS and independent sector.

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Objective: To evaluate the role of LigasureTM Vessel Sealing System (LVSS) in Otolaryngology–Head and Neck Surgery. Emphasis was given to the duration of the procedure, efﬁcacy of haemostasis, and relevant postoperative complications. Methods: A prospective study was conducted, on patients undergoing thyroidectomy, laryngectomy, neck dissection, parotidectomy, and tonsillectomy procedures with the use of LVSS device as the primary means of ligation. All patients’ records were placed in a database. Efﬁcacy of haemostasis, operation time and postoperative complications were assessed. Results were compared to previous surgical procedures done by our team when the LVSS was not available. Results: LVSS proved effective in providing ligation and haemostasis in 120 total thyroidectomies, 19 total laryngectomies with unilateral radical neck dissection, 41 superﬁcial parotidectomies, and 201 tonsillectomies. There was a mean reduction in operating time of 23 min in total thyroidectomies, 30 min in total laryngectomy with unilateral radical neck dissections, and 52 min in superﬁcial parotidectomies compared to our historical control group. Postoperative complications did not differ statistically compared to previous surgical procedures done when the LVSS was not available. Conclusions: LVSS proved quite a reliable and safe device in otolaryngology head and neck surgery procedures, providing sufﬁcient haemostasis and reducing operative time.

HP 112 ‘‘One-stop’’ head and neck clinic: does it make a difference? P. Anand, A. H. Sadr, E. Gruber, D. J. Courtney Department of Head and Neck Surgery, Derriford Hospital, Plymouth, UK Objective: To evaluate the efﬁcacy of One Stop Head and Neck clinic in terms of costs, patients’ satisfaction and accuracy of diagnosis in patients with suspected head and neck lumps. Methods: We conducted a prospective study of 277 patients attending the clinic over a period of 10 months. The clinical examination, Ultrasound scan, FNA, and cytology results were examined. Patient satisfaction was also assessed using a satisfaction questionnaire. Results: Average cost of seeing a patient in this clinic was £78 compared to £56 for a normal clinic. 30% of patients were discharged on the ﬁrst visit. Findings included: malignancy (17.3%), cysts (3.6%), Lipoma (5.4%), salivary gland tumours (14.1%), Thyroid disease (11.6%), benign lymphadenopathy(42%) and no abnormality in (6%). 50.2% of patients had an FNA during the visit. 6.5% had inconclusive cytology results. 95.3% had an USS with a 100% sensitivity in diagnosing malignancy. FNA results yield rose from 50 to 90% by using USS thus reducing the number of follow up visits and the overall costs (£14122 annually).87.9% of responders were conﬁdent that they were given a diagnosis on the day and 100% of them preferred the one stop clinic. Conclusions: USS guided FNA increases the adequacy of cytology. One stop clinic results in better communication and more accurate diagnosis. Based on our experience, this service is cost effective in long term and brings higher patient satisfaction.

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HP 113 Lipoid proteinosis: a rare entity with signiﬁcant ENT involvement George Patrikakos, Christina Sophia Nousia, Vasilios Mitsios, and Konstantinos Karentzos Department of Otorhinolaryngology, Ioannina General Hospital, Ioannina, Greece Objective: Lipoid proteinosis is a rare, autosomal recessive genodermatosis in which there is deposition of a hyaline material rich in proteins, lipids and carbohydrates in extra-cellular spaces in and around the walls of blood vessels. Methods: We present a case of a 23-year old male suffering from lipoid proteinosis, exhibiting typical dermatological, biochemical, histological and radiological features caused by deposits of hyalinelike material in skin, mucosa, and viscera. Results: Skin appeared waxy, thickened, and yellowish, with papules, plaques, and nodules arising on patient’s face, axillae, and scrotum. Various sites within the oral mucosa (lip mucosa, tongue and gingival) were involved. The patient complained about hoarseness and dysphagia due to inﬁltration of the larynx, vocal cords, and surrounding structures. Radiographic ﬁndings included bilateral, intracranial, bean-shaped suprasellar calciﬁcations in the temporal lobe. Polymerase chain ampliﬁcation and direct nucleotide sequencing of the ECM1 gene together with skin biopsy of affected cutaneous or mucosal sites conﬁrmed the diagnosis. Conclusions: Lipoid proteinosis is a chronic disease that can involve many organ systems. The disease follows a stable, chronic course but may ﬂuctuate in intensity. No uniformly successful treatment is available. Consultations with the appropriate specialists, depending on the system involved, are indicated. Life span is usually normal unless altered by laryngeal obstruction or epilepsy. Patients with signiﬁcant airway compromise may require permanent tracheostomy. Parents should be educated about the risk of having affected offspring.

HP 114 Sarcoidosis presenting with upper respiratory tract manifestations Christina Sophia Nousia, George Patrikakos, Vasilios Mitsios, Kostantinos Karentzos Dept of Otorhinolaryngology, ‘‘G. Hatzikosta’’ General Hospital of Ioannina, Greece Objective: Sarcoidosis is a systemic disorder of unknown cause, characterized by non-caseating granulomatous inﬂammation of the organs involved. Upper respiratory tract manifestations are considered rare. Methods: We report the rare case of a young woman with Sarcoidosis, which was ﬁrst manifested with upper respiratory tract clinical disorders. Upper respiratory was the only ﬁeld clinically affected from the disease, with lesions mainly focused in the nose and the supraglottic region of the larynx.

S105 Results: Sarcoidosis presenting features are protean, ranging from asymptomatic but abnormal ﬁndings on chest radiography in many patients to progressive multiorgan failure in a minority. It predominantly affects the respiratory tract with preference for the lower. Most patients report acute or insidious respiratory problems, variably accompanied by symptoms affecting the skin, eyes, or other organs. Non-caseating granuloma holds the key to the diagnosis. It is strongly recommended that all suspected cases must be conﬁrmed by biopsy to exclude infection or malignant conditions. The disease is usually self limiting with spontaneous resolution, although in a few patients there is progressive downhill course, culminating in irreversible ﬁbrosis and severe impairment of organ function. Corticosteroids remain the mainstay of therapy. Conclusions: Even though manifestations from the upper respiratory tract are most uncommon in Sarcoidosis, presenting features of granulomatous inﬂammation in the nose, paranasal sinuses or larynx should always alert the Otorhinolaryngologist to include Sarcoidosis in the differential diagnosis. Lower respiratory tract estimation and biopsies are considered the basic steps for diagnosis and consequent appropriate management.

HP 115 Relapsing polychondritis: case report and review of literature D. Lefantzis, M. Artopoulos, Z. Antonopoulou, V. Tzavara, G. Papazoglou ENT Department ‘‘RED CROSS’’ Hospital, Athens, Greece Objective: Relapsing polychondritis(RP) is a chronic multisystem disease, most likely of autoimmune etiology, characterized by a variety of manifestations which are caused by recurrent episodes of inﬂammation of cartilaginous tissues. But most important, relapsing polychondritis is a disease whose diagnosis is very challenging for the otolaryngologist. Methods: A case of a 35-year-old woman who came to our hospital reporting pain and redness of both ears and a history of severe rhinitis with nasal cartilage inﬂammation and several episodes of bronchitis the last few months. Laboratory studies were made and the patient received treatment consisted of iv. administrated prednisone. Her symptoms were remitted from the ﬁrst day of administration. Results: The patient’s diagnosis of RP was made primarily on the basis of her clinical manifestations and her response to systemic corticosteroids. Conclusions: The most important step in the diagnosis of relapsing polychondritis is made once the otolaryngologist suspects this diagnosis. Laboratory studies and biopsy are very helpful, but in the end the diagnosis of RP is clinical. The cooperation of a rheumatologist may often be valuable especially in the management of additional systemic manifestations.

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HP 116 Arteriovenous malformation of lower lip Umit Taskin, Ozgur Yigit, A. Volkan Sunter Istanbul Training and Research Hospital, ENT department, Istanbul Vascular malformations can be categorized into low-ﬂow lesions and high-ﬂow lesions according to blood ﬂow volume. Arteriovenous malformation (AVM) kind of arterial lesions is high-ﬂow vascular anomalies consisting of a nidus or a network of abnormal vascular channels between feeding arteries and draining veins. Incidence of AVM in the oral and maxillofacial region is rare but potentially life threatening vascular lesion. They have a high propensity to bleed, which maybe life-threatening. Angiography is most important diagnostic technique for determination of location and ﬂow characteristics of vascular lesions. Total resection of lesion is the only treatment that could result in radical cure, and at the same time total resection is quite hard to perform for AVM in the head and neck because the lesion some times invades deep tissues, and lesions may have several feeding arteries that are directly derived from the internal or external carotid artery, this could cause uncontrollable bleeding during surgery. In our case, lesion was in right lower lib extending to chin. First of all, lesion was diagnosed with angiography showed AVM supplied from mainly right facial artery, slightly from contralateral facial artery. Main suppliying artery was embolized and than total excision of lesion was done. During surgery, to minimize cosmetic defect, submandibular skin incision was done to reach and resect right facial artery, than lesion was excised totally intraorally. Remaining small feeding arteries was cauterized intraorally. So we did not need for closure of defect with local ﬂap. There was no cosmetic problem and recurrence after surgery.

HP 117 Aneurysms of the facial artery; an unusual presentation of neck lump James Barraclough, Harpreet Uppal, Janet O’Connell Birmingham City Hospital, UK Objective: We present a case of a 78-year-old female who presented with a slowly enlarging neck lump in the right submandibular triangle. There was no associated history of trauma to the face, no risk factors for cardiovascular disease and otorhinolaryngological examination was unremarkable. The lump was ﬁrm and non-pulsatile. Methods: The lump was investigated initially with ﬁne needle aspiration which revealed blood only. She then went on to have a computed tomography (CT) scan with intravenous contrast. Results: The CT scan revealed a 2.2 cm aneurysm of the right facial artery just below the mandible. There was calciﬁcation of the wall and thrombus formation within the lumen. In theatre, the aneurysm was dissected open and feeding vessels were identiﬁed and ligated. She made a good post-operative recovery. Conclusions: This case is unique as the lesion was identiﬁed using computed tomography scanning due to the unusual presentation. The vast majority of aneurysms of the head and neck have a traumatic aetiology giving rise to false aneurysms: true aneurysms are extremely rare. We discuss the implications of such a lesion and its management.

HP 118 Head and neck injuries by Asiatic black bear attacks Kohei Honda, Wenghoe Wong, Teruyuki Sato, Takashi Saito, Naoko Fukui, Kazuo Ishikawa Division of Otorhinolaryngology, Head and Neck Surgery, Department of Sensory Medicine, Akita University, School of Medicine, 1-1-1, Hondo, Akita, Japan

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Objective: The Asiatic black bear lives in the mountainous areas on the main island of Japan. The bear is an omnivorous animal eating insects, fruits and nuts, with weights reaching up to 70– 150 kg weight. Recently injuries by bear’s attacks are increasing in Akita prefecture in Japan. We studied the pattern and characteristics on head and neck injuries from a view point of planning treatment procedure. Methods: Six head and neck injury cases attacked by Asian black bear which occurred in the past 12 years, were analized. Results: There are four men and two women with ages ranging from 47 to 76 years old (means 65.7 years old). Of six cases, four cases were attacked by the bear while picking up edible wild plants. Two cases were attacked while working in a vegetable patch. One case was attacked while working in woods. Multiple wide severe injuries were found with their head, eye, face, and oral cavity by the bear’s hand, teeth and claws. Tracheostomy was performed in all cases. In three cases additional operations were performed because of sever defects of the skin tissues. Conclusions: Injuries by Asiatic black bear attack usually are not fatal, although some cases suffered from defect of tissues of head and neck. In most cases team approach might be needed to obtain the best result.

HP 119 Hydatid cyst of maxillofacial region with blindness presentation Nasrin Yazdani*, J. Yazdani*, M. Hossein Dadgarnia**, M. Saeidi* *Tehran University of Medical Sciences **Yazd Shahid Sadughi University of Medical Sciences Objective: Hydatid cyst is a common disease in the endemic regions, especially in the Middle East. Liver and pulmonary involvement is very common but primary hydatid cyst of the maxillofacial region is very rare. Patient and methods: A 13-years-old child presented with exophthalmia of right eye and visual loss since 10 days ago. Physical examination showed limitation of eye movements, and visual acuity was hand motion. In the past history, she had history of multiple brain hydatid cysts and seizure 8 years ago who has underwent craniotomy. Paranasal sinus CT scan showed cystic mass in the right maxillary sinus eroding the inferior orbital wall and compressing the orbit. Sonography from liver and surprisingly chest-X ray were normal. The patient underwent surgery and three hidatid cysts were removed from right maxillary sinus by standard Caldwell-Luc approach. Pathology report conﬁrmed hydatid cyst. 4 month after surgery in physical examination, visual acuity and eye movements were normal. Results: Hydatosis is a well known disease for general surgeons but it may present diagnostic difﬁculties for otolaryngologist or maxillofacial surgeons, because hydatid cyst is very rare in the head and neck region. Therefore, we must be to think about this rare disease until can diagnose and apply appropriate treatment. Conclusions: Hydatid cyst should be considered in differentiated diagnosIs of any cystic mass in the patient who living in the endemic areas. With due attention to that there is no effective medical treatment in cases of head and neck hydatid cysts, total excision of cysts is the treatment of choice.

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HP 120 The ‘‘Mini-packer’’ syndrome. An unusual case of oesophageal foreign body Anastasia Konstantinou ENT Department, General Hospital of Halkis, Greece Objective: Body stuffer, sometimes called ‘mini-packer’, is the deﬁnition of someone who admits to, or is strongly suspected of ingesting illegal drugs in order to escape detection by authorities, and not for recreational purposes or to transport the drug across borders. Cocaine is the drug most commonly involved in the body stuffer syndrome. Methods: This report describes the successful oesophagoscopic retrieval of a cocaine balloon after ingestion. A 42-year-old Gipsy presented himself in the Emergency Room with anxiety, complaining of dysphagia. There was no stridor. Even if body-packers are often dishonest historians, he admitted swallowing a single bag of cocaine in order to avoid police detection. Results: At oesophagoscopy, a small yellow, intact balloon visualized at 30 cm, was removed. Toxicological analysis of the balloon contents found cocaine. The packaging used was not sophisticated. The powder was packed inside a condom without extra covering. Conclusions: The description of the case is followed by a short review of the literature, mainly focused on the possible complications of ingested drug packets and possible methods of removal. Reported cases of body stuffer deaths are rare, however while drug packets are inside the body, they can leak or rupture causing acute substance toxicity. Body packers usually present to health care providers for one of three reasons: drug-induced toxic effects, intestinal obstruction, or medical assessment after detention or arrest. Hospital physicians may neglect this type of gastrointestinal foreign body if they are not aware of the body packer syndrome.

HP 121 Sarcoidosis associated with PTC and parathyroid adenoma Zuzana Jandova´1, Jan Plza´k1, 2, 3, Vladimı´ r Zeman4, Jaromı´ r Astl1 1 Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University, Faculty Hospital Motol, V U´valu 84, 150 06 Prague 5, Czech Republic 2 Institute of Anatomy, 1st Faculty of Medicine Charles University, U nemocnice 3, 128 00 Prague 2, Czech Republic 3 Center for Cell Therapy and Tissue Repair, 2nd Faculty of Medicine, Charles University, Faculty Hospital Motol, V U´valu 84, 150 06 Prague 5, Czech Republic 4 Department of Pathology and Molecular Medicine, 2nd Faculty of Medicine, Charles University, Faculty Hospital Motol, V U´valu 84, 150 06 Prague 5, Czech Republic Objective: A coincidence of papillary carcinoma of the thyroid, parathyroid adenoma and sarcoidosis is rare. The importance of detailed histological examination is pointed out in this report. Methods: We present a case of 64-years-old woman suffering from dorsalgia with diagnosed hypercalcemia and hyperparathyroidism. Ultrasonography and MIBI scan detected parathyroid adenoma in the right inferior parathyroid gland and nodules in the

S107 thyroid. FNAB from the thyroid was benign. Surgery was indicated. Results: Total thyroidectomy and partial parathyroidectomy was performed. Subsequent histological examination conﬁrmed presence of parathyroid adenoma and revealed papillary carcinoma in the right thyroid lobe, 0.15 cm in diameter, and sarcoid reaction in adjacent lymph nodes. Concerning the size of the carcinoma surgery itself was an adequate therapy. The patient showed no other supporting evidence for systemic sarcoidosis and was refered to a pneumologist. Conclusions: Anamnesis and detailed examination is mandatory but in case of coincidence of more diagnoses individual symptoms may superpose thereby complicate the establishment of diagnosis and consequent therapy. Acknowledgments: This study was supported by the IGA MZ CR No. NR9049-3, and the MSMT No. 2B06106.

HP 122 A case of oral-facial-digital syndrome type II-diagnosis and treatment Djordje Kravljanac1, Radoje Simic1, Aleksandar Vlahovic1, Vladan Subarevic2 1 Department of plastic and reconstructive surgery, Institute for mother and child health care of Serbia, St. R. Dakic 6-8, Belgrade, Serbia 2 Department of otorhynolaryngology, Institute for mother and child health care of Serbia, St. R. Dakic 6-8, Belgrade, Serbia Objective: Oral-facial-digital (OFD) type II or Mohr syndrome is characterized by facial deformities, midline cleft of the upper lip, high arched or cleft palate, tongue hamartomas, hand and feet deformities. We report the child with clinical features of OFD syndrome type II associated with trigonocephaly. Methods: A 4-year-old girl born at term was ﬁrst time admitted in Institute during her neonatal period. The diagnosis of OFD syndrome was based on clinical and radiological ﬁndings. Surgical treatment was performed in several stages. Results: On physical examination the patient was found to have: trigonocephaly, hypertelorism, broad nasal root, incomplete cleft palate, lobulate tongue with papilliform outgrowths, lopped and low set ears, mandibular hypoplasia, bilateral hand syndactily of the index and middle ﬁnger, right hand syndactily of the ring and small ﬁnger, polydactily of the both feet and muscular hypotonia. Radiographs of the head, hands and feet conﬁrmed clinical ﬁndings and substantiated the diagnosis of OFD syndrome. Surgical treatment started at the age of seven days by excision of accessories digits of the feet. Surgical correction of trigonocephaly was performed at the age of 6 and 5 months later reconstruction of the cleft palate was done. Bilateral hand sindactily was corrected at the age of 18 months. Conclusions: ORD type II or Mohr syndrome is rare autosomal recessive inherited disorder. Early diagnosis is important, because of genetic counseling. Management requires a multidisciplinary approach. Surgical correction of all anomalies causing functional impairment is mandatory.

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HP 123 Treatment of deep phlegmona of the neck-our expirience Anton Mikic, Ivica Pendjer, Aleksandar Trivic Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, Belgrade, Serbia In preantibiotic era, deep phlegmona of the neck and parapharyngeal space, caused by expansion of pathological process form the teeth, tonsils and peritonsillar abscess were very dramatic and ended in lethal outcome. At that time, the only mode of treatment was wide surgical incision and abscess drainage. The use of antibiotics considerably reduced the incidence of disease and lethal outcome, but even today, the surgery holds an important place in treatment of these life-threatening complications. The authors present the results of surgical treatment of deep phlegmona of the neck at the Institute of Otorhinolaryngology and Maxillofacial surgery, Clinical Center of Serbia, in the period November 1991 to November 2005. In this period, 59 patients with deep phlegmona of the neck and parapharyngeal space, caused by anaerobic and aerobic ﬂora were treated in our Institute. The signiﬁcance of multidisciplinary diagnostics and team work were highlighted. Modern approach to surgical management of cervical phlegmon was emphasized, using the deep multiple incisions and regular lavage of the infected region by Hydrogen 3%, Acidum borici 3% and Rivanoli solutions. Such surgical approach and exposure of all cervical spaces, along with high doses of broad-spectrum antibiotics, provide high percentage of survival, speciﬁcally in our series 89.93%. The authors particularly stress out the signiﬁcance of timely referring of patients to treatment and point to the value of preventive measures. Keywords: Deep phlegmon of the neck, Surgical drainage, Conservative treatment

HP 124 Prevalence and type of halitosis and perception Hamed Hateﬁ Department of otolaryngology H&N surgury shohaday kargar hospital Introduction: Halitosis is a common disorder in general population. But there is not accessible exact data about prevalence of halitosis in our society. This study is designed to measure the prevalence of different types of halitosis. Patients, materials and methods: Sampling was based on Cross Sectional method and questionnaire was given to the patients coming to the ENT Clinics of Kargar Shohada Hospital during 2003–2004. One hundred (100) patients were informed completely about the purpose of this research and accepted to ﬁll out the

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 questionnaires voluntarily. The results were analyzed according to the 100 cc-ses. Results and conclusion: Eighty-six (86%) percent of patients in this study showed oral etiology, 7% ENT etiology, 5% unknown etiology, 2% intestitional etiology of halitosis. In patients with oral etiology of halitosis, tongue coating were found to be the main factor. 86.6% of the patients with oral etiology of halitosis had lower level of socioeconomic status. In this research we found that 81% of patients with 25 years age or older and 90% of patients younger than 25 years old showed higher prevalence of oral factor etiology of halitosis.This study shows no meaningful relationship between sex and oral etiology of halitosis but pharynx, intestitional, and unknown factor were more common in male gender. Nasal factor showed to be more prevalent in females comparing to males.In oral etiology subgroup, tongue coating is the main factor.This study shows oral factor has lower prevalence in elderly but other etiologies have higher prevalence in elderly comparing to normal population. In group with oral factor etiology increasing in socioeconomic status showed to have no meaningful relationship with prevalence of halitosis but prevalence of tennyivitis showed a signiﬁcant increase in prevalence in patients with higher socioeconomic status

HP 125 Complex pharyngeal soft-tissue defects: Pre-operative, intra-operative and postoperative management Christiane Motsch, B. Freigang Medizinische Fakulta¨t Irrespective of the approach adopted, whether conventional or by laser surgery, loss of more than 50% of a functional unit entails in both the oral cavity and the pharynx complex soft-tissue defects that cannot be closed immediately or left to secondary granulation. Hence, resection of advanced oropharyngeal carcinomas has only been possible as plastic surgery became established for the closing of defects. In everyday clinical practice, much importance has been attached to routine application of microsurgically revascularised tissue transfer, with preference given to antebrachial fasciocutaneous graft. The outcome of surgery with respect to both prognosis and the functions—breathing, swallowing, voice and speech—does not depend on the surgical technique alone; key aspects include an accurate diagnosis, comorbidity and the patient’s distinctive characteristics, as well as the therapeutical management including postoperative rehabilitation and intensive care. The strategy to diagnosis and therapy that has been experienced to be successul in 320 patients with advanced carcinomas of the oral cavity and the pharynx during the 1994–2006 period is described.

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HP 126 Syphilitic lymphadenopathy: return of an old foe Alexandra Roper, Iain Bruce, S. L. Gayed, M. Dabrwski, Pradeep Morar East Lancashire NHS Trust Objective: Review of the case of a 38-year-old man who presented to the ENT department with a persistent sore throat and cervical lymphadenopathy. Methods: Flexible pharyngolaryngoscopy was normal. The only positive features on examination were sloughing of the left tonsil and a non-speciﬁc rash. A biopsy of the tonsil was performed which was subsequently reported as showing non-speciﬁc inﬂammation. Upon review with the histopathology result, the skin rash had progressed to a non-pruritic, erythematous rash affecting his torso, palms and feet (Figs. 1, 2). At review, he complained of a sore tongue and examination revealed a lesion the midline of the posterior third of the tongue (Fig. 3). A sexual and lifestyle history was taken, indicating a somewhat ‘promiscuous’ lifestyle. Results: Subsequent virology testing, found that he tested positive for syphilis.He was commenced on doxycycline. He made a good recovery, with his rash, lymphadenopathy and chancre resolving completely. Conclusions: It would be unusual for a history of syphilis to be elicited in the ENT outpatient clinic unless it was directly suspected (3). Its presentation to the otolaryngologist is rare, but such are the implications of non-diagnosis to the patient and their sexual partner(s), that diagnosis must not be missed. The rapid increase in the incidence of syphilis is likely to translate into an increase in head and neck presentations. The latest generation of otolaryngologists need to be forewarned if this old adversary is to be promptly identiﬁed and treated.

HP 127 HAE in the head and neck-region J. Greve1, N. Mansour1, M. Bas1, G. Kojda2, H. Bier1, T. K. Hoffmann1 1 Department of Otorhinolaryngology, Heinrich-Heine-University, Du¨sseldorf, Germany 2 Institute for Pharmacology and Clinical Pharmacology, Heinrich-Heine-University, Du¨sseldorf, Germany Objective: Hereditary angioedema (HAE) are caused by increased bradykinin-production due to the lack of functional C1-esterase inhibitor. Affected patients experience recurrent angioedema of the dermis or mucosa. Laryngopharyngeal and lingual manifestations may lead to hoarseness, dysphagia, and dyspnoea as well as suffocation in individual cases. In these particular emergency cases, a fast acting and effective treatment is necessary. Methods: During an ongoing open label study (FAST-2) we treated 6 HAE-patients with Icatibant, a speciﬁc bradykinin-B2receptor-antagonist, which is applied subcutaneously. So far, we have administered Icatibant during 10 acute life-threatening HAE attacks of the laryngopharyngeal (n = 8) region or the tongue (n = 2). Further 13 attacks involved other head-neck-regions (5· lips, 2· face, 6· neck). Symptom score by patient, documentation of time for the onset of symptom relief measured by a visual analog scale and time to complete resolution of symptoms were the main assessments. Results: Following treatment with Icatibant, ﬁrst symptom relief was reported by patients after 37 ± 22 min in patients with lingual edema, 79 ± 13 min in laryngopharyngeal manifestations and 91 ± 11 min when other head and neck regions were af-

S109 fected. Laryngopharyngoscopy revealed complete remission after 4 hours. Except a local skin irritation at the injection site, no other side effects were noticed. Conclusions: Icatibant showed a rapid onset of symptom relief in the treatment of acute, life-threatening HAE attacks with laryngopharyngeal and lingual manifestations.

HP 128 Head and neck localisation of sarcoidosis Olfa Ben Gamra, Sarra Zribi, Samia Ayari, Ines Hariga, Chiraz M’barek, Abdelkader El Khedim ENT department Habib Thameur Hospital Tunis Tunisia Objective: To presise clinical, paraclinical and theraputic aspects of head and neck sarcoidosis. Patients and methods: The authors report a retrospective study of eight cases of head and neck sarcoidosis diagnosed over a period of 10 years (1997–2006). The mean age is 41 years. The sex-ratio is 0.6 (3 men, 5 women). We repport six patients with isolated sarcoidosis of the nose and the sinuses; one case localisated in parotid gland and one cervical node localisation. Results: None of these patients was found to have a pulmonary illness or any other extrapulmonary manifestation of sarcoidosis. The diagnosis was based on clinical and histological confrontation. Conclusion: Sarcoı¨ dosis is an ubiquitary disease, which can inﬁltrate all tissues. The most frequents localisations are cutaneous, ophthalmologic and thoracique. The otorhinolaryngologic localisation are rare. They can be isolated or associated with systemic manifestations. The treatment was based on local and general corticotherapy. The evolution was favorable for all patients with 3 years average following up.

HP 129 Parapharyngeal space abscesses: report of 15 consecutive cases S. Vlachou, C. Diplas, G. Leondis, V. Bakas, P. Kanakis*, C. Christidis, G. Papazoglou ENT Department, Red Cross Hospital, Athens, Greece *Maxillofacial surgery unit, Red Cross Hospital, Athens, Greece Objective: The purpose of the present study was to present our data on parapharyngeal space abscesses. Methods: We report 15 cases diagnosed and treated in our department. The patients were 5 women and 10 men, 25 to 60 years old, with fever, pharyngeal pain, odynophagia, neck swelling and trismus. Four cases were due to oropharyngeal infections, while the rest were odontogenic. All patients were admitted, clinically examined, and submitted to laboratory workup, including neck CT scan. The patients received iv broad spectrum antibiotics. Results: Four patients were treated conservatively. Eleven patients were operated on, nine of whom immediately and two after some days because of an acute deterioration of their condition. One patient was operated twice. Eight patients were submitted to tracheostomy before surgery. All patients underwent an external approach to the parapharyngeal space, and drainage of the abscess. Their post-operative course was uneventful and one stayed in the ICU for 3 weeks Conclusion: Parapharyngeal space abscess present still a clinical entity which has to be treated with care. The evaluation using CT scan along with timely intervention appear to be the critical factors in the successful management of these patients.

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HP 130 Endoscopic removal of foreign bodies in the lung with optical ﬁbers. A case study. Ippokratio Hospital of Thessaloniki Athanasios Skouras, Spiridon Gougousis, George Kontzoglou E.N.T Department of Ippokratio General Hospital of Thessaloniki Objective: The purpose of this paper is to demonstrate that the use of rigid endoscope with optical ﬁbers in removing foreign bodies from the lungs is considered revolutionary not only because it increases the surgeon’s visibility but guarantees the safety of the operation. Methods: It was presented the last decade and has been a challenge due to its obvious advantages. In our hospital we exercised this method in 246 cases there was speculation of foreign body. In 174 cases it was found and removed. Results: In the majority of cases we were able to remove the foreign bodies. In two cases a second effort was needed, whereas in three cases an open thoracotomy was used to remove the foreign body from the lung. Conclusion: The results of our survey have declared the use of rigid endoscope with optical ﬁbers an advanced method, safe and more efﬁcient than the traditional method with rigid bronchoscope.

HP 131 Case report: secondary lingual tuberculosis resembling lingual cancer with lung metastasis Kursat Ceylan, Hulya Bayiz, Ahmet Yavanoglu, Zeynep Kizilkaya, Huseyin Ustun, Erdal Samim, Hasmet Kılıc Ministry of Health Ankara Research and Training Hospital Ear Nose and Throat Department, Ulucanlar Cad. No:1 Mamak Ankara, Turkey Objective: We present a case of secondary lingual tuberculosis with disseminated lesions in lungs and with ulceration and inﬁltration of the tongue. Method: Case report and world literature concerning secondary lingual tuberculosis are presented. Results: Tuberculosis of the tongue is a rare condition that is usually associated with pulmonary tuberculosis. We present a case of secondary lingual tuberculosis in a 51-year-old man, heavy cigarette smoker, an alcoholic, with disseminated lesions in lungs and with ulceration and inﬁltration of the tongue. Treatment with antibiotics was ineffective. He was admitted to the otolaryngological department because of suspicion of the tongue cancer. The clinical manifestations, diagnosis and the response to the antituberculosis treatment are considered. Conclusion: The clinicians should be alert of the possibility of TBC in the differential diagnosis of atypical lesions of the oral cavity, including those appearing as ulcerated and/or granular lesions in a lingual location.

HP 132 Madelung disease: case reports Raluca Grigore1, S. V. G. Bertesteanu1, D. Mirea1, R. C. Popescu1 1 ENT, Head and Neck Surgery Clinic, Coltea Clinical Hospital, Bucharest, Romania Objective: Madelung disease is a rare disorder of fat metabolism that results in an unusual accumulation of fatty tissue around the

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 neck, face, back of the head. The problem of etiology and recurrences is still in discussion. Methods: Authors present three case reports: all were male patients who came to the hospital for giant tumoral masses surrounding the neck and face. One of them presents with moderate to severe dispnea, and one of them with swallowing difﬁculties. Results: All patients were carefully examinated and investigated. We decide that surgical excision is the best option for all these patients presenting with giant fatty masses. Conclusions: Complete excision is very difﬁcult because of the hemorrhagic risk and also because of the fact that the adipose tissue is surrounding important anatomic elements, like carotid arteries, larynx or thyroid gland. This rare disease is not only the cause of aesthetic changes, but can also give respiratory or alimentary troubles. One can recognize and differentiate aerodigestive symptoms from the symptoms of malignancy of head and neck.

HP 133 Evaluation of the necessity of a practical teaching of otolaryngology in a Brazilian Medical School Lisandre Fraza˜o Brunelli Foti1, Osmar Clayton Person1,2, Renata Ribeiro de Mendonc¸a Pilan1, Priscila Bogar Rapoport1 1 Faculty of Medicine of ABC, Sa˜o Paulo, Brazil 2 Centro Universita´rio Sa˜o Camilo, Sa˜o Paulo, Brazil Introduction: The graduation curriculum of the medical schools has been a target for improvement of the formation of a generalist and humanity doctor to attend the basic necessities of a population. In otolaryngology, practically there are no evaluations about it in Brazil. Objective: The purpose of this study was to evaluate the necessity of a practical teaching of otolaryngology in the medical graduation of the ABC Medical School (Sa˜o Paulo, Brazil). Material and method: for that, 87 students of the last period of the course of the ABC Medical School answered a survey analyzing cases and clinical situations in ENT (questionnaire), classifying in order of an urgent assistance by a generalist doctor, an urgent assistance by an otolaryngologist or not urgent. Results: In 80% of the cases the answers were appropriatte; in 16% inappropriatte and in 4% they were suitable, but not the best answer. The main difﬁculties appeared in cases that envolved a practical knowledge of the otolaryngology. Conclusion: The practical basic teaching of otolaryngology in the ABC Medical School can aid in the formation of a generalist doctor.

HP 134 Cutaneous self-extrusion of a foreign body from the upper aero-digestive tract Hong Juan Han, Alvin Kah Leong Tan, Pon Poh Hsu, Peter Lu Changi General Hospital, 2 Simei Street 3, Singapore 529889 Migrated ingested foreign bodies from the upper digestive tract have the potential to cause life-threatening complications. Cases of spontaneous expulsion to the skin of the neck are very rare. We present an unusual case of an ingested foreign body that migrated out of the upper digestive tract and self-extruded via the skin of the neck. An approach to the safe management of such seemingly innocuous foreign bodies is discussed.

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HP 135 Tortuous internal carotid artery narrowing piriform sinus: two cases K. M. Ozcan*, I. Ozcan*, A. Selcuk*, L. Pasaoglu**, G. Hatipoglu**, H. Dere* *Ankara Numune Education and Research Hospital 4th ENT Clinic, Turkey **Ankara Numune Education and Research Hospital Radiology Clinic, Turkey Objective: An elongation of the internal carotid artery should be classiﬁed as a tortuosity or a kink. Tortuosity of the carotid artery is rarely seen in otolaryngologic practice. Methods: Fifty-three and 54-year-old women presenting with foreign body sensation in throats were seen in otolaryngology clinic. In videolaryngoscopic examination bilateral piriform sinus narrowing revealed in one patient and unilateral piriform sinus narrowing revealed in the other patient. Results: Computerized tomography scans showed tortuous internal carotid artery in both patients. No treatment offered. Conclusions: Awareness of the possible internal carotid artery tortuosity is very important to prevent serious complications during laryngeal and pharyngeal surgical procedures.

HP 136 Surgical management of branchial cysts N. Salemis1, K. Nazos2, I. Psarommatis2, N. Bollas1, E. Tsohataridis1 1 2nd Department of Surgery, Army Veterans General Hospital NIMTS, ‘‘P & A Kyriakou’’, Athens, Greece 2 Children’s Hospital, Athens, Greece Objective: The aim of this study is to evaluate the clinical presentation, diagnosis and management of patients who underwent surgical operation due to a branchial cyst at our institution. Materials and methods: Between January 2000 and December 2006, 21 patients with branchial cysts were admitted to our department. There were 13 (61.9%) men and 8 (38.1%) women, ranging in age from 18 to 46 years (mean age 28 years). Seventeen patients (81%) presented with an asymptomatic swelling, while four had clinical manifestations of an infected cyst. Diagnostic evaluation included full blood count, biochemical analysis, ultrasonography, computerized tomography scans (CT) and magnetic resonance imaging (MRI) where indicated. Results: Patients with infected cysts were initially treated with intravenous antibiotics. No surgical intervention at that stage was required. Resection followed 2 months later. All other patients underwent complete resection of the cyst at the time of admission with thorough exploration for a possible sinus tract presence. There were no perioperative complications and the mean hospital stay was 2.1 days. Conclusions: Branchial cysts should always be considered in the differential diagnosis of neck swellings especially in young adults. Patients with clinical manifestations of an infected cyst should be initially treated with intravenous antibiotics. FNA cytology is recommended.

HP 137 Effectiveness of fast track referrals in head and neck surgery Paul Stimpson, Alwyn D’Souza University Hospital Lewisham

S111 Objective: In accordance with UK National Health Service guidelines, we operate a ‘two week wait’ fast track referral system for suspected head and neck malignancy from primary care practitioners as well as other sources. The aim of this study was to assess referrals under this system and evaluate the frequency of cancer diagnoses. Methods: A retrospective review of all 2 week wait referral case notes for the calendar year 2005–2006 was performed. The appropriateness and timeliness of referral was assessed. The number of positive cancer diagnoses was evaluated via SNOMED. Results: During the study period 423 patients were referred with suspected head and neck cancer. A total of 63 patients were subsequently diagnosed with cancer (15%). Three hundred and twenty patients were referred by local GPs via the 2 week wait rule. In this group, 31 patients (10%) were diagnosed with cancer. Also in this group 49 patients (15%) were inappropriately referred according to two week wait guidelines. One hundred and three patients were referred via other sources (GPs not via two week wait system, emergencies, inpatient referrals) and were subsequently ‘upgraded’ to the two week wait system if this were deemed appropriate. In this group, 32 patients (31%) had a diagnosis of cancer. Conclusions: Our results demonstrate a relatively low yield for cancer diagnosis following fast track referral. A large proportion of patients from general practitioners are inappropriately referred whereas those referred via other sources have a higher rate of cancer diagnosis. A high referral rate and low yield is preferable to missed or late diagnosis of cancer. However, we suggest referral criteria should be modiﬁed. This will be most effective in conjunction with improved education of referring practitioners.

HP 138 Cervical lymph node tuberculosis: 12-years experience Ines Hariga, Olfa Ben Gamra, Rabie Ben Hammouda, Sarra Zribi, Chiraz M’barek, Abdelkader El Khedim ENT department Habib Thameur Hospital Tunis Tunisia Objective: The clinical problem of a neck mass in general and lymph nodes in the neck in particular may present a diagnostic dilemma. This retrospective study was conducted to highlight clinical presentation, management, and outcome. Methods: We retrospectively studied 169 cases of lymph cervical node tuberculosis conﬁrmed by pathology from 1994 to 2006 in our hospital. Results: The mean age of the patients at diagnosis was 37 years. It was more common in females (119 females, 70% and 50 males, 30%). Young adults were most frequently involved (49.5%). The patients’ main presenting problems were palpable masses (97.1%). The diameter of the cervical nodes ranged between 1.5 and 5 cm. The neck mass was ﬁxed in (29.1%) cases. Erythrocyte sedimentation rate was accelerated in 68.8 and 77.1% of tuberculin skin testing was positive. All patients had chest radiographs, one patient had concomitant pulmonary tuberculosis and their chest radiographs showed typical tuberculous lesions. The ultrasound examination was systematic. The sensitivity of ﬁne-needle aspiration cytology in the diagnosis was 28.8%.Ninety-eight percent of patients had a cervicotomy explorative with histopathological examination. Patients received antituberculous drugs after histological conﬁrmation. The standard regimens were 8 months. Recurrent disease was observed in six patients (4%). Conclusion: Mycobacterial infections have been shown to be increasing in number worldwide. The histopathological examination was necessary for the diagnosis. The treatment was medical and surgical.

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HP 139 Surgical approaches for oropharyngeal tumors

ation of this chemoradiotherapy modality in locally advanced SCCHN patients.

N. Salemis1, K. Nazos2, I. Psarommatis2, N. Bollas1, E. Tsohataridis1 1 2nd Department of Surgery, Army Veterans General Hospital NIMTS, ‘‘P & A Kyriakou’’, Athens, Greece 2 Children’s Hospital, Athens, Greece

HP 141 3D power Doppler analysis of the vascularization in tumours of the oral cavity

Objective: In this study is reported the value of the four main approaches to oropharyngeal tumors: transoral, transoral/transcervical, transpharyngeal and mandibular splitting approaches. Methods: Both surgical approach and chemoradiotherapy have been used to 80 patients with oropharyngeal tumors in our department during the last 5 years. Fifty-three patients presented malignant forms and 27 patients benign lesions. A selective local resection of the tumor was done in the 33, 7% of our patients with benign tumor and an extended dissection of the tumor and neck lymph nodes (modiﬁed radical neck dissection or radical neck dissection) was performed in 66, 3% of our patients with malignancy. Results: Most oropharyngeal tumors are operable. The tumors are normally resected with 1–2 cm border of grossly normal tissue. Oropharyngeal cancers can be resected through four main surgical approaches. The choice of approach depends on the size and location of the tumor and if a related neck dissection is planned. Visual inspection and palpation are the most accurate ways for determining the dimension of the tumor in the oral pharynx. Determination of bony involvement can be difﬁcult preoperatively, so imaging studies such as CT or MRI should be considered. In cases with palpable nodes or if the primary is large, a modiﬁed radical neck dissection or radical neck dissection may be necessary. Conclusions: It is important for the surgeon in order to select the proper approach to consider the type, size, and location of the tumor which is going to be excised, as well as to follow the best chemoradiotherapy postoperatively.

HP 140 Chemoradiotherapy with CDDP, 5-FU, MTX and LV for head and neck cancer Hideaki Katori1,2, Mamoru Tsukuda3 1 Otolaryngology, Yokohama City Minato Red Cross Hospital, 3-12-1 Shin-Yamashita, Naka-ku, Yokohama 231-8682, Japan 2 Otolaryngology, Yokohama City University Medical Center, 4-57 Urafune-chou, Minami-ku, Yokohama 232-0024, Japan 3 Otolaryngology, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan; Objective: The aim of this study was to evaluate the efﬁcacy and toxicity of concurrent chemoradiotherapy using CDDP, 5-FU, MTX and LV (PFML) in locally advanced squamous cell carcinoma of the head and neck (SCCHN). Methods: Seventy-seven patients with previously untreated stage III-IV SCCHN were included in this trial. Patients received two cycles of chemotherapy repeated every 4 weeks. The chemotherapy regimen consisted CDDP (60 mg/m2, day 4), 5-FU (600 mg/ m2 given over 24 h for 5 days, days 1–5), MTX (30 mg/m2, day 1), and LV (20 mg/m2, days 1–5). Radiation was targeted to begin on the starting day of chemotherapy, day1. The total radiation dose to the primary site and neck lymph nodes was 70.0 Gy. Results: The overall clinical response rate and the pathological complete response (CR) were 94% (72/77) and 71% (55/77). The primary site CR and neck lymph node CR were 79% (61/77) and 85% (44/52), and 3-year survival rate was 73%. Conclusions: This concurrent chemoradiotherapy with PFML was safe and well tolerated. The high CR rate justiﬁes further evalu-

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Janez Rebol Department of Otorhinolaryngology, Maribor Teaching Hospital, Ljubljanska 5, 2000 Maribor, Slovenia Objective: The aim of this study was to determine the volume and vascularization of tumours by 3D power Doppler ultrasound in patients with oral cavity tumours. Methods: 3D power Doppler ultrasound investigation was performed pre-operatively on 49 patients with oral cavity carcinomas. Digitally-stored data were analysed with 3D View program software, a part of which is the ‘‘VOCAL-Imaging program’’. By using VOCAL, the borders of a structure (tumour) can be determined and its volume calculated. The vascularization of the tumour was determined by analysing 3D colour histograms, and the vascularization indices were calculated. Results: Vascularization indices VI and VFI were signiﬁcantly higher in patients with neck metastases. The differences between the vascularization indices in N+ and N0 neck were statistically signiﬁcant (P < 0.05). The ﬂow index (FI) values between N+ and N0 neck were not statistically different. Conclusions: The volume of oral cavity tumours and their vascularization could be determined effectively by 3D power Doppler ultrasound. Tumour vascularization is higher in metastatic than in non-metastatic tumours.

HP 142 Basaloid type of the squamous cell carcinoma B. Vukomanovic-Djurdjevic1, R. Kozomara2, A. Peric3, N. Baletic3, M. Jovic1 1 Military Medical Academy, Institute for Pathology, Crnotravska 17, Belgrade 2 Military Medical Academy, Clinic for Maxillofacial and Oral Surgery, Crnotravska 17, Belgrade 3 Military Medical Academy, Clinic for Otorhinolaryngology, Crnotravska, Belgrade Objective: Basaloid squamous cell carcinoma is rare variant tumor of uper aerodigestive tract. This tumor have more aggressive biological maner and poor prognosis. Methods: Clinical examination, ultrasonography, radiography, operation, histopathology analysis. Results: Female, 60 years old, had egsophytic tumor on the lateral margin of the tongue. Tumor was sesile and without pain and without erosion of the mucosa above the tumor. Ultrasonography of the neck and radiography of the lung and heart did not present metastasis. Surgical excision of the tumor was done with margin of the normal tissue. On the hystopathology examination, tumor had two areas of cells. Basaloid cells had numerous mitoses and many comedo- necrosis. Althout, there was areas with tipical squamous cell carcinoma with keratinisation as well as keratinisation in basaloid patterns. Musosa above the tumor had high degree of displasion. Immunohystochemical staining and this mycroscopical picture determinated dyagnosis of the basaloid type of the squamous cell carcinoma. Conclusion: It is necessary continous examination of patient with basaloid type of the squamous cell carcinoma, because aggressive nature of the tumor.

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HP 143 Lymphoma of nasolacrimal drainage system D. Marev1, N. Sapundzhiev1, I. Krasnaliev2, M. Alamo3 1 Department of Oto-rhino-laryngology, St. Marina University hospital – Varna, Bulgaria 2 Department of General and Clinical Pathology, St. Marina University hospital – Varna, Bulgaria 3 Department of Radiology, St. Marina University hospital – Varna, Bulgaria Introduction: Primary lymphoma of the lacrimal drainage system (LDS) presents an extremely rare condition. Case report: A 70-year old female preseneted at the Department of oto-rhino-laryngology with complains of a palpable mass over right median eye angle with local pain and epiphora since approximately 3 months. The mass was approximately 2.5 cm with no signs of ﬂuctuation or inﬂammatory changes in the overlying skin. Head CT scan revealed solid tumoral mass without osteolytic changes and no involvement of the eyeball and orbital fat pad. After the complete surgical resection the specimen was stained with H&E and an immunohistochemical panel with antibodies directed against CD3 and CD20 was applied. B-cell nonHodgkin’s lymphoma (NHL) was diagnosed. Further staging by CT and sonography revealed no enlarged lymph nodes or other bulky tumor, but bone marrow examination showed massive inﬁltration with NHL cells (stage IV HNL). Ttreatment with the CHOP protocol was started. Conclusion: Primary involvement of LDS by NHL is extremely rare. The most cases described in the literature are of the B-cell type, the T-cell type being extreme rareness. As only of patients with LDS involvement the incidence of NHL is estimated at 1/2000.

HP 144 Head and neck SCC in chronic lymphocytic leukaemia: a high risk group? Annabelle Leong, Leonard Liew, John Shotton, Nicholas Rowell Department of Head and Neck Surgery and Oncology, Kent Oncology Centre, Maidstone Hospital, UK The increased incidence of second cancers in CLL has been documented. Although there is little speciﬁc data focusing on the behaviour of head and neck squamous cell cancers (HNSCC) in CLL patients, it has been suggested that these tumours are more aggressive and carry a poor prognosis. Objective: Study the natural history of HNSCC in CLL patients. Methods: A retrospective review of all patients with concurrent diagnoses of CLL and HNSCC who had attended the Multidisciplinary Head and Neck Clinic at a regional oncology centre over 10 years (1996–2006). Demographics, site of SCC, stage of disease, CLL management, treatments and outcomes were studied. Results: Thirteen patients with CLL and HNSCC were identiﬁed (0.7% of total HNSCC referrals in this period). They presented as cutaneous primaries (6 pinna, 1 post-auricular, 1 scalp, 1 eyebrow, 1 nasal columella, 1 lower lip), or head and neck primaries (1 parotid and 1 unknown- metastatic cervical lymph nodes). Patients were treated with surgery and/or radiotherapy but 7 of 13 relapsed. CLL treatment encompassed chlorambucil, ﬂudarabine, or cyclophosphamide, while 5 of 13 had no treatment. Survival times from time of primary HNSCC diagnosis ranged from 3 to 62 months (mean 19.3, median 22). Conclusions: Prognosis for HNSCC is worse for patients with CLL. Close monitoring is advised for development of second tumours, as more aggressive treatment may be needed. The increased susceptibility to second cancers is thought to be due to the

S113 immunosuppression by the leukaemia, but an exacerbation from chemotherapy cannot be excluded.

HP 145 Epidemiological study of skin tumors of the head and neck Evdoxia Gerostergiou1, Georgia Vergou1, Christos Ganohoritis3, Dimitrios Batzakakis1, Ioannis Tsitiridis1, Ioannis Bardanis2, Georgios Vrionis4, Panagiotis Karagounis1 1 ENT Clinic General Hospital of Larissa 2 ENT Clinic General Hospital of Ikaria 3 General Practitioner Health Center of Gonoi 4 Opthalmologist General Hospital of Larissa Objective: Facial skin tumors can be benign or malignant.The differential diagnosis is based on the biological behavior and the histological type as deﬁned after their surgical excision. In this survey, we tried to deﬁne the most common types of benign and malignant skin tumors located on the head and neck, the correlation between the age and the appearance of the tumors and the frequency of tumors in males-females the period 2003–2005 in the ENT Clinic of Larissa’s General Hospital. Method: During the years 2003–2005, 432 patients underwent surgical excision and biopsy of skin tumors located on the head and neck. All the tumors were sent for histological examination. Results: From the whole of the cases 235 persons were male (54.4%) and 197 were female (45.6%). The age range in both sexes was 20–92 years. The tumors were diagnosed as malignant in 65.74% of the patient and as benign in 34.24%. Basal cell carcinoma is the most common malignant skin tumor (47.92%) and it is located at the nose area in the 36% of the patients. The area of the lips was the most common location of benign skin tumors. Conclusions: Men are most frequently affected of skin tumors than women. The 2/3 of the cases suffered from malignant skin tumors, which are most commonly a basal cell carcinoma, so that surgical excision and biopsy is imperative in all tumors with suspicious behavior.

HP 146 Gigantic laterocervical tumor: case report Daniel Mirea, Serban Vifor Gabriel Bertesteanu, Raluca Grigore, Cristian Radu Popescu ENT Department, Coltea Clinical Hospital, 1st IC Bratianu Blvd, Bucharest, Romania Objective: The authors present a rare case of a gigantic laterocervical tumor. The difﬁculties of surgical treatment and hystopathological ﬁndings were the most important particularities of this case. Method: A 66-years-old female was admitted in our department for enlarging painless soft tissue mass located in the left laterocervical region. Tumor dimension at the time of admission was 13/ 18 cm. MRI was useful to appreciate tumor extension. A needle biopsy was performed shown the presence of malignant cells. Possible distant metastasis were not found. Results: Tumor excision was very difﬁcult because tumor dimenssions and proximity of the great neck vessels. Hystopathological examination, including imunohistochemistry, showed the presence of a malignant ﬁbrous histiocytoma. Conclusions: Diagnosis of this gigantic laterocervical mass was possible after its removal. Immunohistochemistry was useful to eliminate other types of sarcomas (liposarcoma). Prognosis is poor because tumor dimensions, despite the absence of distant metastasis.

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HP 147 Castelman’s disease located in neck: case report Besim Boci, Emirjona Vajushi Department of Otorhinolaryngology–Ophtalmology; University Hospital Center of Tirana ‘‘Mother Theresa’’ Albania Castelman’s disease is a rare disorder charecterized of a non cancerogenic growth of lymph nodes all over the human body. There are two histologic variants of this disease: the hyaline-vascular type (90% of cases) and the plasmacellular type. The hyaline-vascular type and plasmacellular type. We report a case of a male patient with the hyaline–vascular type of Castelman’s disease located in neck. Materials and methods: A 37 year old male-patient S.H. was admitted to our hospital with a history of 7 months of an mass in right posterior triangle of neck. The patient underwent surgical excision. Results: Cervical CT revealed a 8 · 5 cm well-deﬁned homogenous solid mass that ﬁxes contrast. The mass has close contact with the posterior wall of internal jugular vein, does not inﬁltrate it but moves it. The histological examination showed a lymph nodular structure with little follicles and sclero-hyaline changes highly indicative of Castleman’s disease. Immunohistochimic examination revealed production of polyclonal Ig from plasmocytes and increase of T-suppressor cells in interfollicular regions. Conclusions: This report presents a rare disease of lymph nodes located in neck with dimension 80 mm which is larger than reportes in literature (literature reports cases of about 20 mm). Patient is in good health and under recurrent checkup.

HP 148 Primary sinonasal non-Hodgkin’s lymphoma: case report Istva´n Bartku, Ibolya Elek, Erzse´bet Fu¨le, Ja´nos Jako´* Department of Otorhinolaryngology-Head and Neck Surgery, Jo´sa Andra´s County Hospital, Nyı´ regyha´za, Hungary *Department of Hematology, Jo´sa Andra´s County Hospital, Nyı´ regyha´za, Hungary Objective: Non-Hodgkin’s lymphomas of the nasal cavity and paranasal sinuses are uncommon manifestations of malignant lymphomas. This study was performed to report two cases, to discuss the primary NHL of the sinonasal tract and to remind us of the importance of histopathological examination. Methods: Presenting two cases (age, clinical symptoms, site involvement, stage, histological type, imaging, treatment, prognosis) and a review of literature.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Results: The initial clinical symptoms of the primary sinonasal NHL—nasal obstruction, rhinorrhea, epistaxis—are non-speciﬁc and mostly found in benign nasal disease. It may mimic a chronic rhinosinusitis and the histopathology proves the unexpected result: non-Hodgkin’s lymphoma. Demonstrating these cases and with a review of literature we tried to identify some speciﬁc signs in the clinical and radiological manifestations, and we have found that in the early stage there is no evident sign to settle the correct diagnosis, which can delay the appropriate treatment. We underline that in case of any mass in the nasal cavity the surgical biopsy to the early diagnosis is essential. Conclusions: The primary sinonasal NHL is a rare entity, and it is difﬁcult to distinguish from benign diseases or other malignancies. The initial symptoms are not speciﬁc, and the key for the diagnosis and optimal treatment is the biopsy.

HP 149 Parapharyngeal hemangiopericytoma: clinical case S¸erban Vifor Gabriel Bertesteanu, Daniel Mirea, Raluca Grigore, Cristian Radu Popescu ENT Department of Coltea Clinical Hospital, 1st I.C. Bratianu Blvd., Bucharest, Romania Objectives: Hemangiopericytomas account for only 1% of blood vessel tumor and 3% soft tissue sarcomas. Hemangiopericytomas in the region of the head and neck pose special problems in diagnosis. We want to present an uncommon tumor of the parapharyngeal space. Tumors of the parapharyngeal space are rare, approximately 0,5% of the head and neck tumors. Methods: The authors present a case of 62-year-old with right parapharyngeal space tumor. CT scan is not speciﬁc but angiograms show a characteristic picture. The tumor is very interesting for the differential diagnosis. The histopathological and imunohistochemical aspect was speciﬁc for hemangioperycitoma. We used the surgical approach for the removal of the tumor with postoperative radiation therapy (44 Gy) and chemotherapy. Results: After surgery the patient was followed up for 5 year. The evolution was good, without recurrences. Conclusions: The radical surgery with postoperative radiotherapy is required in less well-differentiated hemangiopericytomas. Usually metastasis becomes apparent within a period of 5 years after the initial diagnosis, but late metastases occurring 10 or more years after the initial diagnosis are not uncommon. We must follow up the patients for minimum 5 years.

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HP 150 Esophageal Lugol staining in head and neck cancers: is it worthwhile? P. Komı´ nek1, P. Vı´ tek2, O. Urban3, P. Vantuch1, P. Matousek1 1 Faculty Hospital Ostrava, Czech Republic 2 City Hospital Fry´dek-Mı´ stek, Czech Republic 3 Vı´ tkovice Hospital Ostrava, Czech Republic Objective: Patients with squamous-cell carcinoma in the head and neck (HNSCC) often develop second primary esophageal squamous-cell carcinomas (ESCC). Widespread epithelial oncogenic alterations are frequently observed in the esophagus and can be made visible as multiple lugol-voiding lesion (multiple LVL) by Lugol chromoendoscopy. Methods: Since 2004 44 patients with HNSCC have been examined with esophagoscopy with chromoendoscopy (3% Lugol solution). The iodine in the solution rapidly stains glycogen in normal squamous mucosa brown, and area of dysplasia or early cancer are unstained (LVL). The biopsy specimens were obtained from the unstained streaks. Results: LVLs were identiﬁed in 18 cases (41%). One detected esophageal SCC was also visible macroscopically, not only chromoendoscopically. Low grade dysplasia was detected 1·, hyperkeratosis 1·, hyperplasia 1·. Nonspeciﬁc mucosal inﬂammatory changes were detected in the other cases. The reﬂux esophagitis was detected in 17 cases (39%). Conclusion: Lugol chromoendoscopy should be carried out in patients with primary HNSCC to detect synchronnous early esophageal carcinomas.

HP 151 Surgical and reconstructive characteristics of head and neck skin cancer in a regional referral center L. G. McClymont, M. Dhiwaker ENT Department, Raigmore Hospital, Inverness, UK Objective: To determine the demographic, pathologic and surgical characteristics of a large cohort of patients undergoing surgical removal of head and neck skin cancers. Methods: All cases of head and neck skin cancers (excluding malignant melanoma) undergoing surgical resection in a regional referral center over a 10-year period were retrospectively reviewed. A total of 463 patients (638 cases) were eligible for inclusion. Results: The male to female ratio was 2.3:1. The majority of lesions were basal cell carcinoma (68%), followed by squamous cell carcinoma (27%). Nose, cheek and ear in descending order of frequency were the commonest sites of incidence. Most (78%) lesions were amenable to local anaesthetic excision. The mean size of lesions (±SD) was 1.2 (±1.5) cm2, warranting excision of an

S115 average area of skin 5 (1.1) cm2 in size to achieve macroscopic clearance. There was a need for a local ﬂap or skin graft to reconstruct the defect in approximately half (49%) the cases. The excision margin was positive in 10% of cases, with re-excision most commonly required for squamous cell carcinomas. There was no perioperative mortality and minimal morbidity. During the follow-up period, there were 4 local and 10 regional recurrences, which were treated by re-excision, neck dissection, radiotherapy or combination therapy. There was only one diseasespeciﬁc mortality (distant metastasis from merkel cell carcinoma). Conclusion: We present a large series of head and neck skin cancers treated at a regional referral center. The current study provides important data on their site predilection and pathological, surgical and reconstructive characteristics.

HP 152 Preoperative embolization in the management of hypervascular tumors of the head and neck Ihar Belatsarkouski, Uladzimir Akinfeyeu N.N. Alexandrov’s Research Institute of Oncology and Medical Radiology, Minsk, Belarus Objective: To study results of surgical treatment and preoperative embolization of neck paragangliomas and juvenile nasal angioﬁbromas (JNA). Methods: A retrospective analysis of treatment results of 48 patients treated since 1996 till 2006 was performed. Patients were devided in two groups. First group consisted of 38 patients (11 M/ 27 F, mean age 44 years) with neck paragangliomas. There were 32 (85%) carotid body tumors (CBT) and 6 (15%) vagal paragangliomas. Second group consisted of 10 male adolescents with JNA. Preoperaive embolization was performed in nine patients in the ﬁrst group and in all the patients of second one. In the ﬁrst group subadventitial tumor removal was performed in 26 (68%) of cases (20- CBT, 6-vagal paraganglioma). Tumor removal with external carotid artery resection was applied in 9 (24%) cases. Tumor removal with resection of external and internal carotid arteries with autovenous grafting was performed in 3 (6%) of cases. In the second group tumor removal was performed using a Denker or Weber-Ferguson rhinotomy approach. Results: 1st group: Total tumor devascularization after embolization was achieved in six cases and subtotal in 3. Surgical complications was noticed in 19 patients (including two cases of brain ischemia). Mean intraoperative blood loss was 150 ml among embolized patients comparing with 400 ml without embolization. 2nd group: No complications of embolization was noticed. Mean intraoperative blood loss was 200 ml. Conclusions: Preoperative embolization should be considered as useful method to prevent intraoperative blood loss in patients with paragangliomas and JNA.

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HP 153 Sentinel lymph node biopsy: a new prospective in parotid gland carcinoma? Ivo Sta´rek1, Pavel Koranda2 1 ENT Clinic, Faculty Hospital, I.P.Pavlova 30, Olomouc, Czech Republic 2 Clinic of Nuclear Medicince, Faculty Hospital, I.P.Pavlova 30, Olomouc, Czech Republic Objective: Indications for elective neck dissection in N0 staged patients with parotid gland carcinomas are inconsistent. A pilot study was performed to test the feasibility and efﬁcacy of radioguided sentinel lymph node biopsy (SLNB) in these tumors. Methods: In seven consecutive N0 patients with parotid gland carcinoma preoperative lymphoscintigraphy, followed by parotidectomy and elective neck dissection with radio-guided identiﬁcation of sentinel lymph nodes (SLNs) was performed. The histopathological status of particular SLNs was then compared to that of the remaining lymphatic basin. Results: The SLNB exactly reﬂected the positive and negative histopathological status of the remaining lymphatic basin in three and four patients, respectively. There was no case of false negativity of the SLN. Conclusions: The study suggests that SLNB could provide reliable information on the status of regional lymph nodes, making it possible to base the neck dissection on the actual presence of the micrometastases. Before this method can be used in everyday practice, an extended and ideally multicentric and long-term trial will have to be performed.

HP 154 The role of ultrasound guided ﬁne needle aspiration cytology (USgFNAC) in detection of occult metastases in cancer of head and neck Ljiljana Cvorovic, Zoran Milutinovic, Aleksandar Oroz, Ljubomir Pavicevic* Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zemun, Belgrade, Serbia *Department of Otorhinolaryngology, Head and Neck Surgery, Military Academy, Belgrade, Serbia Objective: To evaluate US and USgFNAC criteria based on nodal size, shape, vascularity and cytology ﬁndings with respect to their value for comparative determination of metastatic lymph nodes in head and neck carcinoma. Method: A prospective study was performed in 50 patients with head and neck squamous cell carcinoma without node enlarge-

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 ment on CT. Nodes were evaluated sonographically, by cytology and histopathology. Results: With ultrasound of high resolution 84% enlarged lymph nodes were considered malignant by size, in 64% by shape and 69% by vascularity. USgFNAC had a high diagnostic accuracy of 99% for detection metastatic nodal disease. Conclusion: USg FNAC should be used for preoperative staging and for follow up on the status of the neck in cancer of the head and neck carcinoma. In the present managed care environment, it proves cost-effective.

HP 155 Aesthetic aspects of pectoralis major ﬂap in reconstruction of head and neck region A. L. Klochihin, M. A. Klochihin Yaroslavl Regional Oncological Hospital Objective: Alongside with radical removal of the tumour in modern ENT oncology, an important part is improvement of aesthetic correction of postsurgical defects. Methods: Sixty-nine patients undergone expanded resections of ENT organs with simultaneous or delayed reconstruction using myo-cutaneous or myo-facial pectoralis major ﬂap. Classical technique with slanting section of skin in a thoracoacromialis projection and carrying it above the clavicle was performed at 59 patients (control group). The base group consisted of 10 patients where preparation of the ﬂap was performed from two horizontal incisions appropriative to relaxed skin tension lines and reconstruction of defects was carried out by pectoralis major ﬂap passing it below the clavicle. Results: This technique of preparation of the ﬂap had not affected negatively on healing of wounds. At 9 of 10 (90%) patients of base group healing was primary. Failure in one case, in our opinion, can be explained by formation of not enough width of tunnel below the clavicle, where the pedicle was wide and mastering of subcutaneous surgical approach from two horizontal incisions. Sewing the skin with release of tension, parallel to tension lines, allowed us to apply continuous intracutaneous suture. Occasionally it was necessary to sever the pedicle. That arose only in control group after reconstruction of middle and upper third of the face, when there were problems with head motion, unaesthetic appearance. There was no sectioning of the pedicle in the basic group, as it was long enough and was less appreciable on a neck in connection with passing it below the clavicle. Conclusions: Displacement of the muscle below the clavicle allowed us to increase the length of ﬂap by 2–5 cm and decrease it visualization that enables to decline of it severing. Mobilization of pectoralis ﬂap below the clavicle from two horizontal sections parallel to tension lines of a chest gave good aesthetic results.

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HP 156 Correlation of human papillomavirus with oral cavity and oropharyngeal carcinoma P. Jeremic, M. Dimitrijevic, T. Jovanovic, Z. Vujicic,V. Djukic, G. Bjelogrlic Institut for otorhinolaryngology and maxillofacial surgery, Clinical Centre of Serbia, Pasterova 2, 11000 Belgrade, Serbia Aims: Human papillomavirus (HPV) is the cause of some benign lesions as papillomas, but some types, especially HPV 16, has been associated with SCC of the head and neck and it is an area of intensive investigation. The aims of this study were to investigate the presence and type of HPV in SCC tissue of oral cavity and oropharynx and determinate their correlation-association. Methods: We examined 33 parafﬁn-embedded SCC tissues of head and neck, including 29 men and 4 women. Twenty of the tumors were located in the oral cavity and 13 in the oropharynx. As control group we used 30 benign parafﬁn-embedded tissue samples from the oral cavity and oropharynx. In situ Hybridization technique was used for the detection and typing of the HPV. Results: HPV was detected in 15.15% of the 33 SCC samples. HPV was detected in 38.46% of tonsil SCC samples while HPV was not detected in none of the oral cavity SCC samples. HPV types 16 and 18 were detected in 3 of the 5 positive carcinoma samples while in the remaining two samples HPV 16 was detected in one and mixed type 16 + 18 + 6/11in the other carcinoma sample. In the control group HPV was detected in 6,6% of benign lessions. Conclusion: Our results reveal that there is no statisticaly signiﬁcant difference between the experimental and control group regarding the detection of HPV. The results also reveal that HPV 16 and 18 may have a signiﬁcant correlation with the SCC of the tonsil, while its correlation with the SCC of the oral cavity is less signiﬁcant

HP 157 Pathologic evaluation of nasopharyngeal masses in adults Ilker Cavusoglu, Ozgur Yigit, Umit Taskin Istanbul Training and Research Hospital, ENT department, Istanbul Adenoid hypertrophy in adults is uncommon and most of them are misdiagnosed because of difﬁculty of examination of nasopharynx and most of them are asymptomatic. With use of endoscopies, diagnosis of adenoid hypertrophy in adult are increased. Cause of enlargement of adenoid hypertrophy is mostly multifactorial including viral and bacterial nasopharyngeal infections, exposure with external irritants like smoking, chemicals. Adenoid hypertrophy causes nonspeciﬁc symptoms in adults, so it should be in mind always especially in patients with headaches, nasal obstructions, nasal bleeding, postnasal bleeding, aural fullness, postnasal dripping, cervical masses. Differential diagnosis of nasopharyngeal masses in adults includes nasopharyngeal carcinomas, nasopharyngeal cysts, nasopharyn-

S117 geal vascular lesions including nasopharyngeal angioﬁbroma. Exact diagnosis of adenoid hypertrophy is done with histopathological examination of biopsy specimen. But also radiological and endoscopical examinations are indicative for nasopharyngeal mass but not distinguish malign and benign form. In our study, 62 adults diagnosed as nasopharyngeal mass with complaints of nasal obstruction, neck masses, otological problems, epistaxis were evaluated. All patients were examined endoscopically and radiological conﬁrmation was done with nasopharyngeal computed tomography in malign expected group. If any nasopharyngeal mass, mucosal hypertrophy, mucosal irregularity was detected endoscopically, punch biopsies were taken from different part of nasopharyngeal masses under topical anesthesia and histopathological examination was done. The pathological ﬁndings showed a non speciﬁc inﬂammation in 15 (24.1%) cases, predominant follicular hyperplasia in 32 (51.6%) cases, nasopharyngeal carcinoma in 10 (16.1%) cases. Our study described that the adenoid can be persistent in later years of life. Furthermore, it may present as a nasopharyngeal mass causing obstructive symptomatology and necessitating diagnostic biopsy.

HP 158 Possibility of the extended radical neck dissection on account of metastasis of the squamous cell carcinoma of the head and neck A. L. Klochikhin, S. V. Movergoz, V. V. Vinogradov Yaroslavl Regional Clinical Oncological Hospital, Head and Neck Center, Octyabrya av., 67, Yaroslavl, Russia, 150040 Objective: Extended tumors of head and neck is an urgent problem in ENT and oncology. Aim of the study is to improve the results of treatment of patients with head and neck cancer with extensive regional metastasis. Methods: The study is based on the results of treatment of 36 patients with head and neck cancer, treated in Yaroslavl Head and Neck Center from 2000 to 2006, mean age 59 years old, males 31 (86%), females 5 (14%). In primary tumor localization oropharyngeal cancer prevailed, 15 patients (42%). Squamous cell carcinoma of high differentiation prevailed, 76%. All of the patients had extensive regional metastasis, corresponding N3. In the majority of the cases extension of the dissection was in wide resection of soft tissues of the neck with reconstruction of the defect with musculocutanious pectoralis major ﬂap, 19 cases. The other structures which were resected in addition to standard volume of radical neck dissection were: common carotid artery, hyoid bone, thyroid gland, parotid gland, scalenus muscles, brachial plexus, n. vagus, ﬂour of the mouth, temporal bone. Results: Three years survival was 17% (6 patients). A recurrence on the neck was in 23 patients (64%), which was mortal. The worth prognosis was in the cases of tumor invasion into scalenus muscles and common carotid artery. Conclusion: It is possible to perform extended radical neck dissection in the cases of absence of tumor invasion into scalenus muscles and common carotid artery.

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HP 159 Clinical analysis of the minor salivary gland tumor in the oral cavity and pharynx Satoshi Nakamura, Kazuhiko Takeuchi, Yuichi Majima Department of Otorhinolaryngology-Head and Neck Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan Objective: To elucidate prognostic factors of the minor salivary gland tumor in the oral cavity and pharynx. Methods: A retrospective study in our otorhinolaryngology department of a university hospital. Results: Of a total of 23 patients suffering from the minor salivary gland tumor in the oral cavity and pharynx experienced between 1986 and 2005, 12 (six men and six women) had benign tumors, all of which were pleomorphic adenoma. The other 11 (8 men and 3 women) cases were of malignant tumor. There were three patients with stage I, four with stage II, one with Stage III, two with stage IVA and one with IVB. All patients underwent surgical therapy. Five cases in early stages remains cancer free. In four of them, postoperative pathologic examination conﬁrmed complete resection of cancer. However, ﬁve case (in advanced stages) died due to local recurrence of the cancer (n = 1) or distant metastasis (n = 2). Their surgical resection margins were found insufﬁcient by postoperative pathologic examination. Although three of the ﬁve underwent postoperative irradiation, two of them could not survive for ﬁve years. Conclusions: Completeness of surgical resection of the tumor is critical to good prognosis of the minor salivary gland cancer in the oral cavity and pharynx.

HP 160 Craniofacial Resection of Juvenile Nasopharyngeal Angioﬁbroma D. Zabolotnyi, G. Timen, O. Palamar, D. Zinchenko Institute of Otolaryngology of Academy of Medical Sciences of Ukraine, Kiev, Ukraine Objective: The medical records of 225 patients treated for Juvenile Nasopharyngeal Angioﬁbroma (JNA) between the years 1985 and 2005 at our Institute were examined. The surgical approaches mainly consisted of the traditional Denker procedure and lateral rhinotomy. The recurrence occurred in 10.2% cases that encouraged us for further search of optimal surgical approach to large and advanced JNA. Aim: To investigate the efﬁcacy of combined craniofacial resection of large and advanced JNA. Method: Ten patients suffered from JNA with stage III or IV according to the Fisch classiﬁcation were studied. Five patients

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 were diagnosed as having intracranial extension of JNA. All the patients were males in age ranged from 9 to 20 years with mean of 14.8 years. Many of them (9 of 10) were secondary patients (operated earlier). Results: All patients underwent combined surgery with craniofacial approach as ﬁrst stage. Above mentioned approach included resection of the orbitozygomatic complex and the ﬂoor of the middle cranial fossa. By doing this it was possible to mobilize the tumor in the infratemporal fossa of the cranium in cases of intracranial extension. In all cases but one there was extradural resection. In one case there was intracerebral extension and we used subdural resection. All the tumors were completely resected. There were no serious complications during postoperative period. No recurrence was found in a follow-up period of 36–54 months. Conclusions: Combined craniofacial approach is an effective treatment for large and advanced JNA that signiﬁcantly reduce recurrence rate.

HP 161 Nasopharyngeal angioﬁbroma Gheorghe Iovanescu, Stan Cotulbea, Stelian Lupescu, Alin Horia Marin E.N.T. Department, University of Medicine and Pharmacy ‘‘Victor Babes’’ Timisoara Objective:Nasopharyngeal angioﬁbroma (NAF), occurring mostly in young men, is histologically a benign tumor with aggressive clinical behavior that includes repeated epistaxis and intractable nasal obstruction. Methods: This paper reviews our experience regarding clinical features and the treatment of NAF at E.N.T. Department-Timisoara. Nineteen patients with diagnosis of NAF from 1984 to 2006 were included, and their clinical presentations, imaging studies, treatments and outcomes were retrospectively analyzed. The duration of symptoms in the current study was 8–9 months. The current treatment modality was in all cases surgery. All patients underwent combined transpalatal or retropalatal and lateral rhinotomy approach. Results: In present series there were three recurrences due to failure in complete removing of the tumor. They were all reoperated by lateral rhintomy approach and they are now free of disease. The follow up period was at least 18 month for all patients, even for recurrences Conclusions: Contemporary radiographic methods (C.T., M.R.I.) improve the evaluation of the patients, and provide essential information for the surgeon regarding the approach to use, and improve the postoperative results.

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HP 162 Tongue base cancer: transhyoid pharyngotomy approach Stelian Lupescu, Stan Cotulbea, Gheorghe Iovanescu, Alin Horia Marin, Horatiu Stefanescu ENT Department, University of Medicine and Pharmacy ‘‘Victor Babes’’ Timisoara Objective: There is an aprox. 1/4 incident rate between malign tumors of the tongue base and the malign tumors of the tongue’s mobile part. Methods: The study was made in the ENT Clinic Timisoara, for a period of 10 years. It presents the therapy of 30 patients treated for neoplasm with tongue-base localization. Clinically positive cervical node at the initial visit was found in 26 (86.66%) of those patients at the moment of examination. Treatment for all patients was initial surgery followed by postoperative radiation. Surgical procedures performed (1) tongue base tumor removal trough transhyoid pharyngotomy approach (2) tongue base tumor removal + epiglottectomy (3) tongue base tumor removal + horizontal supraglottic laryngectomy. Results: The post-operative evaluation factors were: resection borders healthiness, postoperative complications, level of postoperative disfagia. Long term evaluation after surgical treatment. At 25 of 30 patients the post-operative evolution was positive without signs of loco-regional or ganglionar recidivae. One patient died after one and a half-year from the operation. Death was caused by an abdominal tumor. Another patient died after eight month with local recurence. One patient presented a pharyngeal ﬁstula which necessitated pharyngoplasty with latissimus dorsi. The nasophageal nutrition catheter was suppressed after three weeks for all the patients. None of the cases required postoperative gastrostoma. Conclusions: The resections of the neoplasms using the transhyoidian approach is a useful procedure that permits postoperative deglutition and comparable rate of the tumor control for a long time, with lower postoperative morbidity.

HP 163 Histopathological parameters of neck metastases of oral/oropharynx carcinomas Giancarlo Tirelli1, Giacomarra Vittorio1, Barbara Cutrera1, Ledia Papanikolla1, Rossana Bussani2 1 ENT Clinic, University of Trieste 2 Anatomical Pathology Department, University of Trieste Objective: To predict the presence of occult metastases in oral/ oropharynx cancer by correlation between tumor (T) and related parameters. Methods: Evaluation of four parameters: tumor size (T), Broder’s grading of histologic differentiation (G), invasive cell grading (ICG) and thickness in (a) occult metastases in N0 neck disease (b) metastases independently from node (N) class, (c) extracapsular spread. Considering previous results, we gave a score to each parameter and we compared the predicitivity of metastases of single parameters to the sum of them (global score, GS) in 61 patients, who underwent T and N surgery. Results: A high correlation between G, ICG and presence of occult metastases; a strong correlation between ICG ‡ 13 and ex-

S119 tracapsular spread; no correlation between T and presence of occult metastases; a high predicitivity of the GS obtained from G and ICG. Conclusions: Elective neck dissection is mandatory in N0 neck disease of T1-T2 oral/oropharynx carcinomas with ICG ‡ 13 and GS ‡ 9.

HP 164 A giant mixed tumor in soft palate Ylli Sallavaci, Tahsin Demi, Bledi Nini, Sonil Mone, Igli Zhilla, Suela Sallavaci University Hospital Centre ‘‘Mother Teresa’’, Department of ENT, Rr. Dibra Nr.372, Tirana, Albania Methods: The patient V.M, 70 years old was presented on april 2006. She got a tumor in soft palate, since 15 years which was increased too much last year. Clinically: Dysphagia, dysphonia, compensated dyspnea. Inspection: A tumor, same measures with a large egg, soft and mobile, originated from soft palate. Results: The tumor was removed, the palatoplasty was performed. Histologically: Giant mixed tumor of soft palate. Actually she is healthy.

HP 165 Lip reconstruction following lip cancer resection: our experience Sever Pop, Marcel Cosgarea, Constantin Iencica, Alma Maniu, Magdalena Chirila, Violeta Necula ‘‘Iuliu Hatieganu’’ University of Medicine Cluj-Napoca, Romania ENT Clinic, Clinicilor street, nr 2-4, Cluj-Napoca, Romania Objective: Several factors should be considered when planning a resection and reconstruction for a patient with lip carcinoma. Reconstructive algorithms are based on the proportion of lip resected. In this paper we present our experience in lip reconstruction following lip carcinoma resection. Methods: A number of 22 patients underwent surgery for lip cancer in our clinic between 2001 and 2006. Besides tumor resection, lip reconstruction and neck dissection, the management of these patients involved collaboration with the oncologist. Results: Male–female ratio was 10:1, and the mean age was 68.5 (50–86). All cancers were located on the lower lip (100%), and all were squamous cell carcinomas (100%). The surgical procedures consisted of: vermillionectomy in two cases (9.09%), standard V excision followed by primary closure in nine cases (40.9%), wide excision followed by reconstruction in 11 cases (50%). The reconstructive methods included the Abbe-Estlander ﬂap in ﬁve cases (22.73%), the Karapandzic ﬂap in ﬁve cases (22.73%) and the Gillies fan-ﬂap in one case (4.54%). Complications: Sutures dehiscence in six cases (27.27%), microstomia in three cases (13.63%), loco-regional recurrence in ﬁve cases (22.72%). Conclusions: Lip reconstruction remains one of the most challenging tasks for the head and neck surgeon. The use of various ﬂaps allows a wider resection within safety limits and enables an appropriate restoration of facial aesthetics.

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HP 166 Treatment of tongue cancer with NSC 631570: case report Aleksejus Mickonas1, Gedrius Shalkus2, Romualdas Meshkauskas2, Jolita Rimiene2 1 Oncology Institute of Vilnius University, Lithuania 2 National Center of Pathology. Lithuania Objective: To present a case report of a woman with advanced cancer of tongue (T3N0M0), successful treated with NSC 631570. Patient and method: A 48-year-old woman presented with a 6month history of progressive canker, pain and discomfort in the tongue. The tumor inﬁltrated the middle third of the right side of the tongue, more than 4 cm in size without obvious boundaries. Biopsy showed poorly differentiated squamous cell carcinoma (G3). Resection of the half of the tongue and concomitant chemoradiotherapy was not acceptable for the patient because of speech disorder and fear to loose job. The patient consumed 400 mg of the drug (NSC 631570) until the surgery. Results: After 2 month therapy an organ save resection of the tongue was possibility. Pathological examination revealed 2.5 cm diameter encapsulated mass of the tongue. Microscopically tumor is moderately differentiated squamous cell carcinoma. Tumor shows focal moderate desmoplastic stromal reaction. After 1 and 2 months of follow-up, the patient remained free of disease, and ultrasound control was normalized without residual tumor. Conclusion: Treating with NSC 631570 the tumor gradually decreased and tumor border has become more obvious, therefore an organ save surgery was possible to perform with high functional results. Speech and swallowing function did not suffer and did not inﬂuence the career of the patient. Treatment with NSC 631570 was used instead of resection of the half of the tongue and/or aggressive chemoradiotherapy treatment. Tumor resection specimen showed higher degree of lymphoid inﬁltration and ﬁbrosis comparing to biopsy, possibly reﬂecting enhanced immune response of the patient.

HP 167 Multiple ﬂuorophore-analysis (MFA) for qualitative tissue diagnosis in oral cavity M. Havel1, R. Pauli2, H. Stepp2, R. Sroka2, A. Leunig1, C. S. Betz1 1 Department of Otorhinolaryngology, Head & Neck Surgery, Ludwig Maximilian University, Munich, Germany 2 Laser-Research Centre, Ludwig Maximilian University, Munich, Germany Introduction: Early detection of head and neck tumours is usually achieved via surgical tissue biopsy. The measurement of speciﬁc autoﬂuorescence of endogenous ﬂuorophores with tumour-speciﬁc distributions might represent a non invasive method to assess tissue dignity (‘‘optical biopsy‘‘). Materials and methods: We performed ﬂuorescence measurements of oral mucosa tissue on 22 subjects with a clinical aspect of malignant lesion, as well as on seven healthy controls. The excitation and spectroscopic detection was achieved with mercury

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 vapour lamp equipped with ﬁlter sets designed to detect predominantly tryptophan, NADH, FAD. Inclusion of simultaneously recorded white light remission spectra into the analysis enabled the calculation of ‘‘intrinsic’’ ﬂuorescence spectra. Spectroscopy results were then compared to histopathological ﬁndings of the subsequently excised lesions. Results: Quantitative results analysis indicated intrinsic ﬂuorescence spectra of endogenous ﬂuorophores of (pre)malignant mucosa to present signiﬁcant intensity differences compared to healthy tissue. NADH- and FAD-modes in particular showed tumour speciﬁc ﬂuorescence intensity proﬁles whereas for tryptophane-mode no distinct spectral differences were observed. Mucosa of healthy controls yielded similar spectral patterns as did macroscopically intact tissue of patients presenting with neoplasia. Conclusions: The results of this study suggest MFA, in conjunction with an adequate screening method (e.g. autoﬂuorescence imaging), to be a suitable tool for the discrimination of neoplastic changes in oral mucosa.

HP 168 Oncological value of modiﬁed radical dissection of the neck in cervicofacial cancers Aleksandar Trivic, Sanja Krejovic-Trivic, Zeljko Petrovic, Vojko Djukic, Anton Mikic, Zlatko Vujicic Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, Belgrade, Serbia Objective: Modiﬁed radical dissection removes ‘‘en bloc’’ the same lymph nodes and lymphatics as radical dissection, but preservation of one or more non-lymphatic structures. Methods: The study was conducted at the Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, Belgrade. It involved 319 patients who were operated on in the period January 1, 1995 to December 31, 1997, and followed up 5 years after surgery by doctors’ consultation board. Results: It was found that the recurring metastases developed in 57/319 (17.86%) of subjects. Immediately after the operation, in the ﬁrst three postoperative months, the recurrences occurred in one-seventh of patients, in the ﬁrst 12 months in 2/3 of patients, and in 24 months in almost 90% of patients. The recurred metastases by N categories found that the largest number of recurrence belonged to N1 and N2 categories. It could be expected since N1 category was the most prevalent, accounting for 42.94% in the overall series of patients; in addition, the majority of unilateral cervical dissections was done in this category, 137/291 (47.08%), while modiﬁed radical dissections were on the ﬁrst place. Conclusions: Highly signiﬁcant difference of the incidence of subjects with recurred metastases was found in relation to primary tumor localization (P < 0.01), where the incidence of laryngeal and pharyngeal localizations was signiﬁcantly higher (P < 0.01). There was highly signiﬁcant difference of frequency of recurred metastases in relation to N categories. The incidence of N3 and N0 tumors was signiﬁcantly lower, while it was highly signiﬁcant within N1 and N2 categories (P < 0.01).

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HP 169 Risk factors in the occurrence of nasopharyngeal carcinoma: an anamnestic study Vladimir Nesic1, Sandra Sipetic2, Zeljko Petrovic1, Svetlana Stosic1, Snezana Jesic1, Vladimir Djordjevic1 1 Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Centre of Serbia, Belgrade 2 Institute of Epidemiology, School of Medicine, Belgrade University Objective: The aim of this study was to point out possible risk factors that lead to the occurrence of undifferentiated carcinoma of nasopharyngeal type (UCNT). Method: An anamnestic study was carried out in the period from 2001 to 2003. The study included 45 individuals, suffering from histologically veriﬁed UCNT and 90 controls (individuals with orthopaedic disorders and injuries). Only new patients with this diagnosis were taken into consideration. The subjects and the controls were individually matched according to age (±3 years), sex, and place of residence. All subjects were polled by questionnaire by a single doctor and data were gathered about sociodemographic characteristics, on-the-job exposure to harmful agents, habits, diet, individual anamnesis and family anamnesis. During the statistical analysis of the data, univariate (ULRA) and multivariate (MLRA) logistic regression analyses were applied. Results: On the basis of the results of a MLRA, independent risk factors for UCNT were found to be: passive ‘‘smoking’’ of tobacco in the family during the childhood of the subjects suffering from malignant tumours (RR = 4.04; CI = 1.10–14.85), extensive use of industrially manufactured food additives for enhancing ﬂavour (RR = 43.93; CI = 6.01–321.25), and frequent consumption of white bread (RR = 1.63; CI = 1.07–2.49). Conclusion: Passive ‘‘smoking’’ of tobacco in the family during childhood, daily consumption of industrially manufactured food additives for enhancing ﬂavour, and more frequent consumption of white bread, represent independent risk factors in the occurrence of UCNT.

HP 170 Solitary ﬁbrous tumor of the nasal cavity, paranasal sinuses and anterior fossa Marek Lukomski, Zbigniew Kozlowski, Katarzyna Dabrowska Medical University of Lodz, Departament of Otolaryngology, Barlicki Hospital, Kopcinskiego 22, Lodz, Poland SFT is a rare mesenchymal neoplasm that usually arises in the pleura or less commonly is related to other serosal surfaces. There were reported SFTs in some extrapleural locations. These locations cause diagnostic difﬁculties. Ethmoid sinuses, nasal cavity and anterior fossa are rare site for SFTs. Such case is presented aiming to show the difﬁculty and importance of recognition. 33-

S121 year-old woman had suffered from 1-year difﬁculty in breathing through the nose, anosmia and headaches of different locations for 5 years. Examination revealed tumor in the left nasal cavity, obstructing the posterior left choanae and deforming the nose. CT and MRI scans presented a large mass arising from ethmoid cells into the the left nasal cavity and anterior fossa. Finally histology revealed a lesion with hypo- and hypercellular regions with a spindle-cells arranged in paternless fashion. Immunohistochemical studies ﬁnally conﬁrmed SFT. The patient underwent left lateral rhinotomy and craniectomy for total resection of the tumor. She has been followed up for 10 months with no sign of reccurence. SFTs located in the sinonasal tract cause some diagnostic difﬁculty. In these cases the diagnosis is often based not only on their histologic similarity to the pleural SFTs but also on exclusions others spindle cells lesions. This report pays attention that SFT should be taken into consideration during diagnostic process of spindle-cell lesions of nasal cavity in order to avoid some confusions.

HP 171 TRANSORAL laser management of hypopharygeal low-grade malignant peripheral nerve sheet tumor (MPNST) Zsolt Kasza´s, Pe´ter Poga´ny, Gyo¨rgy Lichtenberger Szent Ro´kus Hosp. and Inst. Dept. of ORL-HNS, 1085 Budapest, Gyulai P.u.2, Hungary Objective: The study reports a case of a patient with an extremely large hypopharyngeal low-grade malignant peripheral nerve sheet tumor (MPNST), causing severe dyspnoe and swallowing inability. Methods and results: The oval tumor ﬁlled the whole hypopharynx and the entrance of the larynx. As the patient suffered from serious, life threatening dyspnoe, tracheostomy became mandatory. The tumor recurred twice on slightly different localization in a 19-year period. The tumor appearance site varied from left aryepiglottical fold to left arytenoid region. We removed the tumor with laser. After removal of the tumor there was a constant diffuse bleeding. While the bleeding couldn’t be controlled by coagulation, we used the transoral ligature-suture technique performed by Lichtenberger. It was not easy to set up the exact histological diagnosis of this rare tumor. On the ﬁrst two occasions the diagnosis was lipoma. Finally the exact histological diagnosis proved to be MPNST. From our point of view the MPNST corresponds much more with the patient’s clinical symptoms and case history than lipoma. After the trans oral operation we preformed, the patient could be decanulated. The patient has a one-year symptom free follow up since the last surgery. Conclusion: We would like to recommend to follow the patients suffering from rare diseases like MPNST regularly, at least in every 2 months, and in case of recurrence to perform immediate transoral laser surgery preserving the delicate parts of larynx.

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HP 172 Primary thyroid-like papillary adenocarcinoma of the nasopharynx Kai-Ping Chang1, Chia-Hsiang Fu1, Shir-Hwa Ueng2 1 Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan 2 Department of Pathology, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan Objective: To demonstrate a rare case with primary thyroid-like papillary adenocarcinoma of the nasopharynxy. Methods: An otherwise healthy 68-year-old male visited our clinic and complained of only a globus sensation of his throat for 2 weeks. No nasal obstruction, epistaxis, tinnitus, or aural fullness was noted. Physical examination of this individual revealed a pedunculated tumor with its stalk attaching to the roof of the nasopharynx. A subsequent endoscopic biopsy revealed the presence of a papillary adenocarcinoma. No suspicious cervical lymph nodes were detected. Thyroid ultrasonography and systemic work-ups revealed negative results for any thyroid neoplasm or distant metastasis. Results: The tumor was completely resected in an en-bloc fashion by way of a facial translocation approach. Immunohistochemical studies revealed that this tumor was immunoreactively positive for TTF-1 and CK 7, but negative for thyroglobulin and CK 20. As regards the association EBV, in-situ hybridization investigation for the presence of EBER, and PCR ampliﬁcation for EBV LMP1 oncogene both revealed negative results. The postoperative course for this patient was uneventful and he remained free of disease for 1 year until recent follow-up. Conclusions: We presented the clinicopathological manifestations of this rather rare case of a primary thyroid-like nasopharyngeal papillary adenocarcinoma in order to remind clinicians that sufﬁcient attention and subsequent nasopharyngoscopic-assisted biopsy of the lesion are mandatory for the imminent management.

HP 173 Breast cancer metastases to a tonsillar remnant Alexandra Roper, Iain Bruce, Pradeep Morar East Lancashire NHS Trust Objective: Review of the case of a 54-year-old woman treated for breast cancer who presented with dysphagia and foreign body sensation in the throat Methods: Fifty-four-year-old woman presented to the ENT department complaining of dysphagia and a foreign body sensation in the left side of her throat. She had been diagnosed with left breast carcinoma. Her breast carcinoma was T1 N1 M0 and she underwent a wide local excision and axillary node clearance nearly 3 years earlier. Unfortunately, she then developed a solitary brain metastasis for which she received radiotherapy. At the time of referral, she had also developed multiple cutaneous lesions which had not been histologically diagnosed. She had undergone a tonsillectomy as a child but was found to have a 1–2 cm. lesions on the superior pole of the left tonsillar fossa, extending on to the soft palate. The mass was excised under general anaesthetic.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Results: Histological analysis showed ﬁbrovascular tissue and skeletal muscle inﬁltrated by poorly differentiated invasive carcinoma, with no evidence of lymphoid tissue. Conclusions: Metastases to the tonsil cannot be ruled out by a history of tonsillectomy.

HP 174 Immediate reconstruction of the mandible with titanium plate and rib graft after a large segmental mandibulectomy due to multilocular ameloblastoma in an edentulous patient Ahmet Kutluhan*, Sami Berc¸in*, Go¨khan Yalc¸ıner*, _ Huseyin C¸etin**, Hasan Mete Inanc ¸ lı* *Ataturk Education and Research Hospital, ENT Department, Ankara, Turkey **Ataturk Education and Research Hospital, Radiology Department, Ankara, Turkey Resection and the reconstruction with a titanium plate and a rib graft of an ameloblastoma of the mandible in an edentulous patient.

HP 175 Contact endoscopy in early diagnosis of oral and soft palate lesions Alberto Santos, Joaquim Amaral, Iuri Gaspar, Maria Joa˜o Barros, Carlos Macor, O´scar Dias, Ma´rio Andrea Department of Otolaryngology, Voice and Communication Disorders, Faculty of Medicine of Lisbon, Lisbon University, Santa Maria Hospital, Lisbon Objective: Contact Endoscopy allows the assessment in vivo and in situ of epithelial cells, glandular ostia and microvascular network (60·, 150·). The authors describe the potentialities of contact endoscopy to perform real time histological diagnosis and/or guided biopsies in an ofﬁce setting. Methods: The authors carried out a retrospective double blind study of a population of 86 patients with oral and soft palate mucosal lesions which persisted after 3 weeks and were diagnosed by contact endoscopy and histology. Results: The examination made by contact endoscopy allowed, with a similar accuracy as histological examination, to classify the lesions in three groups: benign (n = 36), displasia (n = 23) and malignant (n = 16). Carcinoma is characterized by a heterogeneous tissue pattern and cells have a hyperchromatic nucleus with increased and irregular dimensions. The vascular pattern is represented by a chaotic architecture made by vessels with atypical shape, ectasis, intravascular micro thrombosis and a vascular fragility. Contact endoscopy is also important for follow up because it allows not only a macroscopic but also a microscopic observation in an ofﬁce setting. Conclusions: In our study, contact endoscopy, a non-invasive technique, allowed to do a precise diagnosis in an ofﬁce setting, with similar effectiveness as histology. It was an important aid for biopsy guiding and surgical excision limits and also allowed an improvement in follow up efﬁcacy.

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HP 176 Head and neck liposarcomas J. Kalhous1, D. Musilova´2, R. Neubauer1, K. Sultani3, K. st. Sla´ma1 1 Department of ENT and Head and Neck Surgery, Masaryk Hospital, U´stı´ nad Labem 2 Department of Radiation Oncology, Masaryk Hospital, U´stı´ nad Labem 3 Department of Pathology, Masaryk Hospital, U´stı´ nad Labem Liposarcomas are the second most common soft tissue sarcomas, but in the head and neck region they are rare. They were ﬁrst described by Virchow in 1857. Present WHO classiﬁcation divides liposarcomas into six basic forms: well differentiated, myxoid, round-cell, pleomorphic, myxed-type and dedifferentiated. Myxoid and well-differentiated are the most common types of liposarcoma. Dedifferentiated liposarcoma is very rare in the head and neck region. Complete surgical excision with wide tumor-free margins is the treatment of choise. Routine elective neck dissection is not recommended because regional lymph node metastases are rare. Planning of adjuvant therapy depends on the size, grading and resectability of the primary tumor. We present two cases of head and neck liposarcomas. The ﬁrst is a well-diferentiated liposarcoma of the tongue, treated surgically, the second is a myxoid liposarcoma of the larynx, treated surgically and by adjuvant radiotherapy.

HP 177 Schwannoma of vagus nerve: a case report S. Triantos, P. Chaira, N. Gaitanakis, A Papadopoulou, D. Louverdis, G. Papazoglou ENT Department, Red Cross Hospital, Athens, Greece Objective: This paper presents a case of an unusual neck neoplasm, a vagal schwannoma. Methods: A 64-year-old patient presented with a 8-month history of neck mass and dysphagia as the main symptom. The imaging study (MRI) demonstrated a mass at the parapharyngeal space, without speciﬁc characteristics. Results: The patient was operated on and a total resection of the mass was performed. Intraoperatively, the tumor was found to originate from the vagus nerve, which had to be sacriﬁced. Conclusion: The possibility of a neurogenic tumor occurring in the parapharyngeal space has to be considered in the differential diagnosis of the tumors of the area.

HP 178 Application of MPR CT reconstructions in the imaging of pathological changes of paranasal sinuses, causing bones destruction Emilia Ka˛tska1, Ewa Dybiec2, Gra_zyna Niedzielska1, Pawe Wieczorek2 1 Department of Paediatric Otolaryngology, Phoniatry and Audiology, Medical University of Lublin 2 Department of Paediatric Radiology, Medical University of Lublin Introduction: The presence of bone structure damage is still the most important criterion in the differantiation of benign and malignant changes within paranasal sinuses. MPR CT examina-

S123 tion of a high-resolution may be usefull in the evaluation of inconsiderable destruction of thin bone structures, which are not visible on conventional CT scans. The aim: The aim of this study was to evaluate the usefulness of MPR CT reconstructons in the visualization of bone destructive changes in the chosen pathologies of paranosal sinuses. Materials and methods: In the 2004–2006 year, performed CT examinations of sinuses in 215 children. In 11 cases the changes of the sinuses walls, suggesting bone destruction, were visualized on conventional CT scans. In this cases, MPR CT reconstructions were performed to conﬁrm the presence of destruction and to estimate its range. All children were underwent surgical treatment, and the results of CT imagings were conﬁrmed by histopathological examinations. Results: In MPR reconstructions were visualized changes of bone structure in seven children of analyzed cases: in two cases observed a bone sclerosis concomitant with chronic sinusitis, in one case visualized a destroing of bone structure as a result of posttraumatic osteitis, in four children observed a very aggressive bone destruction as a result of intensive proliferation. Conclusions: MPR CT reconstructions allow for deﬁnitive diagnosis of destructive changes in bones. MPR CT reconstructions allow to point out on exact localization of bone destruction, what is useful in a delimitation of the range of a surgical intervention

HP 179 A modiﬁed technique for bypass of the external carotid artery to the proximal middle cerebral artery Kayhan Ozturk1, Sahika Liva Cengiz2, Aynur Emine Cicekcibasi3, Ahmet Salbacak3, Mehmet Erkan Ustun2 1 Department of Otolaryngology, Meram Medical Faculty, Selcuk University, Konya, Turkey 2 Department of Neurosurgery, Meram Medical Faculty, Selcuk University, Konya, Turkey 3 Department of Anatomy, Meram Medical Faculty, Selcuk University, Konya, Turkey Objective: We aimed to evaluate whether bypass of the external carotid artery (ECA) to the middle cerebral artery (MCA) can be established by a short saphenous vein graft in order to increase the anastomosis patency. Materials and methods: The method was performed to ﬁve adult cadaver sides bilaterally. We described a modiﬁed technique for bypass of the ECA to the M2 segment of MCA. The diameters of the vessels and graft length were measured by using an electronic micrometer. Results: The mean diameter of the superior, middle and inferior trunks of the MCA with trifurcation were 1.7 ± 0.15, 2.2 ± 0.25 and 2 ± 0.2 mm, respectively whereas the mean diameter of the superior and inferior trunks of the MCA with bifurcation were 2.1 ± 0.2 and 2.3 ± 0.3 mm, respectively. The mean diameter of the ECA was 3.75 ± 0.4 mm. The mean length of the saphenous vein graft was 71.5 ± 3.9 mm. Conclusions: The high-ﬂow ECA to proximal MCA bypass using a short venous graft can supply enough blood ﬂow to establish cerebral revascularization with a straighter route. Keywords: Anterior circulation, Blood ﬂow, Middle cranial fossa, Vein graft

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HP 180 A 10 year comparative study of FNAC and histology in head and neck lesions James Benton, Sankalap Tandon, Samit Ghosh, Jonathon Sheard, Terry Jones Department of Head and Neck Surgery, University Hospital Aintree, Lower Lane, Liverpool, L9 7AL, UK Objective: To assess the sensitivity, speciﬁcity, positive predictive value and negative predictive value for ﬁne needle aspiration cytology (FNAC) compared with histology for head and neck pathology in a tertiary referral centre. Methods: All FNACs performed in the ten year period from January 1996 to December 2005 at our institution were identiﬁed from the head and neck and histopathology databases. From this list all patients who underwent formal histological evaluation of the same lesion were identiﬁed. This group included benign and malignant pathology including lymphoma. Predominant anatomical sites were lymph node, salivary gland and thyroid gland. Results: A total of 2,258 head and neck FNACs were performed in the ten year period. Of these, 728 had corresponding histological samples taken. Forty (5.5%) samples were inadequate and 45 (6.2%) were non-diagnostic. Cytology and histology results were compared and analysed by construct of a 4 · 4 table. From this the overall sensitivity for FNAC was 93.7%; speciﬁcity was 96.6%. Positive predictive value was 97.0% and negative predictive value was 92.8%. Accuracy was 95.0%. Conclusions: FNAC is still the primary modality for obtaining tissue diagnosis with a high degree of accuracy and certainty. Clinical suspicion should however always be borne in mind when interpreting results of the cytology.

HP 181 Case report: primary squamous cell carcinoma of the nasal septum Zeynep Kizilkaya, Ilhan Unlu, Erdal Samim, Hakki Uzunkulaoglu, Kursat Ceylan, Hakan Gocmen, Unal Bayiz, Sedat Alagoz Ministry of Health Ankara Research and Training Hospital Ear Nose and Throat Department, Ulucanlar Cad. No:1 Mamak Ankara, Turkey Objective: We report an extremely rare case of primary squamous cell carcinoma of the nasal septum. Method: Case report and world literature concerning primary squamous cell carcinoma of the nasal septum are presented. Results: Malign neoplasms of the nose and paranasal sinuses comprises 1% of the overall malign tumours of the head and neck. Primary carcinomas of the nasal septum are rare entities and constitutes 9% of the malign neoplasms of the nasal cavity. In this paper we report a case of primary squamous cell carcinoma of the nasal septum in a 60-year-old male patient Conclusion: Importance of early diagnosis is emphasized with the report of a rare case of primary squamous cell carcinoma of the nasal septum

HP 182 Cancer of the oropharynx: modern therapeutic approach P. Vlastarakos1, T. Nikolopoulos1, A. Tzagaroulakis1, K. Nazos2, N. Salemis3, E. Ferekidis1 1 Hippokrateion General Hospital, Athens, Greece 2 ’’P & A Kyriakou‘‘, Children’s Hospital, Athens, Greece 3 2nd Department of Surgery, Army Veterans General Hospital NIMTS, Athens, Greece

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Introduction: The surgical treatment of oropharyngeal cancer frequently necessitates radical surgical interventions, which may result in obvious functional impairment. Therefore, newer approaches, which include the combined use of interstitial brachytherapy and chemoradiation, are beginning to take their place in the treatment of locally advanced disease, in an effort to achieve better quality of life for patients, without compromising LRC and 5-year OSR. Materials and methods: Literature review from Medline and database sources. Twenty randomised controlled trials, 5 controlled clinical trials, 19 clinical trials, 2 prospective non-randomised studies, 8 retrospective studies, 1 laboratory study, 3 metaanalyses, 1 practice guidelines and 13 systematic reviews met the deﬁned criteria and were included in study selection. Data synthesis: Head and neck tumors are conventionally dealt with Ir192 LDR brachytherapy. HDR brachytherapy seems more advantageous, by achieving better dose control, as also PDR regimens. Chemoradiation improves both LRC and 5-year OSR. The timing of chemoradiation is crucial. Concurrent or alternating chemoradiotherapy seems more effective. There is also a trend for brachytherapy treatment of certain cases with N+ neck disease. Conclusion: The combination of interstitial brachytherapy and chemoradiation has proven a safe therapeutic modality, with satisfying results for selected patients with oropharyngeal carcinomas; however, randomized control trials are needed, to determine the group of patients which would beneﬁt the most from this combined approach.

HP 183 Predictors of extracapsular spread in lymph node metastases Kadir Imre, Ercan Pinar, Semih Oncel, Caglar Calli, Bekir Tatar Ataturk Training and Research Hospital, Izmir, Turkey Objective: We investigated effect of clinical and pathologic parameters on extracapsular spread(ECS) in patients with lymph node metastases in laryngeal cancer. Methods: 186 patients and 342 neck dissection were included in this study. Relationship between ECS and tumor location, T stage, clinic and pathologic N stage, tumor differantiation, number of metastatic lymph nodes, diameter of metastatic lymph node and impact of presence ECS on contralateral neck metastasis were evaluated. Results: Tumor location, clinic and pathologic N stage of the tumor, number of metastatic lymph node metastases, diameter of positive node and contralateral neck metastases were signiﬁcantly associated with ECS (P < 0.05). Signiﬁcant parameters were included in multivariate logistic regression model. Only number of (‡3) lymph node metastases was independently related with ECS (P < 0.05; OR:11.6). Conclusion: Presence of ECS in lymph node metastases is believed to be an indicator of poor prognosis. Physician should be paid more attention to patients who have an increased risk of ECS. Bilateral neck dissection should be performed in patients with ECS in positive nodes.

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HP 184 Multiple primary malignancies in patients with head and neck cancer in our department Hiroyoshi Iguchi, Makoto Kusuki, Taichi Uyama, Aki Nakamura, Akimori Kanazawa, Hisao Amatsu, and Hideo Yamane Department of Otolaryngology and Head and Neck Surgery, Osaka, City University Graduate School of Medicine, Osaka, Japan, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan Objective: It has recently been recognized that head and neck cancers (HNC) frequently accompany other primary malignancies especially those originating from the upper gastrointestinal tract. We investigated multiple primary malignancies in patients with HNC in our department. Methods: One hundred and nineteen patients with multiple primary malignancies other than malignant lymphoma out of 696 patients with HNC treated in our department between September 1997 and August 2005 were entered in this study. Results: The incidence of multiple primary malignancy was 17.1% (119/696). Double cancers developed in 91 patients, triple cancers in 27, and quintuple cancers in 1 patient, with 268 malignancies altogether. The most frequently affected site of the head and neck was the larynx (34.4%), followed by the hypopharynx (20.9%). The most frequent site of malignancies outside the head and neck region was the esophagus (29.1%), followed by the stomach (23.1%). In 51 patients with HNC as the initial malignancy, malignancies were subsequently detected in the esophagus (36.0%), stomach (16.4%), and lung (11.5%), in order of frequency. The incidence of HNC accompanying esophageal cancer was 32.8% (39/119), and the hypopharynx was the most frequent site of HNC accompanying esophageal cancer. The interval of detection of each malignancy was generally within one year because of our screening program for multiple primary malignancies. Conclusions: The upper gastrointestinal tract needs to be carefully examined in patients with HNC. Screening programs for multiple primary malignancies are required to manage such malignancies as early as possible.

HP 185 Cervical metastases of cancer of unknown primary site Sanja Krejovic-Trivic, Aleksandar. Trivic, Zeljko Petrovic, Vojko Djukic, Anton Mikic Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical center of Serbia, Belgrade, Serbia Objective: The largest number of metastases originates from primary cancer of the head and neck. Methods: The study was carried out from January 1, 1990 to December 31, 1999 at the Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, Belgrade. The study included 67 patients with enlarged persistent cervical lymph nodes. Results: The analysis of treatment outcome showed that 22 or 32.8% of cases survived and 45 or 67.2% died. Mortality rate in primary tumors detected late was 69.6%, and in patients with undetected primary tumor it was slightly lower, 65.9% of patients. Statistical tests failed to conﬁrm the difference of mor-

S125 tality rates as signiﬁcant (v2 = 0.092; P > 0.05); in patients with undetected primary tumor, death of recurrent metastases was the most frequent (79.4%), while among patients with primary tumor detected late, 75.0% died precisely because of such tumor. Conclusions: Highly signiﬁcant differences of causes of death were found between group B1-1 of patients with cancer detected late and B1-2 of patients with undetected primary cancer (v2 = 35.180; P < 0.001). In B1 group of patients, 75.0% of cases died due to development and evolution of primary cancer, while in group B2, 79.4% them died for recurring metastases. Cumulative probability of survival in group B1-1 was 30.43% with an average length of survival probability of 34 months, and in group B1-2, cumulative probability of survival was 34.09% with an average length of survival probability of 39 months. No signiﬁcant difference of cumulative probabilities of survival was found between these groups (log rank = 0.38; P > 0.05).

HP 186 Prognostic factors for nasopharyngeal carcinoma Afgir Said, Ismaili Nabil, SbittiYassir, Errihani Hassan, Benjaafar Nourredine, K. ElGueddari Brahim Service of Medical Oncology, National Institute of Oncology (NIO) Rabat, Morocco Background: Nasopharyngeal carcinoma (NPC) is a distinct form of cancer of the upper respiratory or digestive tract in which the epidemiologic features, origin, histopathologic types, treatment, and prognosis are different from those associated with other malignant neoplasms of this anatomical area. Objective: To describe the survival of NPC patients in NIO, verify the prognostic value of the revised (2002) TNM staging system, and develop a multivariate prognostic model for NPC. Methods: A retrospectively maintained database containing clinical and computed tomography scan data was used to reclassify 468 NPC patients treated between 1999 and 2001. Overall and stage speciﬁc survival were analyzed using the Kaplan-Meir method and the log rank test. Univariate and multivariate cox proportional hazards regression analysis were used to obtain prognostic models. Results: 468 pts were enrolled: median age was 42 years (range 10– 83); histology subtype OMS 3 in 405 pts (86.5%); 380 (81%) were stage T3 T4; 319 (68%) N2N3 and 42 pts (9%) M1. With a median follow-up of 26 months (3–74) 128 pts (27.4%) are alive and free of disease. No differences between treatment arms were found (P = 0.1). The 5-year survival rate was 26.6%. In univariate analysis, signiﬁcant prognostic factors were: age (P < 0.001), delay of consultation (P = 0.0015), node lymph status (P < 0.001) and metastasis (P < 0.001). After multivariate analysis, independently prognostic factors were: lymph node status (P = 0.0014) and metastasis (P < 0.001). Conclusion: We conﬁrm the need to determine the risk factors in patients with NPC, and we demonstrated long term survival. New therapeutic approaches are warranted in order to improve the outcome of these patients.

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HP 187 Sleep apnea: snoring. New and alternative surgical techniques. P. Theodosis, D. Gourziotis, B. Gregoriou, S. Papaspyrou General Hospital Of Athens ’Eyaggelismos’ Introduction: Sleep apnea is a disturbance of breathing, which can ﬂuctuate from relatively innocent as snoring or severe obstructive apneas, which, could lead to very serious lesions of the cardiorespiratory system. Diagnosis, differential diagnosis and the treatment command the cooperation of many medical specialties: ENT surgeon, lung disease physician, maxillar surgeon, and dentist. The surgical treatment of the problem has been studied by ENT surgeons and different operative techniques have been suggested. Most of them are focused on the reconstruction of the soft palate and the uvula combined or not with tonsillectomy or surgical improvement of the rhinal respiration. Materials and methods: In the last 4 years we have treated 78 cases with sleep apnea. The patients ﬁrstly answered to a detailed questionnaire, which was followed by a clinical and laboratory control. The treatment was personalized to every patient according to his symptoms, mainly using Laser CO2. Results: Seventy percent had exceptional decreasing symptoms, 15% had an improvement of the sleep, 15% showed alteration of LSAT, RDI, AL to satisfactory levels, 90% of the patients were treated with Laser CO2. Complications have not been notiﬁed. Conclusions: The multifactoral etiology of sleep apnea as well as the majority of the therapeutic methods shows the difﬁculty of solving the problem. Keeping always in mind how easy the method can be performed and also the absence of complication, the use of Laser CO2 is highly recommended.

HP 188 One-year treatment with a Herbest mandibular advancement splint improves obstructive sleep apnea and endothelial function S. Itzhaki, G. Clark, H. Dorcin, L. Lavie, P.Lavie, G. Pillar Sleep laboratory, Rambam Medical Center and Technion – Israel Institute of Technology, Haifa, Israel Objective: We sought for the ﬁrst time to assess the effect of longterm Herbst mandibular advancement splint (MAS) treatment on obstructive sleep apnea (OSA) and on endothelial function (ED, a condition precedes ischemic heart disease). We hypothesized that both will improve with treatment, and that the magnitude of improvement in ED will be correlated with the magnitude of improvement in OSA. Methods: Sixteen patients (11 m) aged 54.0 ± 8.3/year participated. Apnea severity was assessed by polysomnography and by

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Watch-PAT100. ED was measured in the morning using the Endo-PAT 2000. Apnea severity and ED were assessed after 3 months and 1 year on MAS treatment. Results: Mean apnea-hypopnea index (AHI) signiﬁcantly improved from a baseline (pre-treatment) of 29.7 ± 18.5/h to 17.7 ± 11.1/h after 3 months and to 19.6 ± 11.5/h after 1 year with MAS treatment (P < 0.005 for both). Endothelial functioning improved signiﬁcantly from a 1.77 ± 0.4 (baseline) to 2.1 ± 0.4 (3 months) and 2.0 ± 0.3 (1 year). There was a signiﬁcant correlation between the improvement in AHI and endothelial functioning (r = 0.55, P = 0.05). Conclusions: These results indicate that the Herbst MAS may be an effective treatment in patients with OSA, at least for 1 year, improving both breathing and endothelial function. The signiﬁcant correlation between the improvement in apnea indices and endothelial function suggest that the respiratory abnormality causes the vascular abnormality. The fact that endothelial function signiﬁcantly improved to level similar to normal controls without a complete elimination of apneic events suggests that there is a threshold effect of OSA on endothelial functioning.

HP 189 Use of IDAS versus standard lasers in laser assisted uvulopalatoplasty for treatment of snoring Pavelec Vaclav, Slipka Jaroslav Charles University Hospital in Plzen, Czech Republic Objective:The aim of this study was to compare the effectiveness of ﬁve power lasers (CO2, diode, KTP, ErCrYSGG, and IDAS) in laser assisted uvulopalatoplasty. Methods: This is a prospective study of 100 patients who were treated for snoring by laser assisted uvulopalatoplasty with either CO2 (n = 21), diode (n = 19), KTP (n = 21), ErCr:YSGG (n = 21) or with IDAS laser (n = 18). Results: Differences in sex ratios among the lasers were analyzed with the Chi-square test with the PROC FREQ procedure of SAS. Difference in snoring score among the lasers has been tested by the Kruskal–Wallis test with the PROC NPAR1WAY procedure of SAS. The number of days of pain medication use and the time to return to normal diet were used as indicators of recovery from surgery. Pain medications were used on average for 10.1, 6.5, 6.5, 4.1 and 4.9 days and the times to return to normal diet were on average 8.6, 6.7, 6.8, 4.5 and 5.9 days in the CO2, diode, KTP, ErCrYSGG and IDAS groups, respectively. Conclusions: Differences in post op recovery were observed. Probands treated with IDAS laser recovered more quickly than the diode, KTP and CO2 group, however more slowly than the ErCrYSGG group. IDAS laser is a suitable laser sytem for laser assisted uvulopalatoplasty.

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HP 190 Laser-assisted uvulopalatoplasty shows substantial improvement in obstructive sleep apnea

index value.We should like to show the fact that the patients from the same group, meaning with the same AHI value, there are really different ESS values probably caused by some secondary factors. The patients were divided in four groups by the AHI index values. Poligraphic registration were made to these patients, with ENT examination followed by a self evaluation through completing the ESS questionnaire. The study was completed by following the inﬂuence of the ENT diseases associated with the respiratory pathology during the sleep. The daily activity is in strong relationship with the sleeping quality and inﬂuenced by the associated ENT diseases. So this is why the treatment of the respiratory disturbances during sleep achieved by solving the ENT problems, contribues to the raising of the life quality by reducing the diurnal sleepnes times and improving the ESS values.

Yves Kamami1, Mario Olszakier2, Giora Pillar3. 1 Otolaryngology Department, Hoˆpital Saint-Cloud, Paris, France 2 Itamar Medical, Caesarea, Israel 3 Sleep laboratory, Rambam Medical Center and Technion school of Medicine, Haifa, Israel Objective: UvuloPapatoPharyngoPlastic surgery (UPPP) and laser-assisted-uvulopalatoplasty (LAUP) have been suggested as treatments for obstructive sleep apnea (OSA). Unlike UPPP, LAUP is performed in the ofﬁce using only local anesthesia, with fewer side-effects and complications, and shorter recovery time. We have recently shown that improving OSA, even without completely abolishing it, results in a substantial potential protection from cardiovascular complications. Methods: Nine males aged 59 ± 7 years with a diagnosis of OSA (2 with mild OSA - Respiratory Disturbance Index; RDI < 15, 2 with Moderate OSA, and 5 with severe OSA - RDI > 30/h) underwent a LAUP by the same surgeon. All underwent a pre treatment ambulatory sleep study (Watch-PAT100; Itamar-Medical, Caesarea, Israel), followed by the same study performed on the average 2.2 months following treatment. Results: Following treatment, mean RDI decreased from 35 ± 18/ h to 21 ± 17/h (P < 0.0001). In 5 (56%) of the patients (2 severe) treatment was clearly considered successful (reduction of RDI by at least 50% and under 20, or to below 10/h). Mean Oxygen Desaturation Index (ODI) decreased from 22 ± 16/h to 12 ± 12/h (P < 0.003). Subjectively, patients reported substantial improvement in snoring, quality of sleep and daytime alertness. There were minimal side effects including oral candidiasis and mild pain. Body mass index did not change with treatment. Conclusions: We conclude that the laser-assisted ablation of the soft palate may signiﬁcantly improve OSA, and should be offered for patients, especially when refusing CPAP. We also conclude that the WP100 system is a convenient and easy method to quantify their OSA in their home.

HP 191 The relationship between Epworth sleepnes scale values and the grade of the obstructive sleep apneea Neagos Adriana1, Muehlfay Georg2 1 Emergency County Hospital, ENT Department Tg. Mures, Romania 2 University of Medicine and Pharmacy, ENT Department Tg. Mures, Romania The life quality is affected by the obstructive sleep apneea, fact which has remained unexplored in many situations during the examinations made in laboratories. In appreciation of the life quality there are used questionnaires through which diurnal sleepnes grades are evaluated. The Epworth Sleepnes Scale (ESS) represents an own questionnaire for measuring the risk of falling asleep of the patient in everyday situations. The marks are situated on a 0–24 scale which can be correlated with the OSAS severity. The aim of the study is to demonstrate the way in which the ESS value is being or not inﬂuenced by the AHI

HP 192 CPAP compliance of OSA patients in Singapore Alvin Tan, Pon Poh Hsu, Peter Kuo Sun Lu Department of Otolaryngology, Changi General Hospital, 2 Simei Street 3, Singapore 529889 Objective: To investigate the compliance rate of CPAP usage in OSA patients in Singapore. To investigate if self-payment of CPAP affects compliance rate Methods: Prospective study conducted in 2004 to 2006 looking into all patients with OSA who were sent for CPAP treatment. Emphasis placed on the number of patients who eventually ended up purchasing CPAP after the trial period and the subsequent compliance of CPAP usage. Investigate the main reasons why some patients do not purchase CPAP and why the rest do. Results: The percentage of patients who have been referred for CPAP treatment and eventually end up buying CPAP is low. However, for those who eventually end up buying CPAP, there is a high compliance rate. Conclusions: Medical coverage of patients is important in inﬂuencing the take-up rate of CPAP and compliance is strongly inﬂuenced by whether the patient pays for the CPAP personally.

HP 193 Simple snoring: diode laser treatment Michel Jakobowicz, Fre´de´ric Tanke´re´, Elizabeth.Vitte ENT Department Pitie´-Salpeˆtrie`re-Paris, France Objective: Amelioration of quality of respiration, sleep and snoring. Methods: After an exploration of OSAS, patients in sitting position were treated under local anaesthesia, with Diode Laser, ﬁrst, on turbinate, three sessions and secondly, on velum, three to six sessions. If necessary, we ask patients for: loosing weight, stopping hypnotics, tobacco and alcohol. Results: Six hundred and twenty patients were treated since 1998 with the following results: 62.5% (very good); 25% (good); 8.5% (failures) and 4% missing. Conclusion: 87.5% of amelioration without pain using Diode Laser 940 nm. This laser induces deep retractile scare and the results are stable in time.

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HP 194 Laser-assisted uvulopalatoplasty in treatment of snoring and obstructive sleep apnea syndrome Rita Blotsky, Alexsandr Blotsky Amur State Medical Academy, Blagoveshchensk, Russia Last 10 years snoring and obstructive sleep apnea syndrome (OSAS) are considered as a public health problem. We have developed several of Laser Uvulopalatoplasty (LUPP) performed with Nd:YAG laser in contact mode and continious wave. The ﬁrst type of the procedure consists of 5–7 mm long incisions with laser on the mucosa of the soft palate without damage of mucosal pharyngeal surface of soft palate, if necessary, 2/3 of the uvula may be excised. The second type consists of two steps. First, contours for forthcoming resection are made with subsequent resection of soft palate mucosa duplication 5–7 mm wide. In third LUPP type we have preserved about 1.5 cm of soft palate with a creation of new uvula. We evaluated the functional results of the surgery by the repeated polysomnography in 4 weeks after LUPP with simultaneous registration of snoring frequency. It appears that contact Nd:YAG laser is highly comfortable in use, allows to provide LUPP, contribute to soft palate wrinkling because of scarring, increases pharyngeal air volume and decreases the number of apnea/hypopnea episodes in patients suffered from OSAS.

HP 195 Coblation assisted Uvulo-palatoplasty (CAUP) Huw Williams, Neela Mouli Doddi ENT Department, Royal Glamorgan Hospital, Ynysmaerdy, Llantrisant, CF72 8XR, UK Objective: To know the efﬁcacy of CAUP in treating snoring and to compare our results of CAUP with those of Laser assisted Uvulopalatoplasty (LAUP) in literature. Methods: It is a retrospective study of 35 cases between 2003 and 2006 at the Pontypridd and Rhondda NHS Trust. The data was collected from the patient’s case notes in the Medical records department. Results: Snoring was totally abolished in 32 patients. Two patients snored less while one patient showed no improvement in snoring. Conclusions: CAUP when compared to LAUP is equally effective but has the added advantages of a less. Painful recovery, low postoperative morbidity and faster healing. Moreover the learning curve is less, operative theatre need not be setup like in laser and is economical. Hence CAUP is our preferred choice of palatal surgery.

HP 196 Quantitative analysis of anatomical improvements following modiﬁed UPF and lateral pharyngoplasty Pon Poh Hsu, Alvin Kah Leong Tan, Eng Cern Gan, Peter Kuo Sun Lu Department of Otolaryngology, Changi General Hospital, 2 Simei Street 3, Singapore 529889

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Objective: To assess the static and dynamic upper airway morphological changes in patients with obstructive sleep apnea (OSA) who underwent modiﬁed uvulopalatoﬂap (UPF) and to derive predictors of surgical outcomes from these changes. Methods: A prospective study of pre- and post-operative videoendoscopic computer assisted measurements (CAM) of upper airway parameters of 22 subjects with OSA between the period of May 2004 till January 2006 was undertaken. Measurements were performed at the retropalatal and retrolingual areas during quiet respiration and Mueller’s maneuvers. Results: Patients who underwent modiﬁed UPF surgery increased the retropalatal area by 66%, widened the transverse and longitudinal diameters of the retropalatal area by 28 and 39%, respectively. There was a signiﬁcant decrease in palatal collapsibility and an overall improvement in AHI postoperatively. Conclusions: Modiﬁed uvulopalatoﬂap and lateral pharyngoplasty is an effective surgical technique for the treatment of OSA patients with predominantly retropalatal and lateral pharyngeal collapse. With the aid of CAM, improvements in post-operative anatomical dimensions can be quantiﬁed in a static and dynamic manner.

HP 197 Comorbidities in patients with obstructive sleep apnea T. Chimona1, E. Proimos1, G. Perogamvrakis1, M. Tzanakakis1, E. Theodoraki1, E. Michelaki2, C. Papadakis1 1 ENT Department, General Hospital of Chania, Greece 2 Pulmonary Department, General Hospital of Chania, Greece Objective: Obstructive sleep apnea (OSA) is a complex disease process with multifactorial etiology. The objective of this study is to ﬁnd out diseases or conditions that coexist with moderate and severe OSA. Methods: Four hundred and twenty-four adults with OSA were referred to our clinic after polysomnography from January 2005 to August 2006. Ninety-four patients had mild OSA with Apnea Hypopnea Index (AHI) < 15/h and were excluded from the study. Two hundred and two patients suffered from moderate OSA (AHI) = 15–30/h, whereas 128 patients suffered from severe OSA (AHI > 30/h). Full patients’ history related with cardiovascular or lung diseases and medication was obtained. All patients underwent clinical examination, Mueller’s maneuver, Body Mass Index (BMI) calculation and abdominal perimeter measurement. Furthermore, blood pressure measurement was obtained as well as, serum ﬁbrinogen, glucose, CRP, cholesterol and triglycerides. Results: Sixty per cent of patients with moderate OSA had Sleep Disordered Breathing (SDB) score >8. In the same group 56% were hypertensives, 23% had high glucose levels and 48% were dyslipidemic patients. High ﬁbrinogen and CRP levels were found in 33.6 and 38%, respectively. In the group with severe OSA 82% of the patients had SDB score >8, 78% were hypertensives, 75% had high glucose levels and 83% were dyslipidemics. Forty-eight per cent of patients presented with high ﬁbrinogen levels and 42% had high CRP levels. Conclusions: Obstructive sleep apnea syndrome seems to be a systematic disease which presents common parameters with metabolic syndrome. The more severe the OSA, the greater is the risk for atherosis and thromboembolic episodes.

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HP 198 Clinical parameters in obstructive sleep apnoea: are there any correlations? Jiun Thong, Kenny Pang Department of Otorhinolaryngology, Tan Tock Seng Hospital, Singapore Objective: To assess the correlation between clinical symptoms and examination ﬁndings with severity of obstructive sleep apnoea (OSA). Methods: A prospective study was conducted on patients referred to the Sleep clinic with a suspected diagnosis of OSA. Clinical examination documented the Epworth sleepiness score (ESS), body-mass index (BMI), tonsil size, modiﬁed Mallampati index (MMP), Muller’s manoeuvre score and reﬂux ﬁnding score (RFS). All patients underwent Level 1 overnight polysomnography. Regression analysis was performed to assess relationships between patient characteristics and various aspects of symptoms and signs with polysomnographic measures relating to the severity of OSA. A P value of less than 0.05 was considered statically signiﬁcant. Results: Eighty patients (14 female, 66 male) with a mean age of 42.9 years (range 22–66) were included in the study. Mean BMI was 27.6 (range 20–39). Correlation was found between ESS and anteroposterior pharyngeal wall collapse at level of soft palate during Muller’s manoeuvre (r = 0.3,P = 0.02). BMI was signiﬁcantly associated with a history of hypertension (r = 0.3,P = 0.01), MMP (r = 0.3,P = 0.001) and lateral wall collapse at level of soft palate during Muller’s manoeuvre (r = 0.4,P = 0.0001). OSA severity correlated signiﬁcantly with the male gender (P = 0.02), history of hypertension (r = 0.5, P < 0.0001), BMI (r = 0.2, P = 0.03), MMP (r = 0.3, P = 0.003) and upper airway collapse during Muller’s manoeuvre. Conclusions: Clinical ﬁndings in patients with OSA do correlate with severity of OSA and polysomnographic ﬁndings. Degree of upper airway collapse during Muller’s manoeuvre correlates well with AHI severity. Accuracy in predicting presence and severity of OSA allows for greater cost-effectiveness in screening patients prior to polysomnography.

HP 199 Outpatient esophagopharyngeal pressure monitoring Martin Patscheider; Alfred Dreher; Christine Klemens; Robert Bodlaj; Richard de la Chaux ENT-Department, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377 Munich, Germany Objective: Esophagopharyngeal pressure monitoring (EPPM) is helpful in the topodiagnosis of primary snoring, to determine the obstruction level in patients suffering from obstructive sleep apnoea syndrome (OSAS) as well as for the diagnosis of the upper airway resistance syndrome (UARS). We report about our experience with the ﬁrst portable screening device.

S129 Methods: Forty-one patients complaining of snoring and sleep apnea were investigated with a portable data logger at home. Five subjects did not tolerate the placement of the nasal probe. The following parameters were recorded for six consecutive sleeping hours: oxygen saturation, esophageal and pharyngeal pressure, body position, nasal and oral airﬂow, snoring events. The obstruction level was found by analysing pressure amplitudes. Results: The mean apnea hypopnea index was 18.2 with an average minimum oxygen saturation of 82.2%. Thirty out of 41 patients had an AHI > 5, deﬁned as OSAS. Seventy-three percent of the patients presented an upper level obstruction, while 27% showed a lower or multilevel obstruction. Conclusions: Ambulant EPPM is useful to distinguish central from obstructive breathing disorders as a screening method. In addition to other devices it indicates the obstruction level. It still has to be proven if this information can increase operative success rates. Limitations arise from a 12% intolerance rate.

HP 200 Microtia: technique and results of auricular reconstruction with autogenous rib cartilage R. Staudenmaier ENT-Department, Klinikum rechts der Isar, Technical University Munich, Germany Introduction: Their are various ways treating the classic microtia, the so called peanut ear. Apart a prosthesis the most common way of auricualr reconstruction is the use of autogenous rib cartilage. This technique requires two to three operations. Technique and results The ﬁrst step is to harvest the rib cartilage from the 6th to the 9th rib. The base of the framework is the 6th and 7th rib cartilage which is taken under preservation of the synchondrosis. To create a satisfactory 3D structure the triangular fossa and scapha are carved into the baseplate and the 8th rib is ﬁxed as helical rim on top. After optimizing the framework with additionell pieces of cartilage it is placed in a subcutanous pocket on the mastoid plane. After 3 months the auriculocephalic ankle is built with a cartilage wedge which is placed under the baseplate and covered by a temporalis fascia ﬂap and split thikness skin graft from the hairbearing skull. Commonly a third step is recommended for minor corrections. Discussion: At the moment autogenous rib cartilage seems to be the ideal available material for ear reconstruction, despite the improvements in tissue engineering. The harvesting of the cartilage causes a speciﬁc donor-site morbidity. Operations improving hearing ability by building up the external ear canel and middle ear are mainly done in cases of bilateral microtia. Conclusion: Following our own experience with more than 100 cases of total ear reconstruction with autogenous rib cartilage its possible to produce replicable aesthetic results from about the age of 8. Keywords: Ear deformity, Microtia, Auricle reconstruction

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HP 201 Nasal septal teratoma in a Nigerian child Titus S. Ibekwe1, Daniel D. Kokong1, Betrand A. Ngwu2, Oluwole A. Akinyemi3, Onyekwere G. Nwaorgu1, Efﬁong E. Akang2 1 Department of Otorhinolaryngology, University College Hospital, Ibadan, Nigeria 2 Department of Pathology, University College Hospital, Ibadan, Nigeria 3 Department of Anaesthesia, University College Hospital, Ibadan, Nigeria Teratoma is an uncommon developmental neoplasm that arises from totipotential tumor stem cells. Some cases had been recorded in head and neck which constitutes about 10% of all cases. Objective: To present a rare tumour (teratoma) with an unusual site of presentation (nasal septum) and outline the management/ outcome. Method: Case report. Results: We report a case of mature teratoma, arising from the nasal septum into the left nasal cavity, in an 18-month-old Nigerian female. She had total surgical excision of the lesion which which was conﬁrmed histologically as mature teratoma. The patient remained free of recurrence 31 months after. Conclusion: This is the ﬁrst reported case in Africa and second in the world literature (Medline search) and both cases were managed similarly with good outcome. Therefore, the prognosis for benign teratoma is good with total excision.

HP 202 Parapharyngeal neuroblastoma in newborn-case report R. Simic1, A. Vlahovic1, V. Subarevic2, S. Djuricic3 1 Department of Pediatric surgery, Institute for Mother and Child Health care of Serbia, Radoja Dakica street 6-8, Belgrade, Serbia 2 Department of Otorhinolaryngology, Institute for Mother and Child Health care of Serbia, Radoja Dakica street 6-8, Belgrade, Serbia 3 Department of Pathology, Institute for Mother and Child Health care of Serbia, Radoja Dakica street 6-8, Belgrade, Serbia Objective: Neuroblastoma is the most common malignant congenital tumor. It is rare in cervical localization (2–5% of all neuroblastoma in childhood). Cervical neuroblastoma in in the newborn is of special signiﬁcance for hed and neck surgeons. It is often misdiagnosed as lymphatic malformation, branchial cleft cyst, or infectious adenitis. Patients having these conditions may be present with severe feeding and respiratory difﬁculties. Case report: Three-day old female newborn was admitted to the Institute’s intensive care unit (ICU) with oral intubation and nasogastric tube for feeding because of the tumor mass on the right parapharyngeal localization. Prenatal history was unremarkable. At the day of delivery the child was sent to the regional medical center because of stridor and cyanosis. Examination of

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 the oral cavity revealed solid, smooth, painless mass in the neck. The mass caused mechanical obstruction and difﬁculties with swallowing. CT scan showed solid tumor mass arising from the soft tissue of the right side of the neck narrowing the pharyngeal lumen. AT the child’s eight day of age total excision of tumor was performed. Pathology report described solid tumor measuring 4 · 3 · 2 cm, with histogical and immunohistochemical features of neuroblastoma of differentiating subtype. Tumor was completely covered by pseudocapsule (stage 1). There was no MYCN ampliﬁcation and DNA content was in the hypo-triploid range. Result: There was no intraoperative complication. Iatrogenic Horner syndrome was arised postoperatively, but with spontaneous regression after three months. According to standard SIOP protocol chemo and radiotherapy was not administrated. The child is now eight years old and in good health, controlled by oncologist and surgeons. Conclusions: Cervical localization of neuroblastoma is wery rare. Prognosis is better for this than for all other localizations, especially in range I and II in infants under 6 months of age. Decision on the management should be made in agreement by pediatric surgery, otorhinolaryngology, oncology and pathology teams.

HP 203 Indication for pediatric tracheotomy K. Stankovic´, V. Sˇubarevic´, R. Simic´, P. Vasiljevic´, Z.Dudvarski Pediatric Otorhinolaryngology Center, Mother and Child Health care Institute of Serbia ‘‘Dr Vukan Cupic’’, Belgrade, Serbia Pediatric tracheotomy is a life saving procedure when it is performed with in appropriate indication and surgical technique. A percentage of pediatric tracheotomy and indcations had shown a slight decrease because of endotracheal intubation, which is a very good solution for disease which was treated with tracehotomy 20 years ago.We wont to report our experience during 15 years in Pediatric Otorhinolaryngology Department in the Institute for Mother and Child health care Serbia ‘‘Dr Vukan Cupic‘‘ in Belgrade. A retrospective study included 86 children with traheostomy between 1991 and 2006. The youngest child with tracehotomy was 3 days old, and the oldest was 11 years old. Fifty-six (65.1%)patients were younger than 12 months. The most common indication for pediatric tracheotomy was airway obstruction because of congenital anomaly of the upper respiratory organs, head and neck. Fifty-one (59.3%) patient had congenital anomaly of upper respiratory organs and 12 (13.9%) had congenital anomaly of the head and neck organs. Other indications that were treated with tracheotomy, as only possible solution, were prolonged intubation because of the respiratory insufﬁciency: eight (9.3%) children with neurological diseases, six(7%) children with muscular diseases, four (4.6%) with malignant head and neck tumors, three (3.5%) with cardiopulmonary diseases and two (2.4%) with traumatic lesions. The pediatric surgeons dealing with this procedure should be aware of the tracheotomy care problems, fatal complications and the need for reconstructive surgery.

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HP 204 Lower airway papillomatosis in children

HP 206 Congenital midline cervical cleft

Lidia Zawadzka-Glos, Anna Jakubowska, Micha Brzewski, Mieczysaw Chmielik ENT Paediatric Department of Medical University of Warsaw

Radoje Simic, Aleksandar Vlahovic, Djordje Kravljanac, Vladan Subarevic Institute for Mother and Child Health Care of Serbia, New Belgrade, 8 Radoje Dakic Str.

Objective: Laryngeal papillomatosis in children is a frequent disease caused by human papilloma virus (HPV) type 6 or type 11. In some cases papilloma may affect the lower levels of the respiratory tract. In this study among 90 patients treated for laryngeal papillomatosis in four children papilloma of trachea, bronchi and lung tissue were detected in endoscopic and radiological examination. Methods: Papilloma of the larynx, trachea and bronchi were recognised during laryngotracheobronchoscopy. All children had ultrasonography of the larynx and chest X-ray. Results: Multiple papillomatomies had indicated a progression of papillomatous changes in the trachea and bronchi and the frequency of surgery was increased. Three children died at the 13th, 9th and 7th year of age due to chronic respiratory insufﬁciency. One patient is now 24 years old and 4 years ago had tracheotomy because of massive growth of papilloma and progressive respiratory insufﬁciency. Conclusions: Recurrent pneumonia in children with recognised laryngeal papillomatosis may suggest the spread of the disease to lung tissue. All children with recognised laryngeal papillomatosis should be given chest X-rays.

HP 205 Rare forms of children’s respiratory papillomatosis duration V. N. Bakumov, I. V. Konovalova, V. V. Reznikov ORL-Clinic Of Volgograd Region Gullet papillomatosis is not difﬁcult to diagnose and cure. Earlier we have not observed cases with rapid growth of papillary tumors, so we found it interesting to supervise a 7-year old patient with a large gullet papilloma that has appeared in the period between 1.5 and 2 months. The child has gone though a medical examination about 1.5 months prior to the diagnosis, and no pathology was revealed. Registered illness’ symptoms included rhinolalia clausa, dysphagia caused by the papilloma (size 2.5 · 2 · 2.5 cm) located between palatine glands. The tumor originated from the soft palate. Under endotracheal narcosis the gullet papilloma was removed with the help of CO2-laser. The patient was supervised during 2 years after the surgery, and no recurrence was revealed. The uniqueness of this case is in the rapid growth and substantial size of the child’s papilloma. Another patient with such diagnosis is 13 years old and has been under medical observation for 8 years due to recurrent papillomatosis of the right side of nose and trachea on the level of I-II rings. Relapses occurred every 6– 9 months and were accompanied by trachea stenosis, which forced annual (sometimes more often) removals of papillomas. During last 2 years no recurrence of the disease was observed in the right side of nose. However, papillomas continue to grow in the trachea with the same localization with no tendency to deeper trachea expansion or upwards to the larynx. This case conﬁrms the fact of the most common localization the human papilloma virus lesions.

Congenital midline cervical cleft (CMCC) is a rare cervical disorder clinically evident at birth. Usually it is initially evaluated by pediatrician or surgeons for adults who misinterprets CMCC as a thyroglossal duct cyst (TDC) or branchial cleft deformity. During the past 10 years, ﬁve cases of CMCC were treated at our hospital. They were 3 females and 2 males with age ranged from 1 month to 8 years. For three infants, with typical CMCC, (two were 1 and one was 2 months old) treatment entails complete surgical excision of the cleft, ﬁbrous cord, skin protuberance and sinus tract with closure via multiple Z-plasties. The female infant was misdiagnosed and treated as TDC by the plastic surgeon in another hospital. Anterior cervical contracture persisted and girl was cured many years after primary operation by removal of the underlying cord and Z-plasties. Five months old infant had lower lip cleft hemangioma, associated with cleft of the mandible, sternum and ﬂexion neck contracture. This type of the CMCC was treated after excision of the hemangioma and cheiloplasty by excision of the underlying ﬁbrotic tissue and multiple Z-plasties. All patients did not develop secondary contracture. CMCC is a rare developmental abnormality that may be isolated or associated with a spectrum of midline defects. Treatment of CMCC consists of excision of the midline cleft with a Z-plasty repair to avoid a vertical scar and subsequent cicatricial contracture.

HP 207 Neuroendocrine carcinoma of the tongue in a child: case report D. Martu, Luminita Radulescu, Loreta Ungureanu, C. M. Martu, B. Cavaleriu University of Medicine and Pharmacy ‘‘Gr.T.Popa’’ Iasi, Romania Neuroendocrine carcinomas arising outside the appendix are extremely rare in the pediatric population. Objective: We present a case of neuroendocrine carcinoma of the base of the tongue. Method: In a 7 years old male child presented with some other complains, the examination of the oropharynx revealed a smooth, large mass in the middle of the base of the tongue. Excision of the tumor and bilateral neck dissection followed by histological examination and immunohistochemical analyses conﬁrmed the neuroendocrine nature of the tumor. The surgery was followed by chemotherapy. No other primary or secondary site was identiﬁed. Results: The evolution of the child is good 3 years after the diagnosis. Conclusions: The neuroendocrine carcinoma of the base of the tongue is an extremely rare tumor so recognition of this site is important so that proper management can be initiated.

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HP 208 Is there a need for cross-training between paediatrics and otolaryngology?

radiotherapy. From functional aspect, these two methods have advantage over open chordectomy.

Paul Goodyear, Samit Ghosh, Krishna Reddy Department of Otolaryngology, North Cheshire Hospitals NHS Trust, Warrington Hospital, Lovely Lane, Warrington, UK

HP 210 Acoustic parameters of voice and quality of life in bilateral vocal cord paralysis

Objective: To evaluate the need for cross-training between the two specialties paediatrics and otolaryngology. Method: A conﬁdential telephone enquiry of on call otolaryngology and paediatrics trainees in NHS trusts in the UK, between September 2005 and November 2005. Otolaryngology trainees were asked whether they felt teaching by paediatricians would be beneﬁcial. If yes, they were asked to clarify whether it was lectures/rounds, clinics or rotation. What areas they perceive would be important for relating to paediatrics. Similarly, paediatricians were asked the same questions. Results: One hundred and sixty-four on call Otolaryngology trainees were contacted, 155 of these completed the survey (94.5%).On average they saw ﬁve paediatric patients per week. 130 (84%) trainees said that they don’t receive any formal training by paediatricians. The majority felt that paediatric clinical experience either through clinics (38.9%), lectures (32.2%), rotation (22.5%) or paediatric courses (12.9%) would be beneﬁcial. Formal teaching on resuscitation, dealing with sick child was considered beneﬁcial. 144 on call paediatric trainees were contacted 124 responded (86.1%). 85 (68.5%) said they will see ﬁve patients with ENT problems per week. n = 118 (95.1%) said that they do not receive any formal training in ENT. Similar responses were observed from the paediatric trainee responses. Conclusions: This study has demonstrated that otolaryngology and paediatric trainees feel cross-training is important. This ultimately impacts on patient care.

W. Harnisch1, S. Brosch1, R. Hagen1 1 Univ. -ENT-Clinic Wuerzburg, Germany

HP 209 Phoniatric treatment results of patients with initial glottic cancers V. Djukic, P. Stankovic, A. Ugrinovic, Z. Dudvarski Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, Belgrade Objective: Comparative analysis of values of relevant vocal parameter before and after therapy, for different therapeutical modalities. Methods: Laser chordectomy was done in 82 patients; 85 patients were operated through laryngoﬁssure by open chordectomy; 84 patients were treated by primary radiotherapy. Out of 251 patients, 24 were females and 227 males, with different age (ranging from 30 to 71 years). Using the computer analysis of the voice, before surgery and after 6 months of treatment, the following parameters were tested: maximum phonation time (s), modal intensity (dB), intensity range (dB), fundamental frequency (Hz), Jitter (%) and Shimmer (%). Results: Longer maximum phonation time was most pronounced after primary radiotherapy. Higher mean values of fundamental frequency, Jitter, Shimmer, harmonic-to-noise ratio and intensity range were most marked after laser chordectomy. Phonation was much better after primary radiotherapy than upon open chordectomy. Laser surgery resulted more frequently in moderate hoarseness than primary radiotherapy, as well as in higher level of fundamental frequency of speech voice. Conclusions: Analysis of relevant voice parameters revealed that there was no essential difference of laser surgery and primary

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Objectives: The aim of this study was to evaluate the long-term effect of surgical treatment on acoustic parameters of voice and related quality of life in patients with bilateral vocal cord paralysis. Methods: Ten patients underwent acoustic assessment (computerized voice analysis: Go¨ttingen Hoarseness Diagramm (GHD), voice range proﬁle, expert evaluation of roughness, breathiness, hoarseness) at least 6 months after glottal surgery. The voice handicap index (VHI) was used to assess patient’s voice related quality of life. Indirect microlaryngostroboscopy was performed to reveal residual vocal fold movement and mucosal wave. Results: In ﬁve patients minimal vocal fold movement was preserved. Seven patients showed uni- or bilateral mucosal wave movement, indicating residual recurrent nerve functioning. Voice range was reduced in all patients. The irregularity component of the GHD (perturbation parameters) as well as voice range were correlated with residual recurrent nerve function. High breathiness (noise component of the GHD) and maximal phonation time lead to increased VHI scores. Conclusions: Microlaryngostroboscopic ﬁndings did not necessarily correspond to subjective vocal complaints. VHI scores tended to be correlated with computerized voice analysis.

HP 211 The new approaches in the voice disorder diagnostics E. V. Osipenko Federal Research Clinical Centr of ENT of Russia Objective: The purpose of research is to study the coefﬁcient accommodation (CA) of the patients who suffer from functional and organic voice disorder. CA indicates of the accommodative ability of nerve and allows to estimate a degree of the muscular innervation. Methods: Two hundred and ﬁfty-six patients have been examined (214 women and 42 men). They were divided into 4 groups: I group consists of the patients who suffer from functional voice disorder (n = 117), II group one consists of the patients who suffer from unilateral laryngeal paralysis (n = 61); III group with acute laryngitis (n = 53); IV group is the control one (n = 25). CA (a) was determined in the conditions of videostrobolaryngoscopy with the device ’’VOCASTIM‘‘. Plane electrodes in a monopolar mode were used in the projection of the larynx. Results: Having analysed the received data we have found out that a = 1.5–2 is in I group; a = 0–1 is in II group; a 1.5 is in III group; a 2.2–2.5 is in IV group. Conclusions: (1) the deﬁnition of CA is the objective method of research of the quantitative changes in the nervous-muscular part of the larynx and allow differentiate the degree of innervation’s violation. (2) the most serious innervation’s violations up to denervation were typical of the patients suffered from laryngeal paralysis. The denervation was typical of the patients who were ill more than for 6 months; (3) the data of the CA is the basis for selection of the appropriate parameters of the current for electrical nervous–muscular stimulation of phonation.

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HP 212 The homeopathic drug in mutation dysphonia teenagers E. Yu. Radtzig, M. R. Bogomilsky Russia State medical University, Moscow, Russia Objective: Mutation dysphonia(MD)-not so often disputable medical problem. Teenagers complain on voice quality changes very rare themselves and do not understand necessity voice and breathing exercises. That is why complex homeopathic drugs are interest for ENT for MD treatment. Methods: The Homeovox efﬁciency estimation as monotherapy (28–56 days in recommended doses) in MD teenagers. The hoarseness reason was revealed after complex investigation (subjective and objective voice analysis, endoscopy and stroboscopy). Results: 30 MD teenagers were examined. Before treatment severe dysphonia were in 3 cases, moderate in 14, mild in 13. After 28 days Homeovox usage normal voice were in 4 cases, severe dysphonia were in 2, moderate in 4, mild in 20. After 56 days Homeovox usage normal voice were in 19 cases, severe dysphonia were in 1, moderate in 2, mild in 8. Conclusions: The complex homeopathic drugs can used in protocol treatment hoarseness children as monotherapy.

HP 213 The voice quality in laryngeal paresis children E. O. Viazmenov, E. Yu. Radtzig, M. R. Bogomilsky Russia State medical University, Moscow, Russia Objective: Our main aim was the voice quality estimation in laryngeal paralysis (LP) children during the conservative treatment. Methods: Under our observation were 10 children with peripheral laryngeal paresis: unilateral in 7 cases, bilateral in 3. The reasons were: trauma in 3 cases, prolonged intubation in 4, in 1 perinathal hypoxic encephalopathia and 1 children-recurrent subglottic stenosis. All of them had breathing and voice disorders: hoarseness (severe in 4, moderate in 3) and aphonia in 3 cases. Results: The conservative treatment includes lidaza and prozerin electrophoresis on laryngeal region, prednizolon (intramuscularly), acupuncture, alkaline ultrasound inhalations and lasts 1– 2 months. After treatment normal voice was in 3 cases, hoarseness still presented in 7 cases (severe in 3, moderate in 1, mild in3). Conclusions: The LP conservative treatment in children is very difﬁcult and actual problem. The reasons are increasing congenital laryngeal abnormalities frequency, numerous operations in head and neck region. The searching of new conservative therapy possibilities are necessary.

HP 214 Endoscopic screening: diagnostics of congenital stridor in infancy Elena Radtzig Moscow Objective: The objectives of this study are to present the technique and results of Endoscopic screening- diagnostics of congenital stridor in infancy. Methods: The authors conducted a retrospective case analysis consisting of 16 infants in the age from 2 months to 6 years old

S133 directed for endoscopic research of a throat in case of stridor. Ten children had various disorders of breath and phonation; 2 had the diagnosis of congenital stridor; other children displayed the symptoms at later age. The ‘‘frame-accurate’’ (time lapse) technique has been used for examination. Results: All 16 infants had basic complaints of ’’squelching‘‘ sounds on inhale, noisy or heavy breathing (which ampliﬁed greatly during physical activity), hoarseness. At three cases the complaints occurred due to inﬂammatory diseases of a respiratory path, at one case-due to vaccination. At the moment of endoscopic examination stridor has been noted at four cases. Laryngomalacia has been diagnosed with 15 children. One case of larynx papyllomatosis has been revealed. None of children had attributes of respiratory insufﬁciency, gastroesophageal reﬂux, inﬂammatory throat diseases and neurologic semiology. Conclusions: From our point of view endoscopic research of a throat should be performed at the ﬁrst and unique case of impaired phonation (stridor, hoarseness) or breath. Equipping ENT doctors’ workplaces with endoscopic technics (outﬁt?) would allow performing screening already at the out-patient stage.

HP 215 A comparison of ﬁndings between videolaryngostroboscopy and digital high-speed videolaryngoscopy: a case report Thomas Woellner1, Andreas Krenmayr2, Katrin Baumbusch1, Markus Rungger1, Patrick Zorowka1 1 Clinical Department of Hearing, Voice and Speech Disorders; Innsbruck Medical University, Anichstr. 35, A-6020 Innsbruck, Austria 2 Christian Doppler Laboratory for Active Implantable Systems, Institute for Applied Physics Objective: This casereport compares the investigation of vocal folds by means of videolaryngostroboscopy (VLS) and high-speed videolaryngoscopy (HSV). Methods: A 77-year-old female patient with persistent dysphonia one year after surgery of a Reinke-edema, treated gastroesophageal reﬂux disease (GERD), and age-related atrophy of the vocal folds underwent a 5-days intensive-voicetherapy in our clinic. Recordings of the vocal fold vibration were made prior and after the therapy, both with a standard VLS-unit and a digital HSV-unit, capable of taking 4,000 greyscale images per second. The HSV-datasets were analyzed according to an algorithm which computes amplitude and phase of vocal fold vibration by means of Fourier analysis, resulting in false-color images. These single images allow diagnosis of vibration amplitude, glottal insufﬁciency, and phase relationships along and between the vocal folds. Results: The ﬁndings in the false-color images computed from the HSV datasets are in complete agreement with the conventional stroboscopic results and partially outperform the standard method due to the straightforward display of vibration properties of the vocal folds. Conclusions: This work shows the clinical value of false-color images to display functional properties of the vocal folds, as assessed with high-speed videolaryngoscopy. The method has the clear advantage of generating plain images, which can be easily ﬁled in the patient’s records.

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HP 216 Applying fourier analysis to high-speed laryngoscopy: applications and limitations Andreas Krenmayr1, Thomas Woellner2, Katrin Baumbusch2, Patrick Zorowka2 1 Christian Doppler Laboratory for Active Implantable Systems, Institute for Applied Physics, University of Innsbruck, Technikerstraße 25, 6020 Innsbruck, Austria 2 Clinical Department of Hearing, Voice and Speech Disorders, Innsbruck Medical University, Austria Objective: This talk presents a method which combines endoscope motion compensation and an algorithm for displaying functional properties of the vocal fold vibration, applicable to digital highspeed laryngoscopy. A special focus is put on interpretation and possible artefacts of the resulting images. Methods: For high-speed laryngoscopy we use the HS-ENDOCAM 5560, which is capable of taking 4,000 greyscale images per second. The resulting images are then segmented in glottal area and environment, thus providing a framework for the subsequent endoscope motion compensation. Currently the compensation algorithm is restricted to translational endoscope movements in the transversal plane. Fourier analysis of the time series of grey values yields phase information and a criterion to decide which parts of the vocal folds participate in the oscillatory movement. This information is then projected as hue and saturation into a single image of the vocal folds. Results: The resulting false colour images of the vocal folds are suitable for displaying phase relationships between or along the vocal folds as well as for displaying glottal insufﬁciency. Conclusions: Although some of the patterns found in the false colour images can readily be matched to distinct functional properties of the vocal folds, the signiﬁcance of some other patterns, especially subtle phase differences, is harder to determine. Compared to videolaryngostroboscopy, this method has the clear advantage of producing single images which present morphological as well as functional information at one glance.

HP 217 Comparison of the accuracy of panoramic radiography, coronal and axial Ctscan in diagnosis of mandibular fractures Payman Dabirmoghadom1, Mohammed Hossein Baradaranfar2, Shabnam Azari3, Fatemeh Ezoddinni-Ardakan4, Abdorreza Sadr-Arhami5, Hamid reza Mansourian5 1 Assistant Professor of Otolarnygology and Head and Neck surgery, Tehran University of Medical sciences 2 Associated Professor of Otolarygology and Head and Neck surgery, Yazd University of Medical sciences 3 Otolanygologyist, Charmehal Bakhtiary University of Medical sciences 4 Professor of Marxillofacial, Yazd University of Medical sciences 5 Assistant professor of Radiology, Yazd University of Medical sciences Introduction: Mandibular fracture is the most common facial bone fracture due to facial trauma. A variety of imagings have been

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 used for diagnosis of mandibular fractures. However, the choice of imaging for diagnosis of mandibular fractures is controversial. Present study compares the accuracy of the three most common imaging methods in mandibular fracture diagnosis; panoramic radiography, coronal CT and axial CT scan. Methods: This cross sectional diagnostic study was performed on 45 patients a clinical diagnosis of post traumatic mandibular fracture at the ENT department of Shaheed Sadoughi hospital, Yazd patients underwent panoramic radiography and CT scan (both axial and coronal) Then, all were operated for reduction of fracture (either closed or open) and Fixation done with arch bar and MMF in combination with or without rigid internal Fixation. The physical examination and observation during operation was considered as the exact diagnosis. The radiological ﬁndings were reported by three different radiologists. Finally, the accuracy and sensitivity of each method was compared with the other methods. Results: There was no signiﬁcant difference between the accuracy of panoramic radiography and coronal. CT scan in all of the regions, but the accuracy of axial CT was signiﬁcantly less that coronal CT in certain regions. Conclusion: The accuracy of panoramic radiography and coronal CT scan in diagnosis of mandibular fractures is the same or higher than axial CT scan. Additionally, panoramic radiography is more accessible and less expensive that coronal CT scan. Therefore, this study recommends oral panoramic radiography as the ﬁrst Radiologic test for diagnosis and localization of mandibular fracture.

HP 218 Advancement in the minimally invasive management of parotid duct calculus: the intracorporeal electrokinetic lithotripsy option Prince Cheriyan Modayil1, Vinay Jacob2, George Manjaly1, Graham Watson3 1 Department of Otorhinolaryngology, Eastbourne DGH, East Sussex, UK 2 The Queen Victoria Hospital, East Grinstead, West Sussex, UK 3 Urology Department, Eastbourne DGH, East Sussex, UK Objective: Modify existing techniques of sialolith lithotripsy to avoid injury to the duct or to any of the local structures by direct application of the shock wave to the stone under direct vision. Method: The beneﬁcial effects of the endoscopically controlled electrokinetic lithotripsy which is normally used for the treatment of the lower ureteric stone has been applied to the treatment of the parotid duct calculus to minimize concomitant tissue damage. Result: Application of the shock wave to the stone under direct vision avoided injury to the duct or to any of the local structures. The patient had an uneventful post procedure recovery and has been asymptomatic at 18 months. Conclusion: Continuous endoscopically monitored electrokinetic lithotripsy with good irrigation gives a well illuminated ﬁeld for an absolute delivery of the energy to the target. It avoids side effects of the shock wave to the parotid duct and the adjacent anatomical structures, thereby making it a safer procedure.

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HP 219 Investigations on chemical dissolution of salivary calculi Robert Schatton1, Ajit-Joe Pothen2, Gerhard Rettinger1, Helmut Schatton3 1 Department of Otorhinolaryngology, University of Ulm, Ulm, Germany 2 Department of Otorhinolaryngology, Alfried-Krupp-Hospital, Essen, Germany 3 Hydrometallurgical Engineering, Lu¨nen, Germany Objective: Only little information is available about chemical dissolution of salivary calculi. The purpose of this study was to look for a solvent usable for sialolitholysis in vitro. Methods: Since sialoliths contain 50–80% inorganic material with hydroxyapatite (HP) as the main component, we used HP powder and algae-derived HP granules as model substances. Amounts of 50 mg HP were treated with 150 ml diluted acetic acid, lactic acid, citric acid, tartaric acid (all at pH 2,78), diluted NaOH, NaOH combined with cesium carbonate or sodium carbonate (all at pH 12.85) and EDTA (at pH 9), for 30 min. at 36C. Phosphate in solution was photometrically analyzed and used to calculate the amount of dissolved HP. The best dissolution agent was selected for litholysis of seven salivary calculi, each with 300 ml solvent for three hours at 36C. Results: The most effective agent to dissolve HP was acetic acid (39.2 mg HP powder, 8.9 mg HP granules). The mean weight reduction of salivary calculi was 6.8% after litholysis with acetic acid, corresponding to an increase of phosphate in solution. Conclusions: Carbonic acids, especially acetic acid, are potent solvents of HP, the main inorganic component of salivary calculi. Used for chemical dissolution in vitro, diluted acetic acid can reduce the weight of sialoliths. Further investigations comparing other approaches should be done.

HP 220 Parotid gland tumours: a retrospective study of 286 patients E. Kyrodimos, A. Varsamis, A. Varsamakidou, M. Tanasidis, I. Thomaides, Th. Sidiras Department of Otolaryngology-Head and Neck Surgery, ‘‘Theagenio’’ Cancer Hospital, Thessaloniki, Greece Objective: Parotid gland benign and malignant tumours constitute a highly heterogeneous group in human oncological pathology. They show different clinical, epidemiological, histopathological and evolutionary characteristics. Study design: Retrospective chart review at a tertiary referral centre. Methods: We have tried to identify the epidemiological characteristics of 286 patients, treated surgically from 1995 to 2005, for a benign or a malignant tumour in the parotid gland, to evaluate the

S135 incidence of the different types of tumours and their age and sex distribution. Results: In our study the benign tumours were more common (73%) than the malignant tumours (27%) in the parotid gland. A higher prevalence was observed in the male sex (female /male ratio: 1/1.32) and in the 4th to 7th decade of life (98.25%). The incidence in childhood was rather low (0.43%) with haemangioma the predominant histological type. Pleomorphic adenoma was the most common benign tumour (42.5%), followed by Warthin’s tumor (41.9%) in adults. Metastatic carcinoma (30.6%) and adenoid cystic carcinoma (19.4%) were the most prevalent histological types in the malignant neoplasms in adults, followed by mucoepidermoid carcinoma (12.9%) and adenocarcinoma NOS (8.12%). Superﬁcial parotidectomy was performed approximately in 84%, near-total (subtotal) parotidectomy in 10% and total parotidectomy in 6%. In cases with facial nerve preservation the incidence of temporary facial nerve dysfunction was approximately 1.2%. Conclusions: Malignant tumours were more common in the elderly than in young patients and in our experience the most common histological types were the metastatic carcinoma and the adenoid cystic carcinoma.

HP 221 Sialolithiasis in ent department: our experience Evdoxia Gerostergiou1, Ioannis Panaras1, Dimitrios Batzakakis1, Ioannis Bardanis2, Panagiotis Karagounis1 1 General Hospital of Larissa, ENT Department 2 General Hospital of Ikaria, ENT Department Objective: Sialolithiasis is one of the most common diseases of the salivary glands. With this retrospective analysis we report our experience and diagnostic ﬁndings in a large group of patients suffering from sialolithiasis. Methods: Eighty-seven patients with typical symptoms of sialolithiasis, were collected and analyzed to look for location of stones, size or number of stones, and possible risk factors between 2004 and 2006 in the Department of Otorinolaryngology, General Hospital of Larissa, Greece. Results: Sixty-one of all stones were detected in the submandibular duct and 26 were in the ducts of the parotid gland. The sublingual or other smaller salivary glands were not affected. The predominated age was between 25 and 55 years with a small predilection to male. Seven patients were found with more than one stone and one simultaneous stone of the urinary tract occurred in a male. In three cases the stone was seen only by X-ray and not by ultrasonography. Conclusions: Diagnosis of sialolithiasis demands careful consideration of patient histories and clinical examination. Even if the sonography is the ﬁrst choice of imaging, with X-ray we can have good results. Pathogenesis of sialolithiasis seems to be based to local factors within the salivary glands.

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HP 222 A case of bilateral submandibular gland agenesis Taichi Uyama, Hiroyoshi Iguchi, Makoto Kusuki, Aki Nakamura, Akimori, Kanazawa, Hisao Amatsu, Hideo Yamane Department of Otolaryngology and Head & Neck Surgery, Osaka City University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan Objective: Congenital absence of the major salivary glands is an extremely rare disorder. We present a case of bilateral aplasia of the submandibular glands associated with left submandibular hemangioma. Materials and methods: A 62-year-old woman came to our department complaing of a 10-year history of hydrodispsia. She had noted left submandibular swelling 3 years previously, and subsequent gradual enlargement. We performed left submandibular tumor extirpation. Results: On preoperative examination including computed tomography and ultrasonography, lack of the right submandibular gland and a 2-cm left submandibular mass with caliciﬁcation were demonstrated. We suspected that she had aplasia of the right submandibular gland and left submandibular gland tumor. During the operation, it was found that both the right and left submandibular glands were missing and a left submandibular tumor was present. The left subumandibular tumor was smooth and soft. Postoperatively, we diagnosed bilateral aplasia of the submandibular glands associated with left submandibular hemangioma. The calciﬁcation in the left submandibular mass was found to be a venous stone. Conclusions: Bilateral submandibular gland agenesis associated with submandibular hemangioma is rare. Retrospectively viewed, radiological examinations suggested that the submandibular mass was a hemangioma.

HP 223 Optimising outcomes of parotidectomy using rhytidectomy incision Paul Stimpson, Alwyn D’Souza University Hospital Lewisham Objective: In the current climate successful surgical outcome is dictated by both functional and cosmetic parameters in addition to optimal treatment. Traditional parotidectomy incision has the drawback of an obvious scar in the neck, often disliked by patients. This may be addressed by the use of Rytidectomy approach which is not commonly used by otolaryngologists. In this study we address various aspects of parotid surgery including training beneﬁts from this approach and advocate its use routinely. Methods: A total of 23 patients underwent parotidectomy performed via a rhytidectomy approach over a period of 30 months.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 There were 18 females and 5 males with the average age of 46 years. Histopathology conﬁrmed pleomorphic adenoma in 17, adenolymphoma 3, Sialolithiasis 2, and one with cat scratch disease. Results: Facial nerve was identiﬁed in every case and complete tumour excision was obtained in all patients. There were no major complications. Well hidden scars were obtained in all patients and contour deformities were minimal. No patients have reported Frey’s syndrome to date. All patients reported a high level of cosmetic satisfaction. Conclusions: Rhytidectomy incision is safe and confers a signiﬁcant cosmetic advantage over traditional parotidectomy approaches. In addition, it provides excellent training opportunity to surgeons interested in face lift surgery. We advocate the use of rhytidectomy incision routinely in parotid surgery.

HP 224 Solitary ﬁbrous tumor of submandibular gland Kai-Ping Chang1, Chia-Hsiang Fu1, Shir-Hwa Ueng2 1 Department of Otolaryngology-Head & Neck Surgery 2 Department of Pathology, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan Objective: Solitary ﬁbrous tumor is a rare disease entity in head and neck neoplasms. We demonstrate a rare case with solitary ﬁbrous tumor of submandibular gland. Methods: A 31-year old man presented with a left neck painless mass with progressive enlargement noted for one month. He had no other clinical manifestations in the head and neck region, nor symptoms such as odynophagia, dyspnea, weight loss, night sweats, or fever. No signiﬁcant personal or family medical history was noted. Physical examination revealed a 5 · 3 cm, elastic, immobile, non-tender mass in the left submandibular triangle. Fine-needle aspiration cytology showed some epithelial cell nests with myxoid stroma in a bloody background and no deﬁnite diagnosis could be made. Computed tomography demonstrated the presence of a well-deﬁned tumor in proximity to the left submandibular gland with mild contrast enhancement and without associated adjacent lymph nodes. Results: The tumor was completely resected in an en-bloc fashion by way of a transcervical approach. Histopathological examination revealed a well-circumscribed tumor composed of oval to spindle cells with irregular cellularity and thin-walled branching vessels. Immunohistochemistry showed that the tumor cells were diffusely positive for O13 (CD99) and CD34, and negative for S100 protein and smooth muscle actin (SMA). The patient remained free of disease after 2-year regular follow-up. Conclusions: We presented the clinicopathological manifestations of this rather rare case of solitary ﬁbrious tumor of submandibular gland in order to remind clinicians of sufﬁcient attention and subsequent management for this rare neoplasm in the head and neck region.

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HP 225 In vitro lithotripsy of salivary calculi with FREDDY and Ho:YAG-Laser V. Siedek1, V. Hecht2, M. Vogeser3, C. Betz1, R. Sroka2, A. Leunig1 1 Klinik und Poliklinik fu¨r Hals-Nasen-Ohren Heilkunde, Mu¨nchen, Germany 2 LIFE-Center Laser-Research-Laboratory, Mu¨nchen, Germany 3 Institut fu¨r Klinische Chemie, Klinikum-Großhadern der Ludwig-Maximilians-Universita¨t Mu¨nchen, Marchioninistr 15, 81377 Mu¨nchen, Germany Objective: This in-vitro study investigates laser parameters of FREDDY- and Ho:YAG-Laser for fragmentation, as both lasers promise a good fragmentation rate combined with a minimal risk of soft tissue damage. Methods: The fragmentation capability of the lasers was investigated on 15 salivary calculi. The FREDDY-laser emitted light pulses of 120–160 mJ/pulse, the Ho:YAG pulses of 300–800 mJ/ pulse, both fed into a ﬁbre (230 lm) positioned in front of each stone. For fragmentation each stone (n = 8 FREDDY, n = 7 Ho:YAG) was placed on a garting (mash-diameter 0.1–0.3 mm). The fragmentation rate was calculated to mg(stone-fragment)/J. Stone fragments were analysed spectrographically. Furthermore the laser impact applied from short distance or in contact on human salivary duct mucosa was examined histologically (HE-staining). Results: Spectrographic composition showed difference in variation of protein content from 5 to 25% besides carbonatappatit. Using the Ho:YAG all stones could be vaporized (fragmentation rate 0.2–1 mg/J) while by means of the FREDDY-Laser fragmentation looks like cracking stones and failed in three cases. A dependency on the stone composition could not be found. Pulse effects on soft tissue were limited to the mucosa. Conclusion: While the Ho:YAG vaporises the calculi in a more milling and soft sense, the FREDDY shows a more cracking and explosive destruction. Although, both laser systems showed little direct risk to the surrounding tissue, it has to be proven whether cracked and accelerated particles could insure soft tissue in the case of the FREDDY-laser is used. With respect to this further in-vitro studies are needed and clinical treatments will proof these results.

HP 226 Rare malignant tumors of the salivary glands. Presentation of 26 cases G. Mireas, S. Triantos, D. Louverdis, G. Plessas, M. F. Graikou, S. Vlachou, G. Papazoglou ENT Department, Red Cross Hospital, Athens, Greece Objective: The purpose of the present study was to present our data on rare malignant tumors of the salivary glands.

S137 Methods: We report a total of 26 cases, 21 located in the parotid, 3 in the submandibular and 2 in the minor salivary glands, diagnosed and treated in our Department within 10 years. The patients were 14 women and 12 men, 22 to 76 years old, who presented mainly with neck swelling. The patients were submitted to clinical examination, imaging evaluation using CT, MRI, Echo, Nuclear scanning or Pet scanning and FNA. The patients underwent superﬁcial parotidectomy, total parotidectomy, surgery of submandibular or minor salivary gland, RND, MND, SND, radiation therapy, chemotherapy or combined therapy. Results: The histological examination revealed the following tumor types: Malignant mixed tumors 3, Carcinosarcoma 1, Squamous cell carcinomas 3, Epithelial-myoepithelial carcinomas 4, Undifferentiated carcinomas 7, Undifferentiated lymphoepithelial carcinomas 2, Oncocytic carcinoma 1, Sarcoma 1, Metastatic Tumors 3, Myoepithelial and adenocarcinoma. 1. Local recurrence was found in 3 patients, nodal metastases in 1, distal metastases in 1 and paralysis of n.VII in 1 patient. Conclusion: The treatment of choice and the biological behavior of each tumor is related to its histological type.

HP 227 Simultaneous sublingual sialolithiasis and rhinolithiasis Kayhan Ozturk, Bahar Keles, Hamdi Arbag Department of Otolaryngology, Meram Faculty of Medicine, Selcuk University, Konya, Turkey Sialolithiasis is a common disease of the salivary glands. Sialolithiasis occurs mainly in the submandibular gland (80– 90%) and to a lesser extent in the parotid gland (5–20%). The sublingual gland and the minor salivary glands are rarely affected. Rhinolithiasis is mineralized, calcareous concretions resulting from calciﬁcation of an endogenous or exogenous nidus within the nasal cavity. Rhinolithiasis is a rare pathology in adult. In the study, we present the ﬁrst case with rhinolithiasis and sublingual sialolithiasis. A 20-years-old girl suffered from recurrent diffuse swelling and pain on the right submandibular area admitted to the our department. During the otolaryngological examination, a rhinolithiasis was found in the ﬂoor of the left nasal cavity, incidentally. Panoramic graphy showed simultaneous rhinolithiasis and sialolithiasis at the same case. During surgery, sublingual sialolithiasis was determinated in the anteromedial part of submandibular gland after dissection of submandibular gland. Submandibular and sublingual glands and rhinolithiasis were removed. Surgical removing for the sialolithiasis and rhinolithiasis is offered for treatment. Simultaneous rhinolithiasis and sublingual sialolithiasis should be suspected in adult patients.

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HP 228 Peptidomic analysis of selected parotid and submandibular/sublingual gland secretions Fanali Chiarab, Cabras Tizianac, Inzitari Rosannab, Passali Giulio Cesarea, Picciotti Pasqualina Mariaa, Scarano Emanuelea, Calo` Leaa, Messana Irenec , Castagnola Massimob a Institute of Otolaryngology, Catholic University, Rome b Institute of Biochemistry and Clinical Biochemistry, Catholic University, Rome c Department of Sciences Applied to Biosystems, Cagliari University, Italy

Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 lesions. The patient died about 12 months later despite of intensive chemotherapy.

HP 230 Fine-needle aspiration cytology of parotid gland masses M. Naderpour*, N. Shahidi*, M. Hossein Dadgarnia** *Tehran University of Medical Sciences **Yazd Shahid Sadughi University of Medical Sciences Objective: Differentiating benign from malignant tumors of parotid gland preoperatively is very important from the point of treatment planning. We design this study to evaluate the usefulness and accuracy of ﬁne-needle aspiration cytology (FNAC) in the diagnosis of parotid gland masses. Materials and methods: In a descriptive-case series study the results of FNAC of 124 parotid masses were analyzed and compared with corresponding histopathological diagnosis. Results: The cytological ﬁndings were no diagnostic in 2 (1.6%), true—negative in 84 (67.7%), true- positive in 24 (19.4%), falsenegative 13 (10.5%), and false—positive in 1 (0.8%) cases in detecting malignant tumors. The sensitivity and speciﬁcity in detecting malignant tumors were 64.8 and 98.8%, respectively. Conclusions: Fine-needle aspiration cytology is a valuable adjunct to preoperative assessment of parotid masses. Preoperative recognition of malignant tumors may help prepare both the surgeon and patient for an appropriate surgical procedure.

Objective: The aim of this study is to investigate the differences in peptide secretion of human parotid (Pr) and submandibular/ sublingual (Sm/Sl) glands. Methods: Selected saliva from parotid was collected either by a Lashley’s cup or by small plastic aspirators at the duct exit. Saliva from Sm/Sl glands was collected by a small aspirator at the duct exit. Samples were immediately added with aqueous TFA (0.2%) in 1/1 (v/v) proportion. Solution was centrifuged at 10,000g for 5 min (4C) and the acidic supernatant was immediately analysed by HPLC-MS apparatus or stored at –80C. Results: Basic proline-rich peptides (bPRP) are parotid glandspeciﬁc, while salivary cystatins (S, S1, S2, SA, SN) are almost completely Sm/Sl gland-speciﬁc. Conversely, all the isoforms of acidic-PRP, histatins, statherin and PB peptide are secretion products of both glands. The analysis of the post-translational modiﬁcation of different salivary peptides evidenced: (1) higher kinase activity in the parotid gland, (2) higher convertase activity in Sm/Sl glands, (3) sulfation of histatin-1 is Sm/Sl gland-speciﬁc. Conclusions: This study evidenced sensible differences between peptides secreted by the two glands and their post-translational modiﬁcations, strongly suggesting speciﬁc roles in different districts of the oral cavity.

HP 231 Case report: cystic clear cell myoepithelioma of parotid gland

HP 229 Metastatic myoepithelial carcinoma arising from recurrent pleomorphic adenoma of the parotid gland

Zeynep Kizilkaya, Hatice Emir, Kursat Ceylan, Hakan Gocmen, Mu¨zeyyen Astarci, Erdal Samim, Mehmet Metin, Sedat Dogan Ministry of Health Ankara Research and Training Hospital Ear Nose and Throat Department, Ulucanlar Cad. No:1 Mamak Ankara, Turkey

Shin-ichi Ohba, Masato Fujimori, Hiroyuki Takayanagi, Masateru Hata, Katsuhisa Ikeda Department of Otorhinolaryngology, Juntendo University School of Medicine, Tokyo, Japan A myoepithelial carcinoma, arising in recurrent or pre-existing pleomorphic adenoma of the parotid gland is an extremely rare salivary gland malignancy. General speaking, the biological nature arising in association with a pleomorphic adenoma is known to be a low grade malignancy unlike to de novo in the literature. We report a case of myoepithelial carcinoma arising in recurrent pleomorphic adenoma, which showed a higher metastatic potential. A 53-year-old man, who had undergone superﬁcial lobectomy of the pleomorphic adenoma of the parotid gland 2 years before, presented a recurrent parotid swelling with multiple coin lesions in the lung. The total parotidectomy with a biopsy of lung lesion under bronchoscopy revealed myoepithelial carcinoma of both

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Objective: We report an extremely rare case of cystic clear cell myoepithelioma of parotid gland. Method: Case report and world literature concerning cystic clear cell myoepithelioma of parotid gland are presented. Results: Myoepitheliomas are rare but well-characterized group of tumours, among which myoepithelioma of the salivary glands is the best known. In this paper a cystic clear cell variant of the parotid gland is reported in an 80-year old male patient presenting with a slow growing mass and treated surgically with superﬁcial parotidectomy. To our knowledge this is the ﬁrst case of cystic clear cell myoepithelioma ever reported in the parotid gland. The histopathological features, immunohistochemical proﬁle and clinical behaviour were discussed. Conclusion: Cystic clear cell myoepithelioma should be kept in mind in the differential diagnosis of the cystic neck masses in the parotid region.

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HP 232 Purulent sinusitis due to a supernumerary tooth inside the sinus K. Nazos1, N. Salemis2 I. Psarommatis1, N. Bollas2, E. Tsohataridis2 1 ‘‘P & A Kyriakou’’, Children’s Hospital, Athens, Greece 2 2nd Department of Surgery, Army Veterans General Hospital NIMTS, Athens, Greece Objective: This study is a very rare case report of purulent sinusitis caused by a supernumerary tooth in the sinus of an adult patient. Materials and methods: This case concerns a woman 42 years old in good condition, who came to our clinic complaining about having headaches in the right side of her head for two years, which pain was reﬂecting on the whole face and on the right eye, as well as feeling her face heavy while bending. After having X-ray examination of the visceral cranium and brain tomography, severe right sinus inﬂammation was detected, as well as, the existence of the supernumerary tooth. The patient mentioned that during the recent years she had been taking antibiotics without any result. By using total anesthesia, we proceeded to surgical operation, during which, we managed to dislodge and to open the sinus from which purulent liquid was came out. We drainaged carefully the sinus and pulled out the supernumerary tooth. Moreover, by following the Caldwell-Luc procedure, an enlargement of the inferior meatus and a sizeable androrhinostomy were created. Results: The post-operative progress of the patient was totally positive. Conclusions: The foreign bodies inside the sinuses represent a rare cause of chronic sinusitis and particularly in adults. A high index of suspicion and a proper imaging study are required for successful diagnosis. Surgical removal of the foreign body, conventionally or endoscopically, usually ensures deﬁnitive cure.

HP 233 Total parotidectomy in the management of parotid tumors N. Salemis1, K. Nazos2, I. Psarommatis2, N. Bollas1, E. Tsohataridis1 1 2nd Department of Surgery, Army Veterans General Hospital NIMTS Athens, Greece 2 ‘‘P & A Kyriakou’’, Children’s Hospital, Athens, Greece Objective: The appropriate surgical procedure for the treatment of parotid tumors is often a matter of discussion. The aim of this study is to present our experience in the diagnostic evaluation and management of patients who were admitted with a parotid gland tumor. Materials and methods: Between January 2000 and July 2006, 65 patients with tumors of the parotid gland were admitted to our

S139 department. There were 30 (46.2%) male and 35 (53.8%) female ranging in age from 38 to 69 years (mean age 54 years). Diagnostic evaluation included full blood count, biochemical analysis, ultrasonography, computerized tomography scans (CT) and magnetic resonance imaging (MRI) where indicated. The most common presentation was a painless swelling of the parotid region. Results: Fifty-two patients were diagnosed with benign tumors. The commonest pathology was pleomorphic adenoma (55.7%), while Warthin’s tumors had an incidence of 26.7%. Out of 13 patients with malignant disease, 2 were diagnosed to have a non Hodgkin’s lymphoma (NHL). The most common surgical procedure performed was total conservative parotidectomy (75.4%) followed by conservative superﬁcial parotidectomy (21.5%). The patients with NHL underwent a biopsy. Overall postoperative morbidity was 13.8%. Three patients developed Frey’s syndrome. Median hospitalization was 4 days. Conclusions: Total conservative parotidectomy was the operation of choice. This procedure is associated with a higher incidence of postoperative morbidity, but at the same time with lower recurrence rates. Surgeon’s experience is so important in the total parotidectomy since it can ensure the least complications and the best results in the treatment of parotid tumors.

HP 234 Non-hodgkin’s lymphomas of the parotid gland N. Salemis1, K. Nazos2, I. Psarommatis2, N. Bollas1, E. Tsohataridis1 1 2nd Department of Surgery, Army Veterans General Hospital NIMTS Athens, Greece 2 ‘‘P & A Kyriakou’’, Children’s Hospital, Athens, Greece Objective: The aim of the study is to present two patients who were admitted to our department with a painless parotid swelling and diagnosed to have Non Hodgkin’s parotid gland lymphoma. Materials and methods: Both patients, aged 81 and 88 years, respectively, presented with a relatively mobile and painless swelling of 3–5 months duration. They underwent computed tomography scan, magnetic resonance imaging scan and ﬁne needle aspiration cytology. Results: Diagnosis was established in both patients with incisional biopsies. With pathological examination and immunohistochemical analysis the disease was classiﬁed as follicle center cell Lymphoma in the ﬁrst patient and as a large b-cell Non Hodgkin’s lymphoma in the second. Both patients were referred to the medical oncology department for further investigation and staging. Conclusions: Although rare, Non Hodgkin’s Lymphoma should always be considered in the differential diagnosis of parotid gland swellings especially in the elderly. Chemotherapy and radiotherapy are the preferred therapeutic options.

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HP 235 Benign tumours of the parotid gland: a retrospective analysis of 252 cases D. Koutsimpelas, C. Herzog, W. J. Mann, B. M. Lippert E.N.T Clinic Johannes Gutenberg University of Mainz Objective: The aim of the present study was to review a singleinstitution experience in the treatment of benign tumours of the parotid gland. Methods: We retrospectively reviewed 252 patients treated in our clinic for benign parotid gland tumours over the last 5 years. Demographic details, clinicopathological parameters, type of parotidectomie and postoperative complications were assessed. Results: The most common tumour was Warthin tumour in 115 patients followed by pleomorphic adenom in 107 patients. All of the patients were subjected to ultrasound examination. Concerning the localisation of the tumours, in 237 cases the tumour was localised in the superﬁcial part of the parotid gland while in 15 the deep lobe was involved. We performed 120 limited resections, 114 superﬁcial parotidectomies, 3 enucleations, 14 near total parotidectomies and one total parotidectomie with preservation of the facial nerve. Postoperative 10 patients developed transient partiel facial nerve palsy, 15 salivary ﬁstula, 22 Frey-Syndrome while other complications including wound infection, haematoma or seroma formation were observed in 17 patients. Local reccurence was observed in one case of pleomorphic adenom. Conclusions: In our opinion the ultrasound examination is a valuable adjuncts to preoperative assessment. Superﬁcial and conservative parotidec-tomies demonstrate favourable results with low perioperative and longterm morbidity, as well as very low risk for tumour relapse and they constitute the procedures of choice for most benign tumor masses.

HP 236 Preoperative ﬂurbiprofen for pain after tonsillectomy S. Nishiikea, T. Katob, M.Nagaib, A. Nakagawab, M. Konishib, Y. Sakatab, F. Shimadac, H. Kidac, M. Otac, T. Haradaa a Department of Otolaryngology, Kawasaki Medical School, Kurashiki, Japan b Department of Otolaryngology, Suita Municipal Hospital, Suita, Japan c Department of Anesthesiology, Suita Municipal Hospital, Suita, Japan Objective: This study investigated the analgesic efﬁcacy of preoperative ﬂurbiprofen, an injectable non selective cyclooxygenase inhibitor, on postoperative pain after tonsillectomy. Methods: Twenty-ﬁve participants undergoing tonsillectomy were recruited prospectively. After randomization, one group underwent tonsillectomy with preoperative intravenous 50 mg ﬂurbiprofen, and the other group did without it. Results: The pain score at rest as well as at swallowing 0.5 h after tonsillectomy was signiﬁcantly lower in subjects receiving ﬂurbiprofen than in those without. During the ﬁrst postoperative 1.5 h,

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 signiﬁcantly fewer patients with ﬂurbiprofen required rescue diclofenac suppository. Total dose of required rescue during the postoperative 12 h in subjects with ﬂurbiprofen, however, was not signiﬁcantly different from that in subjects without ﬂurbiprofen. There were no signiﬁcant differences in any of the vital signs during the postanesthetic period. Conclusion: Preoperative ﬂurbiprofen suppressed immediate postoperative pain after tonsillectomy. The analgesic effect, however, disappeared in a few hours and was insufﬁcient for overnight pain relief.

HP 237 Antibiotic treatment of acute tonsillitis ulcero-necrotic forms Ivasi Ofelia, Popa Vladimir, Antohi Ion State Medical and Pharmaceutical University ‘‘Nicoale Testemitanu’’ Objective: To compare effectiveness of three antibiotics of different classes and ways of administration in the conservative treatment of acute tonsillitis ulcero-necrotic forms. Materials and methods: Where examined 50 patients comparable for age and sex, with diagnosis of ulcero-necrotic forms of acute tonsillitis conﬁrmed clinically, divided into three groups according to empirically administered antibiotic during 7 days: Group 1– Penicillin 1 mln · 4 in daily for adults and 250.000– 500.000 in pediatric patients. Group 2 – Augmentin 1.0 g · 2 in a day for adults in tablets, and for pediatric patients in suspension. Group 3– Aksef–cephalosporin with broad spectrum, including beta-lactamasis producing bacteria. Administrated intramuscularly, single injection in a day for adults 750 and 300 mg for pediatric patients. Evaluation criteria: odinophagia at the second day of the treatment; fever after 2 days of treatment; recidives after 2–3 months after treatment; stable remission Results: Criteria

Group 1n = 15

Group 2n = 10

Group 3n = 25

Odinophagia at 2nd day Fever after 2 Days of treatment Recidives Stable remission

12 (80%)

7 (70%)

3 (12%)

5 (33.3%)

4 (40%)

2 (4%)

10 (66.6%) 5 (33.3%)

8 (80%) 2 (20%)

4 (16%) 21 (84%)

Conclusions: Results of this preliminary study shows the priority of Aksef in the treatment of tonsillitis, of severe forms Aksef has the advantage of single dose administration in a day. During this study we did not report any allergic reactions or intolerance to the antibiotic.

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HP 238 Gustatory function after tonsillectomy Christian A. Mueller1, Saher Khatib1, Basile N. Landis2, Andreas F. P. Temmel1, Thomas Hummel3 1 Department of Otorhinolaryngology, Medical University Vienna, Vienna, Austria 2 Clinique de Oto-Rhinologie-Laryngologie et de Chirurgie cervico-faciale, Hopitaux Universitaires de Gene`ve, Switzerland 3 Smell and Taste Clinic, Department of Otorhinolaryngology, University of Dresden Medical School, Dresden, Germany Objective: Due to the anatomical course of the lingual branch of the glossopharyngeal nerve near to the tonsillar bed, taste sensitivity can be affected after tonsillectomy. However, the incidence of taste disorders after tonsillectomy is not clear. The aim of the study was the prospective assessment of taste function before and after surgery. Methods: Sixty-ﬁve patients (42 women, 23 men, mean age 28 years) were included. Taste function was investigated before tonsillectomy with four concentrations each of sweet, sour, salty, bitter taste, respectively, on both sides of the front part and the back part of the tongue. Self-assessment of gustatory function was performed by visual analogue scales. Thirty-two patients were retested 64–173 days after tonsillectomy. Thirty-three patients could not be re-tested after surgery, but were interviewed by telephone. Results: Self-assessed taste function signiﬁcantly decreased (P = 0.001). Importantly, none of the subjects complained of taste dysfunction. Surgery had no major effect on taste test scores (P > 0.27). Conclusions: Persisting taste dysfunction seems to be rare after tonsillectomy.

HP 239 Does ketoprofen prevent postoperative nausea and vomiting in pediatric tonsillectomy? Rana Altaf Ahmad, Amjad Rashid, Khalid A. Al-Mazrou King Saud University, PO Box 245, Riyadh 11411, Saudi Arabia Objective: To compare and determine the efﬁcacy of a single dose of intravenous ketoprofen, midazolam and dexamethasone on postoperative nausea and vomiting (PONV) after tonsillectomy in children. Methods: Randomized, double blind prospective study of 90 children of age 4–12 year. ASA 1 and ASA 11 scheduled for tonsillectomy. These were classiﬁed into three equal groups: dexamethasone (group A), midazolam (group B) and ketoprofen (group C). The anesthetic regimen and surgical procedures were standardized for all patients. All patients were observed in post anesthesia care unit and in the ward for PONV and postoperative pain. Results: Data from 90 patients were analyzed. The overall incidence of early as well as late vomiting was signiﬁcantly less in dexamethasone (group A) as compared to midazolam(group B) and ketoprofen (group C) (P _0.05). Episode of early vomiting were signiﬁcantly high when group C was compared to group A & B. Postoperative pain was signiﬁcantly less in group C. Conclusion: Dexamethasone and midazolam in the given doses are considered effective in postoperative nausea & vomiting. Ketoprofen is not an effective drug for PONV.

HP 240 Valuable symptoms of group A beta hemolytic Streptococcal pharyngitis in differential diagnosis

S141 Objective: The aim of this study was to investigate the clinical prediction criteria for group A beta hemolytic streptococcal (GABHS) pharyngitis in patients with upper respiratory tract infections (URTI). Methods: A total of 420 patients admitted to the outpatient clinics with URTI complaints, were included to the study. The clinical ﬁndings of the patients were recorded and throat cultures were obtained. The clinical features of patients with positive throat cultures for GABHS were compared to those with negative culture results. Results: Throat cultures were positive for GABHS in 95 (22.6%) patients. Signiﬁcant differences between the groups with and without GABHS pharyngitis were noted for the presence of sore throat (P < 0.001), tonsillar swelling (P < 0.001), cough (P < 0.001), fever (P < 0.001), rhinorrhea (P < 0,001), abdominal pain (P < 0,001) and cervical lymphadenopathy (P = 0.001), but not for the presence of fever, headache, tonsillar exudate, otalgia. Conclusions: These symptoms and signs may be helpful in modifying estimates of probability of infection with GABHS. Throat cultures in suspected patients remain necessary.

HP 241 Evaluation and comparison of results of bipolar and cold Tonsillectomies Sami Berc¸in, Ahmet Kutluhan, Veysel Yurttas, Go¨khan Yalc¸ıner, Kazım Bozdemir *Ataturk Education and Research Hospital ENT Dept. Ankara, Turkey Objective: To compare the classical dissection tonsillectomy results with the bipolar couther dissection results in the pediatric age group. Study design: Prospective randomized clinical study. Place: Ankara Atatu¨rk Education and Research Hospital, E.N.T. and Head and Neck Surgery Clinic. Patients and methods: For this study 201 children patient had tonsillectomy between 2004 and 2006 years who has suitable conditions. Ninety-ﬁve (47.26%) of the patients underwent bipolar couther tonsillectomy (group 1), 106 (52.74%) of the patients had classical dissection tonsillectomy. Bleeding amount during the tonsillectomy, operation duration, tonsil volumes, primary and secondary bleedings, postoperative ﬁrst hour and 10th day pain severity and ﬁrst solid food intake time were compared. Results: Operation durations, bleeding amount, postoperative pain scores and ﬁrst solid food intake time compared between the groups and statistically signiﬁcant differences were found. Conclusion: Bipolar couther tonsillectomy is beneﬁcial especially for the patients who has to take short time anesthesia who has limited blood volume, children under 3 years of age and children with coagulopathy. But we recommend classical tonsillectomy technique for the children who has thin body and disabilities of food intake also has poor wound healing. Keywords: Tonsillectomy, Bipolar couther, Cold (classic) dissection, Hemorrhage, Pain

Arzu Yasemin Korkut, Ebru Aktas, Nevin Cambaz, Ozgul Yigit, Betul Sezgin, Meryem Benzer, Emin Ozkaya Department of Otorhinolaryngology-Head and Neck Surgery, Department of Child Health and Disease, Vakıf Gureba Teaching and Research Hospital, Istanbul, Turkey

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HP 242 Bilateral intratonsillar abscess: case report E. D. Andrianopoulos, D. Lefantzis, V. Nikolaidis, M. Artopoulos, G. Papazoglou Department of Otorhinolaryngology, Hellenic Red Cross Hospital, Athens, Greece Objective: The purpose of this study is to report a very rare condition of patient presented with bilateral intratonsillar abscess. Even unilateral intratonsillar abscess is a relatively rare process in which an abscess forms in the tonsil itself. Intratonsillar abscess may form either from extension from an obstructed tonsillar crypt or from an intratonsillar rupture of a peritonsillar abscess. Methods: A 18-year-old male without previous history of tonsillar disease, presented to our department with high fever, sore throat and difﬁculty in swallowing. The patient complained of severe odynophagia, dysphagia, and displayed moderate trismus. Oral exam revealed signiﬁcant bilateral oedematous and erythematous tonsils Grade 4 that made laryngoscopy almost impossible. In order to exclude the possible developing upper airway obstruction and to evaluate the parapharyngeal spaces a CT scan was performed that revealed the presence of purulent accumulation inside the tonsils. Results: Under local anesthesia, thick yellow pus was aspirated from the tonsils and a wide spectrum antibiotic treatment was initiated. The following days the patient reported that the fever is gone, and he is swallowing without difﬁculty. After 4 days of hospitalization the patient was discharged and a follow-up examination was scheduled. Conclusions: Although bilateral intratonsillar abscess is a very rare condition with severe clinical presentation and symptoms, early diagnosis followed by drainage and antibiotic therapy could lead to rapid improvement of all symptoms without complications.

HP 243 Quality of voice childrens after adenotonsillectomy Sˇekib Umihanic´1, Fuad Brkic´1, Nevzeta Salihovic´2, Selma Dzˇinic´1 1 ORL Clinic, University Clinical Center Tuzla, Bosnia and Herzegovina 2 Faculty of Education and Rehabilitation, University of Tuzla, Bosnia and Herzegovina Objective: The aim of this study was to examine acoustical, aerodynamic and subjective voice variables day before, ﬁrst, seventh, and thirtieth day after adenoidectomy or adenotonsillectomy. Methods: The patients were divided into two groups: (1) those who have had an adenotonsillectomy (33 male and 27 females). (2) Those that have had an adenoidectomy (37 male and 23 females). With Cool Edit and EZ VoicePlus were analyzed the sustained phonation of vowel A and friction of S and Z. The statistical

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 analyses were performed by Statistic for Windows and MEDCLAC. Results: The results of research show that there are signiﬁcantly differences between aerodynamic variables of friction S and Z on the ﬁrst, seventh, and thirtieth day such as mean fundamental frequency and frequency oscillation on the ﬁrst and seventh day after adenotonsillectomy. After adenoidectomy there was a signiﬁcantly higher maximum phonation time of friction S and Z on the ﬁrst, seventh, and thirtieth postoperative day. The signiﬁcant differences were determined postoperatively for: pitch, loudness, vocal quality and nasal resonance. The correlation analysis showed statistically signiﬁcant intercorelation between the variables of the same group. Conclusions: The study implies that acustical, aerodynamic and perceptive voice characteristics assessment are very useful to evaluate the complex aspects of respiration, phonation and resonance process.

HP 244 The new adenotom for improvement of the visual control over adenoidectomy V. S. Kozlov*, V. A. Karpov**. *ENT Department General Management Department under the President of Russian Federation, Central Clinical Hospital **ENT Department, Yaroslavl state medical academy, Russia Objective: Improving the effectiveness of the operation of adenoidectomy. Tasks: To compare the effectiveness of operations performed with Beckmann curette and with an curette of our design. Methods: After endoscopy of nasopharinx some variants of the position of adenoid tissue have been revealed: adenoid grows into choanae, adenoid is separated from torus tubarius, adenoid is contiguous to torus tubarius, adenoid covers torus tubarius. These variants conﬁrmed importance of the constant visual control over operation. The adenoidectomy was performed under general anesthesia with a visual control through a laryngeal mirror for all patients. Both a Beckmann adenoid curette and new curette were used. The middle part of the new instrument is bent at a right angle. The curette is slightly unbent and has an additional bend at the distal part of the instrument like a Negus curette. These constructional peculiarities make the curette longer and enable the surgeon to extract the adenoid tissue even from a narrow and long nasopharinx. Results: The patients complaints and endoscopic ﬁnds after surgery showed the advantage and effectiveness of the new adenoid curette. Conclusion: The use of the new adenotom gives a better opportunity for a surgeon to see the surgery ﬁeld through the laryngeal mirror and makes the results of the surgery more effective.

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HP 245 Adenotonsillectomy in children with obstructive sleep apnea syndrome Felicia Manole Faculty of Medicine, Oradea, Romania Introduction: The part played by grossly hypertrophic tonsils and adenoids in the obstructive sleep apnea is most frequently found in children with very large tonsils (meeting in the midline) and adenoids (obliterating the nasopharynx) is largely acknowledged in practice. Objective: The purpose of the study is to delineate how obstructive sleep apnea syndrome is cured by surgery—adenotonsillectomy—and to compare the quality of life of those patients before and after surgical treatment. Methods: The reseach has been carried out on 186 patients (aged between 3 and 6 years) diagnosed with chronic adenotonsillitis in the Pediatric Hospital of Oradea during 2005–2006. Only 52 pediatric patients presented symptoms of chronic hypertrophy adenoids and tonsils associated with sleep apnea syndrome. A sleep questionnaire was completed by parents both before and after surgery. All children underwent adenotonsillectomy. Results: Thirty-eight percent of patients were considered by their parents and pediatric doctor as having a developmental delay preoperatively, where resolved in 62% post surgery. Clinical symptoms: snoring, sleep apnea, frequent movements during sleep, mouth breathing and recurrent awakenings are resolved or improved signiﬁcantly after surgery. Persisting or recurrence of some clinical signs were recorded in 12% patients three month after surgery. Conclusion: Adenotonsillectomy is the mainstay treatment of obstructive sleep apnea syndrome in children, although children with complex medical condition may require additional treatment. Quality of life in children with obstructive sleep apnea syndrome does improve after adenotonsillectomy.

HP 246 Clinical use pulmonary function tests in children with adenotonsillar-hypertrophy Fadullah Aksoy, O¨zgu¨r Yigit, Zeynep Alkan Cakir, Erkan Soylu, Tolgar Kumral, Gu¨lﬁdan Cakmak _ Istanbul Research and Training Hospital Objective: Adenotonsillar hypertrophy which is the most common cause of upper airway obstruction in children causes pulmonary function disorder. In this study pulmonary function tests in children with adenotonsillar hypertrophy who don’t have any other upper and lower respiratory truct disorder have been evaluated preoperatively and postoperatively. Method: Pulmonary function tests have been made preoperatively and at postoperative second month for 60 children who have adenotonsillar hypertrophy.

S143 Result: After adenotonsilectomy, respiratory parameters (Mean FVC, FEV1,PEF,FEF 25–75%, FEF 75%, FEV1/PEF, FEV1/FEV 0,5) have been improved statistically for all of the patients. Much of this improvement has been seen in patients who had tonsillar and adenoid hypertrophy in grade 2–3. Conclusion: Alongside the upper respiratory truct, lower respiratory truct should also be evaluated preoperatively and postoperatively in children with adenotonsillar hypertrophy. At the postoperative fallow-up process, any recurrence could be detected early on and the treatment of the disease could be completed without any pulmonary dysfunction.

HP 247 Comparision of cold dissection method and thermal welding system in tonsilectomy O. Yigit, E. Karaman, A. S. Sisman, Z. A. Cakir _ Istanbul Research and Training Hospital Objective: Tonsillectomy is one of the most frequently applied and the oldest surgical procedures in otorhinolaryngology.While cold dissection method (CDM) is the most frequent technique, new methods are improved in tonsilectomy. Thermal welding system (TWS) is one of the most recent surgical methods. In this prospective study TWS and CDM is compared with respect to per/postoperative parameters under the light of current literature. Method: Fifty-four patients who had undergone tonsillectomy were included in this study. Under general anesthesia we used TWS in 24 of them, CDM in 30 patients for tonsilectomy. During surgery; operating time, intraoperative bleeding and after the surgery postoperative pain, return of the fonation activity and initiation time of oral intake are measured. Results: While mean operative time was 13.92 ± 3.66 minutes for TWS, the time for CDM is 37.80 ± 14.13 minutes (P < 0.001). Mean intraoperative blood loss was 6.33 ± 4.27 g for TWS and 30.17 ± 10.95 g for CDM (P < 0,001). In TWS group higher pain scores (2.71) were observed relative to the CDM group (0.93) (P < 0.001). With this ﬁnding, mean time to recovery of normal fonation activity was 5.42 ± 1.25 days for TWS and 2.37 ± 1 days for CDM group (P < 0.001). However time to recovery of normal oral intake activity was not signiﬁcantly different between two groups (P > 0.05). Discussion: TWS provides a better intraoperative bleeding and operative time. However CDM offers better postoperative comfort. Because there isn’t enough publication about the issue, it is necessary to design new comparative studies between tonsillectomy techniques by means of postoperative bleeding and patient comfort.

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HP 248 Histological aspects of the chronical tonsillitis Elena Ionita˘*, Carmen Mogoanta˘*, Florin Anghelina*, Iulica˘ Ionita˘**, Sorin Ciolofan**, Laurentiu Mogoanta˘*** *ENT Department, University of Medicine and Pharmacy of Craiova **Emergency Hospital of Craiova ***Histology Department, University of Medicine and Pharmacy of Craiova Objective: Chronical tonsillitis represents the most common inﬂammatory lesions of the pharynx determining numerous local or distant evolutive complications. We decided to study the histological and especially immunohistochemical expression of this pathology. Methods: We’ve studied 202 surgical samples representing tonsils resected from 112 patients with chronical tonsillitis. The tonsillectomies were performed in the ENT Clinic of Craiova, between 2005 and 2006. The processed histological samples were stained using hematoxilin-eosin, light green trichromic and argentic impregnation. For the immunohistochemical study we used LSAB method with CD 20 and CD 45 RO antibodies in order to reveal and differentiate T and B lymphocytes. Results: In all samples we found hyperplasia and hypertrophia of the lymphoid follicle with excessive developing of the clear germinal center as a normal reaction to antigens presence. In some cases we remarked micro hemorrhages and hematic extravasations inside the follicles, probably due to the excessive virulence of the pathogens causing endothelial lesions. The conjunctive stroma was enriched in collagen ﬁbers, in some cases organized in strong fascicles with an obvious tendency to divide the tonsils in lobules. The young ﬁbroblastic type cells were numerous. The speciﬁc reticulin ﬁbers had a low representation being disorganized. The immunohistochemical study proved that the clear center of the lymphoid follicles was occupied by B lymphocytes but the T lymphocytes were present in the cortical region of the follicles, peri follicles and in the surface epithelium. Conclusion: In some pathological cases the predominant cellular population of the clear center was formed by T lymphocytes.

HP 249 Multiparametric comparison of tonsillectomy techniques in children T. Chimona, G. Perogamvrakis, E. Proimos, E. Theodoraki, M. Tzanakakis, C. Papadakis ENT Department, General Hospital of Chania, Greece Objective: The aim of the present study is the evaluation of several intraoperative and postoperative parameters of three tonsillectomy techniques. Methods: Ninety children aged between 5 and 13 years were enrolled a prospective trial comparing cold knife tonsillectomy, radiofrequency excision, and tissue welding tonsillectomy.

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Results: Sixty-eight patients underwent tonsillectomy for obstructive sleep apnea, whereas 22 children suffered from recurrent acute tonsillitis. Surgery time for cold knife tonsillectomy was found to be signiﬁcantly prolonged compared to radiofrequency excision (P < 0.001) and tissue welding technique (P < 0.001). No signiﬁcant statistical difference was found comparing the surgery time between radiofrequency and tissue welding techniques (P = 0.21). Mean intraoperative blood loss was 86.8 ml (max = 150 ml, min = 50 ml), 26.3 ml (max = 50 ml, min = 10 ml), 20.3 ml (max = 40 ml, min = 10 ml) for cold knife tonsillectomy, radiofrequency technique and tissue welding technique respectively. Postoperative bleeding presented in a child operated by cold dissection. Cold knife tonsillectomy caused less pain on the seventh postoperative day compared to radiofrequency (P < 0.001) and tissue welding technique (P < 0.001). No signiﬁcant statistical difference was found at the 7th postoperative day comparing the pain between radiofrequency and tissue welding techniques (P = 0.234). Conclusions: Cold dissection tonsillectomy may be more suitable in adults who usually experience prolonged postoperative pain, whereas radiofrequency and tissue welding techniques seem to have indications in patients with coagulopathies or peritonsillar abscess history and in children with small blood volumes.

HP 250 Post-tonsillectomy hemorrhage: a 2-year prospective study Milosevic Dusanka ENT Clinic, Zvezdara University Hospital, Presevska 32, Belgrade, Serbia The aim of this prospective study was to evaluate the incidence, intensity and time of post-tonsillectomy hemorrhage (PTH). The prospective study included 757 patients undergoing inpatient tonsillectomy with or without adenoidectomy during a two-year period in ENT Clinic, Zvezdara University Hospital in Belgrade. Tonsillectomy was performed under endotracheal anesthesia using a standard technique of blunt dissection with snare. The severity of PTH was classiﬁed according to Windfuhr and Seehafer (2001) in grade 1 (spontaneous cessation), grade 2 (inﬁltration anesthesia), grade 3 (treatment under endotracheal anesthesia), grade 4 (ligature of the external carotid artery) and grade 5 (fatal outcome). The time of PTH was classiﬁed as primary (£24 h) and secondary (>24 h). The overall incidence of PTH was 3.96% (30/757). Grade 1 PTH occurred in 21 of 757 patients (2.77%). Six patients (0.79%) had grade 2 and three (0.40%) patients had grade 3 PTH. Grades 4 and 5 bleeding were not recorded and no patient received a blood transfusion. PTH was primary in 65% and secondary in 35% of patients. PTH can be expected in a small number of patients undergoing tonsillectomy. PTH is mostly primary and rarely requires treatment under endotracheal anesthesia and a blood transfusion.

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HP 251 Post-adenoidectomy hemorrhage: a 2-year prospective study Milosevic Dusanka ENT Clinic, Zvezdara University Hospital, Presevska 32, Belgrade, Serbia The aim of this prospective study was to evaluate the incidence, severity and time of post-adenoidectomy hemorrhage (PAH). The study included 1053 patients undergoing inpatient adenoidectomy with or without tonsillectomy during a two-year period in ENT Clinic, Zvezdara University Hospital in Belgrade. Adenoidectomy was performed under endotracheal anesthesia with an adenotome and hemostasis was accomplished by nasopharyngeal packing. The severity of PAH was classiﬁed according to Guida and Mattucci (1990) in grade 1 (mild bleeding which stopped spontaneously), grade 2 (moderate bleeding which required intranasal vasoconstrictors) and grade 3 (severe bleeding which needed haemostatic control under endotracheal anesthesia). The time of PAH was classiﬁed as primary (£24 h) and secondary (>24 h). The overall incidence of PAH was 0.38% (4/1053). Two of patients (0.19%) had grade 1and 2 of patients (0.19%) had grade 3 PAH. Grade 2 was not recorded and no patient received a blood transfusion. PAH was primary in all of patients and it occurred within the ﬁrst six postoperative hours. PAH can be expected in a small number of patients undergoing adenoidectomy. PAH has occurred mostly within the ﬁrst six postoperative hours and rarely requires treatment under endotracheal anesthesia and a blood transfusion.

HP 252 Multicentre study of demographics and incidence of signiﬁcant post-operative haemorrhage in adenoidectomy David Owens1, Carl Passant1, Wendy Harrison2, Victoria Mcclure2, Sue Harrison2, Mark Temple3, Alun Tomkinson1 1 University Hospital of Wales, Heath Park, Cardiff, Wales 2 Centre for Disease Control (Wales), Abton House, Wedal Rd, Cardiff, Wales Objective: To establish the level of serious postoperative haemorrhage and described the demographics of adenoidectomy (Without tonsillectomy). Methods: The patient characteristics and operative details of all patients undergoing adenoidectomy (Without tonsillectomy) in Wales in all hospitals between May 2003 and February 2006 were prospectively examined.

S145 Results: One thousand and sixty-ﬁve adenoidectomies were performed 573 male 491 female with a median age of 7 (Interquartile range 5–10). Adenoid curettage was used in at least 923 (87%) of operations, 26 (2.8%) required diathermy for haemostasis. Primary haemorrhage requiring surgical management was seen in 9 (0.85%) cases and 2 (0.18%) had secondary haemorrhage requiring surgical management. Conclusion: Adenoidectomy is a common operation in a lower age group with a median age of 7. Haemorrhage requiring surgical management is a rare at < 1% in a group predominantly made of cold steel techniques. This is the largest multi-centre study undertaken in Europe.

HP 253 Actinomycosis in the etiology of recurrent tonsillitis and obstructive tonsillar hypertrophy: answer from histopathological point of view Ozan Bagis Ozgursoy1, Ozgur Kemal1, Mustafa Rahmi Saatci1, Ozden Tulunay2 1 Department of Otorhinolaryngology-Head and Neck Surgery, Ankara University Faculty of Medicine, Ibni Sina Hastanesi KBB AD, 06100, Ankara, Turkey 2 Department of Pathology, Ankara University Faculty of Medicine, Ibni Sina Hastanesi KBB AD, 06100, Ankara, Turkey Objective: The aim of the study was to investigate the histopathological proﬁle and clinical presentation of tonsillar disease in the presence of Actinomycetes in children. Methods: A qualitative and quantitative histopathological analysis of palatine tonsil was performed. Tonsillectomy specimens from patients underwent tonsillectomy or adenotonsillectomy were searched for Actinomycetes. Four histologic compartments of tonsil including surface epithelium, reticulated crypt epithelium (lymphoepithelium), lymphoid tissue and interfollicular region were examined. Results: The presence of Actinomycetes in the tonsillectomy specimens of patients with obstructive symptoms (32%) was more prevalent than that of patients with recurrent tonsillitis (14.2). The number of subjectively quantitated total lymphoid follicles, as well as small and medium sized lymphoid follicles of the palatine tonsil were signiﬁcantly increased (P < 0.05) in patients demonstrating ‘‘sulphur granules’’ in their crypts. Highly thick squamous metaplasia of the lymphoepithelium and dilatation of crypts were more prevalent in tonsil tissue revealing Actinomycetes. Conclusions: The presence of Actinomycetes in the tonsillectomy specimens does not indicate active tissue infection. However, the histopathological outcome may indicate a possible etiologic role of Actinomycetes in the development of prominent lymphoid hyperplasia and hypertrophy, in turn, obstructive tonsillar hypertrophy.

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HP 254 Io PTH level is predictive of postoperative hypocalcemia and need for vitamin D supplementation in thyroid surgery Balegh Hamdy, Mohamed El-Shaﬁe, Mohamed Hegazy, Hisham Rizq, Samy Marouf El Minia University Hospital, ENT Department, Egypt Objective: Evaluation of the occurrence of hypoparathyroidism after thyroid surgery and the use of ioPTH levels to predict patients with risk of postoperative hypocalcaemia. Methods: IoPTH and serum calcium were obtained during surgery, 1st postoperative day, and after one month. The accuracy of ioPTH to predict patients at risk for postoperative hypocalcaemia was compared with calcium levels of less than 8 mg/dl on the 1st postoperative day. Result: Ten patients had an ioPTH levels less than 10 pg/ml at skin closure. These patients showed reduction in serum calcium concentration measured on the 1st postoperative day. Patients with an ioPTH level below reference range developed hypocalcaemia (P 0.001) compared to patients with normal range of ioPTH. At the one month evaluation, 6 of these 10 patients required vitamin D supplementation because of persistent hypoparathyroidism or hypocalcaemia (P 0.001). The remaining four patients with ioPTH levels less than 10 pg/ml at skin closure did not require vitamin D supplementation because they were asymptomatic and their PTH and SCa levels had normalized. None of the 35 patients with an ioPTH level greater than 10 pg/ml at skin closure needed vitamin D supplementation at the one month follow-up evaluation. Conclusion: An ioPTH level less than 10 pg/ml at skin closure is a strong predictor of hypoparathyroidism after bilateral thyroid surgery. Patients with ioPTH levels below 10 pg/ml should be given calcium postoperatively, and placed on vitamin D supplementation after surgery to avoid symptomatic hypocalcaemia, facilitating discharge on the ﬁrst day after bilateral thyroidectomy.

HP 255 Primary hyperparathyroidism: surgical approach, lessons learned Mayeul Lecoq, Nicolas Guevara, Jose´ Santini Nice University Hospital, ORL maxillo-facial and head and neck Department Objective: To evaluate the way that we treat patient who have primary hyperparathyroidism, from the diagnosis and the preoperative localisation to the long-term follow-up, regarding to the international recommendations (French Endocrinology Society, National Institute of Health) and to propose surgical algorithm. Method: A retrospective study was conducted on 188 cases treated between January 2000 and July 2005. All patients were asked by mailing for new blood analysis. Preoperative imaging localisation,

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 peroperative procedure, surgical ﬁndings and histopathological types were analysed. Statistical analysis were made using the Statistical Analysis System software. Results: The average follow-up was 21 months post-operative. Positive predictive value to localize the adenoma is almost 99% when Ultrasonography (US) and sestaMIBI scintigraphy are concordant. Sensitivity of US and scintigraphy to localize the side of the lesion is respectively 46 and 79%. We had done 57% unilateral neck dissection (UND), 28% bilateral neck dissection (BND) and 15% minimal invasive surgery. We have found 95.2% adenomas and 4.8% multiple gland hyperplasia disease. Patients with UND had less postoperative hypocalcaemia than those who had BND. There is no signiﬁcant statistical difference between the surgical procedures. There were two treatment failures. Conclusions: We specify the essential role of doing both of preoperative localisation imaging in order to choose the best surgical procedure. Selected patients with pHPT due to single-gland disease and an unequivocally positive preoperative imaging can safely and successfully be managed with a focused unilateral cervical exploration without either frozen section or IOPTH monitoring.

HP 256 Lingual thyroid: a review of 3 cases Imre Fu¨lo¨p, Csongor Gyo¨rgy Lengyel, Erzse´bet Fu¨le Department of Otolaryngology Head & Neck Surgery, Jo´sa Andra´s County Hospital, H-4400, Szent.I. u. 68., Nyı´ regyha´za, Hungary Objective: Lingual thyroid gland is a rare clinical entity that is caused by the failure of the migration of the thyroid gland during embrional development. A lingual thyroid gland as an ectopic thyroid tissue located on the midline of the base of the tongue can cause several problems for the patient, with symptoms of dysphagia, dysphonia, upper airway obstruction or even hemorrhage. The aim of our study is to report of our illustrative cases of lingual thyroid gland, and to give a review of the literature, regarding diagnosis and appropriate therapy. Methods: Three patients of lingual thyroid were presented (all female, aged between 37 and 70 years), their primary symptom was dysphagia. Scintigraphic examination of the neck revealed no thyroid gland at the usual anatomical site in two patients and one patient an orthotopic thyroid. All the patients were managed surgically by an external, transhyoid approach. A tracheostomy was not performed in any of the patients. Results: All the patients remained completely symptom-free, two patients were placed on thyroid hormone replacement therapy and was last reported as clinically euthyroid after more than 10 years. Conclusions: We emphasize the importance of preoperative thyroid scintigraphy. The external approach is advisable, it has never been hazardous and greatly facilitates vision.

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HP 257 Secondary hyperparathyroidism: operative and postoperative ﬁndings F. Debruyne, P. Delaere, V. Vander Poorten, G. Geuens Otorhinolaryngology-Head&Neck Surg., K.U.Leuven, Belgium Records of 189 patients undergoing subtotal parathyroidectomy for secondary hyperparathyroidism (SHPT) were reviewed. In 75 patients PTH levels were measured during the ﬁrst ﬁve postoperative days. In 86% of the patients 4 or more parathyroid glands were visualised and removed. Less than four glands were found in 14%; some of them had previous thyroid surgery. In 82% of the patients all resected glands were enlarged; in 18% we found one or two normal parathyroid glands. Five patients had ﬁve parathyroid glands. There was no signiﬁcant difference between right-left or superior-inferior location of the glands. On each location about 89% of the glands showed hyperplasia, 7% was normal and 4% was not visualised. In 87% of the patients the lowest postoperative PTH value was less than 10 pg/dl, suggesting a successful intervention. However, in some of them less than four glands were identiﬁed. In 9% of the patients the lowest postoperative PTH value remained above 30 pg/dl; they seem to have a higher risk for persistent or recurrent SPTH, although in some of them four glands were removed. In surgery for SHPT the common course is the removal of four enlarged glands, followed by a very low PTH level in the ﬁrst postoperative days. This review of a larger series of operations shows how in a minority of patients the clinical course can be different.

HP 258 Parathyroid adenoma: an incidental ﬁnding in a patient with heart disease M.Taghi Khorsandi*, M. Hossein Dadgarnia** *Tehran University of Medical Sciences ** Yazd Shahid Sadughi University of Medical Sciences Objective: A number of seemingly asymptomatic patients may manifest subtle or even silent sequels of hyperparathyroidism at the time of presentation that would be eliminated by early diagnosis and appropriate surgical operation. Patient and methods: The patient was a 60-year-woman which due to hypertension and chest pain refers to a cardiologist. For evaluation of patient, cardiac thallium scan is requested which showed a suspicious uptake in right lower cervical region. Patient is referred to our clinic that in head and neck physical examination hadn’t any positive ﬁnding. In laboratory evaluation; patient had increased serum total calcium levels with high normal parathyroid hormone level. With diagnosis of primary hyperparathyroidism, localization study by technetium-99 m sestamibi scintography was accomplished which showed nuclear uptake in right lower cervical region. Patient undergoes operation and pathologic result con-

S147 ﬁrmed parathyroid adenoma. Post operation total calcium levels returned to normal limit. Results: Although the majority of patients with primary hyperparathyroidism are asymptomatic and the disorder is detected during health screening or coincidentally during medical examination, these patients may exhibit with cardiac sign and symptoms as hypertension, myocardial ischemia and left ventricular dysfunction which may be reversible after parathyroidectomy. Conclusions: It has been estimated that approximately 90% of people with primary hyperparathyroidism remain undiagnosed. The screening of serum calcium has been a particularly important factor leading to detection of patients with mild symptoms or no symptoms, especially among postmenopausal women that the beneﬁt of parathyroidectomy is most apparent.

HP 259 The value of ﬁne needle aspiration cytology in the management of a thyroid mass: a two centre retrospective study Hiba Al-Reefy, Suresh Baboo, Mike Dilkes, Vikram Dhar, Alistair Balfour St. Bartholemew’s Hospital, London, UK Objective: To evaluate the usefulness and accuracy of Fine Needle Aspiration Cytology (FNAC) in diagnosis of thyroid gland masses. Retrospective review of patients notes who have undergone thyroidectomy. Methods: A retrospective review of patients notes who have undergone thyroidectomy Between Jan. 2003 to Dec. 2005, 146 Thyroidectomies were performed at WhippsCross University Hospital NHS Trust, London. Of these, 98 patients underwent preoperative FNAC. The results of FNAC were analysed and compared with the corresponding histopathlogical diagnosis to determine whether the FNAC was useful in terms of inﬂuencing the management of each case. Results: Of the 98 patients with FNAC, histological evaluation revealed 15 malignant tumours and 83 benign lesions. The cytological ﬁndings were true-negative in 79 (80%), true-positive in 9 (9.1%), false-negative in 6 (6.1%) and false-positive in 4 (4.1%) cases, when trying to detect a malignant tumour. The sensitivity and speciﬁcity were 60 and 95%, respectively. Conclusions: As a preoperative diagnostic tool for the surgical excision of thyroid swellings FNAC is less reliable than is widely accepted. It should be used as an adjunct to clinical examination and experienced ultrasound, rather than as a deﬁnitive test. Negative cytological results do not exclude more serious disease. One should take in to account the cost implications of repeated clinical attendances for review and aspiration, the potential morbidity from aspiration and also the consequences of delayed surgical treatment.

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HP 260 Hemangiosarcoma of the thyroid gland Petra Jerˇ a´bkova´1,2, Jan Plza´k1,3,4, David Vesely´1, Vladimı´ r Zeman5, Jaromı´ r Astl1 1 Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University, Faculty Hospital Motol, V U´valu 84, 150 06 Prague 5, Czech Republic 2 Institute of Physiology, 1st Faculty of Medicine, Charles University, Albertov 5, 128 00 Prague 2, Czech Republic 3 Institute of Anatomy, 1st Faculty of Medicine Charles University, U nemocnice 3, 128 00 Prague 2, Czech Republic 4 Center for Cell Therapy and Tissue Repair, 2nd Faculty of Medicine, Charles University, Faculty Hospital Motol, V U´valu 84, 150 06 Prague 5, Czech Republic 5 Department of Pathology and Molecular Medicine, 2nd Faculty of Medicine, Charles University, Faculty Hospital Motol, V U´valu 84, 150 06 Prague 5, Czech Republic Objective: Hemangiosarcoma of the thyroid gland is a very rare entity. The therapy is difﬁcult because of its locally aggressive and destructive behavior with a high recurrence rate. Methods: We present a case of 60-years-old man with history of one month rapidly enlarging neck mass in the thyroid region and in levels II-III on the left side. Results: Ultrasound examination and CT scan showed resistance 7 · 5 · 7 cm arising from the left thyroid lobe displacing the trachea. FNAC yielded only necrotically changed tumor mass without any cytological speciﬁcation. Total thyroidectomy was indicated. Invasion of the tumor mass into the surrounding tissues was found during the surgery. Therefore only left side hemithyroidectomy was performed. Histopathology including histochemistry proved positivity of factor VIII, fasciin, and CD31 in tumor cells characteristic of hemangiosarcoma. Immediately after the surgery the general status of the patient was getting worse not allowing planned radioand chemotherapy. The patient died 2 months after the surgery because of massive bleeding from the tumor mass. Conclusions: The histological diagnosis is mostly difﬁcult. The treatment of the ﬁrst choice for angiosarcoma is radical surgery. If the tumor is not resecable radiotherapy, eventually chemotherapy is indicated. The prognosis is not favorable and average 5 years survival is nearly 2%. Acknowledgments: This study was supported by the IGA MZ CR No. NR9049-3, and the MSMT No. 2B06106.

HP 261 A ﬂow chart to aid decision making in thyroid lump assessment H. M. Al-Reefy, V. Dhar, A. M. Balfour, M. G. Dilkes Department of Otolaryngology, St Bartholomew’s Hospital, West Smithﬁeld, London EC1A 7BE, UK Objective: The management of thyroid neoplasia varies from institution to institution, and from specialty to specialty. The majority of thyroid surgery nationally is performed by head and neck surgeons, whether ENT or Maxillofacial. There are a large number of tests that can be performed in order to make the key decision: is this cancer? These tests include ultrasound, ﬁne needle aspiration for cytology, core biopsy, CT or MRI scanning, PET scanning and technetium99 uptake scanning. Many surgeons end up removing benign, essentially asymptomatic

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 thyroid tissue in order to make a ﬁnal diagnosis. With the correct decision making, the incidence of this occurring should be reduced. Methods: A group of Consultants with an interest in thyroid disease agreed to work towards a problem-solving ﬂow chart, to keep thyroid lump investigation simple and easy to understand, and to avoid unnecessary surgery. These consultants included specialists from radiology (head and neck ultrasound), pathology (head and neck cytologist), endocrine (professor of endocrinology) and ENT (head and neck surgeon). The main source of referrals was patients presenting to the one-stop neck lump clinic, where immediate ultrasound and FNA-cytology are performed. Over a series of one to one meetings and two open fora, an agreed protocol was reached. This protocol was then used in the one stop clinic. Results: The ﬂow chart has been helpful in streamlining patient investigation, and helping in the decision making process. The next stage is to audit thyroid surgery before the ﬂow chart was introduced, and after. Conclusions: Multi-disciplinary team working in the area of thyroid surgery may reduce the need for diagnostic thyroidectomy.

HP 262 Effect of imatinib on a papillary thyroid carcinoma: a case report Shigeru Nakai, Koichiro Yoshimoto, Kaichiro Ikebuchi, Masahiro Matsui, Hiroshi Nakano, Taketoshi Shimada, Yasuo Hisa Kyoto Prefectural University of Medicine, Department of Otolaryngology-Head and Neck Surgery, Kyoto, Japan Objective: To present the ﬁrst reported case of the anticancer effects of imatinib on papillary thyroid carcinoma. Methods: Case report and review of the literature. Results: The patient was a 79-year-old man who underwent left neck dissection and subtotal thyroidectomy for papillary thyroid carcinoma (T2N1aM0) in 1997. In 2000, the patient developed a swelling on the left lateral wall of the mesopharynx. CT conﬁrmed the diagnosis of lymphadenopathy (diameter, 2.5 · 2 cm) of the left parapharyngeal space, and ﬁne-needle aspiration cytology revealed metastasis of papillary thyroid carcinoma. The patient did not desire treatment, and underwent follow-up. In 2002, the patient also developed chronic myelogenous leukemia, for which administration of imatinib 400 mg/day was initiated. A partial cytogenetic response was achieved after 6 months. After approximately 1 month of imatinib therapy, the swelling of the mesopharynx began to resolve, and the metastatic lymph node was essentially undetectable on CT after 6 months. Although thyroglobulin level was abnormally high on peripheral blood tests conducted prior to imatinib therapy, it decreased to normal levels after 6 months. No further enlargement of the metastatic lymph node was observed over the course of imatinib therapy. A resected sample obtained from the previous thyroidectomy was examined using immunostaining. Overexpression of c-KIT and PDGFR-a was observed, in addition to the primary thyroid tumor and cervical metastatic lymph node. Conclusion:The main emphasis of this report is that if a papillary thyroid carcinoma expresses c-KIT and/or PDGFR-a, there is a possibility that imatinib may inhibit the effects of the cancer.

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HP 263 Perforated rectus abdominis free ﬂap for head and neck reconstruction C. Piazza, J. Cappiello, A. Bolzoni Villaret, B. Pedruzzi, A. Bizzoni, P. Nicolai Department of Otolaryngology, University of Brescia, Spedali Civili, Piazza Spedali Civili 1, 25123 Brescia, Italy Objective: Perforated rectus abdominis free ﬂap (PRAFF) has been introduced from breast reconstructive surgery as an adjunctive tool for head and neck reconstruction. Aim of this paper is to describe our experience in the use of this versatile and minimally morbid fascio-cutaneous ﬂap. Methods: Between 2004 and 2006, 17 patients with oral cavity (7 cases), orbito-maxillary (8), parapharyngeal (1), and skull (1) malignancies received primary microsurgical reconstruction with PRAFF at the end of cancer resection. This ﬂap represents 11% of the total number of free ﬂaps harvested in that period at our Institution. A chart review was performed to collect clinical and functional outcomes of PRAFF. Results: Surgical defects encompassed half of the hard palate in eight patients (with associated ethmoid, orbital, and anterior skull base defects in 7), subtotal glossectomy in 5, total glossectomy in 2, radical extended parotidectomy in 1, unilateral temporo-parietal skin, bone and dura in 1. One patient (6%) developed total necrosis of the PRAFF and another (6%) had partial dehiscence requiring surgical revision for oral-cutaneous ﬁstula. No complications at the donor site were observed. Normal oral diet and good speech intelligibility were resumed with minor limitations for two and three patients, respectively. Conclusions: PRAFF is a valid alternative to the classic myocutaneous rectus abdominis free ﬂap in the head and neck area, particularly when applied to complex maxillo-facial or tongue major defects. Its greatest advantages, in spite of a more timeconsuming dissection of the perforator vessels, are represented by reduced donor site morbidity and more adjustable thickness of the skin paddle, particularly in the obese patients.

HP 264 Nasopharyngeal carcinoma in benin city Nigeria: an update N. E. Okolugbo M.B.B.S., FMCORL and F.O.OGISI DLO, FRCS, FMCORL, FWACS; ENT Unit, Dept of Surgery, University of Benin Teaching hospital, PMB 1111, Benin City, Nigeria Aims and objective: To determine the common modes of presentation of Nasopharyngeal carcinoma in Benin City Nigeria, to make for early diagnosis and better management modalities.

S149 Methodology: Clinical records of patients histologically conﬁrmed to have nasopharyngeal carcinoma over a 7 year period, June 99 and May 2006, were retrieved and studied. Results: Fifty-six cases of nasopharyngeal carcinoma were reviewed. The age range was between 16 and 85 years with a mean age of 44 years. Thirty-six 0f the cases occurred in males, with a male to female ratio of 1.8:1 Neck swelling 71.4%, Nasal obstruction 46.4%, Audiologic symptoms 42.8%, Epistaxis 35.7%, and occular symptoms 28.5% were the commonest symptoms. Conclusion: Most common presenting complaint was neck swelling and 10.5% of these patients had prior lymph node biopsy done by Gen. Surgeons, which led to increased morbidity in these cases. The role of lymph node biopsy in metastatic neck disease is thus discouraged. Fine-needle aspiration cytology may however be useful. Keywords: Nasopharyngeal carcinoma, Presentation, Biopsy, Neck swelling

HP 265 Intravenous hydration can reduce pain following tonsillectomy Ruta Pribuisiene, Virgilijus Ulozas, Algis Babarskas Kaunas University of Medicine, Lithuania Objective: To determine the beneﬁt of intravenous hydration for postoperative pain following tonsillectomy. Methods: The study is consisting of two groups of patients following tonsillectomy performed in a university hospital. One group received adequate intravenous hydration during and after operation while the other did not have and dehydration was detected. 100 mm visual analogue scale (VAS) for detecting postoperative throat pain was used. Two-tailed unpaired Student’s t-test was used to compare the two independent groups. P < 0.05 was accepted as statistically signiﬁcant. Results: The total amount of the intravenous solutions was in mean: 1591.7 (SD 666.7) ml for male (weight 79.1 SD 10.5 kg), 1269.2 (SD 525.0) ml for female (weight 70.4 SD 12.7 kg), 1281.3 (SD 625.6) ml for boys (weight 52.1 SD 13.5 kg), and 1188.5 (SD 641.0) ml for girls (weight 45.1 SD 12.3 kg). The dehydration in 35 (76.1%) patients was detected. There were 19 adults (9 male, 10 female) and 16 children (5 boys, 11 girls) in this group. The hydration (H) group had signiﬁcantly (P < 0.05) less postoperative pain compared with the dehydration (D) group. The mean pain in H group was 21.4 (SD 17.5) VAS points and 36.5 (SD 21.1) points in D group, respectivelly. There was no age dependence. Conclusions: Results of the current study suggest that adequate intravenous hydration can reduce postoperative pain in postoperative period following tonsillectomy in children and adults.

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HP 266 Most frequent symptoms in patients with proved laryngo-pharyngeal reﬂux disease Marianne Vidojevic, Radmila Sladoje, Gordana Golubovic ENT Clinic ‘‘MKM’’, Belgrade, Serbia Introduction: A large number of ENT patients has complaints like pharyngeal sensations, postnasal drip, excessive mucus production, globus pharyngeus, chronic cough a.o. However, these symptoms are manifestations of different diseases including infections, allergy, LPR, etc. Objective: Point out the most frequent symptoms in patients with already proved LPR, on base of which the practicing doctor will suspect reﬂux disease exists in the ENT region. Methods: Frequency and kind of symptoms were retrospectively analysed in 39 patients with laryngo-pharyngeal reﬂux disease, diagnosed using the ‘‘golden standard’’, 24 h pharyngo-esophageal pH-measuring. Before pH measuring some patients underwent microbiological testing, radiography of the paranasal sinuses and/or lungs, allergy testing, pulmonal and neurologic testing or exluding of ACE inhibitors). Results: We found hyperphlegmia and chronic throat clearing in 74.35%, pharyngeal sensations and globus pharyngeus/pharyngeal tightness in 71.79%, dysphonia and dyspnea in 53.85, chronic cough and stickiness of soft palate in 43.6%, postnasal drip and drawing back of it in 41%, nasal obstruction 41.02%, cervical dysphagia, choking,voice breaks, dry mouth, snoring in 28.2%, need to drink with meals 18.18%, strange taste in 15.4%, glossopyrosis, tongue swelling and hyposmia in 10.25%, laryngospasmus in 10.25%, sensation of foreign body in throat in 10.25%,water brash 7.7%, otalgia 2.56%, retrosternal pyrosis/squeezing/sternal heavy weight 33.3/5.12/10.25%, belching and bloating 35.9%, stomach ache or nausea in 10.25/10.25%. Discussion: These results enable the establishing of a reﬂux questionnaire, which it self may already give a justiﬁed suspection of reﬂux disease, and along with a detailed ENT examination leads to the necessity of ﬁnal diagnosing. In this way long-lasting and unadequate treatment with antibiotics, antihistaminics, antimycotics or sedatives will be avoided. Conclusion: The clinical picture of patients with LPR emphasizes the importance of aimed ENT reﬂux anamnesis. The complaints are usually periodic and/or chronic, lasting from a few months to a few years. Many patients do not have typical GERD symptoms (heartburn, stomach swelling or belching), which however does not exclude the necessity of further LPR diagnosing. For complete diagnosing application of the ‘‘golden standard’’, 24 h pharyngo-esophageal pH measuring is necessary, and it justiﬁes the speciﬁc and often long-lasting treatment.

HP 267 Oro-pharyngeal carcinoma: assessment of swallowing with ﬁbreoptic endoscopic evaluation and videoﬂuroscopy S. H. Vyas, S. Gollins, S. Ford Ankara Numune, Education and Research Hospital, 4th ENT Clinic, Turkey

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Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151 Objective: Using Fibre-optic Endoscopic Evaluation of Swallowing (FESS) and Video-ﬂuroscopy (VF); aspiration and penetration were studied in these cancers. Methods: Swallowing in 25 treated oro-pharyngeal cancers (squamous cell carcinoma) was Studied prospectively using FESS or VF on the ‘Swallowing Workstation’.Penetration (score 2–5) and aspiration (score 6–8) were assessed according to a previously validated 8-point scale. Eight patients had a neck dissection with radical radio-therapy to the primary site (Group A). Eight patients underwent resection of the primary with reconstruction and post-operative RT (Group B). Nine patients received radical chemo-radiation alone (Group C). Results: Twelve patients (48%) had penetration alone: 11 (92%) were identiﬁed with FESS and six (50%) by VF. Eight patients (32%) were aspirating: four (50%), were identiﬁed by FESS and seven (88%) by VF. No. of patients (%) penetrating: Group A - 4 (50%); Group B - 4 (50%); Group C - 4 (44%). No. of patients (%) aspirating: Group A - 2 (25%); Group B - 2 (25%); Group C - 4 (44%). 3 of 14 (21%) of tonsil and 5 of 11 (45%) of tongue base tumours aspirated. Conclusions: For oro-pharygeal cancers: (1) Aspiration and penetration is high irrespective of type of treatment used. (2) Videoﬂuroscopy appears to be more reliable at detecting aspiration than FESS. Risk of aspiration is higher with tongue base than tonsillar tumours.

HP 268 Objective, subjective evaluation of voice after partial laryngectomy M. Kulekci, E. Gultekin, F. G. Guzelderen Taksim Egitim ve Arastirma Hospital, Istanbul, Turkey Objective: To compare the voice outcomes of cordectomy, vertical hemilaryngectomy, horizontal supraglottic, vertical frontoanterior and supracricoid laryngectomy by means of patient self assessment, perceptual analysis and acoustic analysis. Methods: A total number of 27 male patients treated with partial laryngectomy were enrolled in this study. Twelve patients (44%) were treated with cordectomy, six (22%) were treated with horizontal supraglottic laryngectomy, three (11%) were treated with vertical frontoanterior laryngectomy, three (11%) were treated with vertical hemilaryngectomy and three (11%) were treated with supracricoid laryngectomy. After surgery, all of the patients were evaluated by using a 0–3 scale and Voice Handicap Index-30 scale. Acoustic analysis were performed for the objective voice evaluation. Results: The means of perturbation measurements, harmonic to noise ratio, maximum phonation time and s/z ratio were signiﬁcantly high in cordectomy and horizontal supraglottic laryngectomy than in vertical frontoanterior laryngectomy, vertical hemilaryngectomy and supracricoid laryngectomy (P < 0.05). On the basis of perceptual evaluation by using a 0–3 scale and Voice Handicap Index-30, mean scores were found to be signiﬁcantly higher in cordectomy and horizontal supraglottic laryngectomy than in vertical frontoanterior laryngectomy, vertical hemilaryngectomy and supracricoid laryngectomy (P < 0.05). Conclusions: Voice quality after partial laryngectomy appears to be better in cordectomy and horizontal supraglottic laryngectomy. Keywords: Partial laryngectomy, Voice quality, Acoustic analysis

Eur Arch Otorhinolaryngol (2007) (Suppl 1) 264:S5–S151

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HP 269 ENT day case turnover in a UK district general hospital

sive, permits to achieve a high rate of success in these patients who are grateful to be part of the modern and functional management of salivary calculi.

Tom Pezier, Paul Stimpson, Rahul Kanegaonkar, David Bowdler University Hospital Lewisham

HP 271 Malignization of laryngeal papilloma

Objectives: In 2000 the NHS plan set a target of 75% of all surgical activity to be performed as day cases. ENT lends itself well to a day case approach. We conducted a retrospective study to evaluate our day case operating rate, in particular otological procedures, in relation to national guidelines. Methods: We retrospectively analysed all elective operations over one calendar year from September 2005 to September 2006. Information was gathered via the GALAXY Theatre coding system software and matched to the patient information management system (PIMS). Results: Two thousand ﬁve hundred and thirty eight elective operations were performed over the study period. All elective ENT operations were included. There were 1,535 adult procedures and 1,003 paediatric procedures ( < 16 years). In the adult group 1,137 procedures were performed as day cases (74%). Of the 1,003 paediatric operations, 730 were day cases (73%). A total of 580 ear operations were performed during the study period. 333 were performed on paediatric patients and 247 on adults. Overall 87.9% of adult procedures were day cases including mastoidectomy (n = 18, 78% day cases), Tympanoplasty (incl. CAT) (n = 53, 87%) and Stapedectomy (n = 20, 100%). 93.4% of paediatric cases were performed as day cases. Procedures included grommets (n = 172, 94%), tympanoplasty (incl. CAT) (n = 15, 80%). Conclusions: Day case surgery is preferred by patients and has well recognised clinical and economical advantages. ENT surgery is well suited to a day case approach and our ﬁgures show that day case rates approaching 75% of all elective operations are achievable in the district general hospital setting. Otology day case rates exceeding national recommendations are achievable even when considering major ear surgery.

HP 270 Extracorporeal shockwave lithotripsy for salivary calculi Pasquale Capaccio Department of Otorhinolaryngological and Opthalmological Sciences - Policlinico Foundation I.R.C.C.S. University of Milan, Italy In the last 15 years the increasing public demand for minimally invasive therapies and rapid development in medical technologies have made feasible different minimally invasive methods for the removal of salivary calculi with preservation of the salivary gland. The long-term experiences acquired in almost four centres around the world, including mine, in the application of extracorporeal shockwave lithotripsy (ESWL) under ultrasonographic monitoring have stated that ESWL is the preferred minimally invasive therapy for all parotid stones and may be also chosen for intraductal submandibular stones of less than 7 mm in young patients. The results of the personal experience, began in 1992, based on 525 patients with parotid and submandibular stones will be compared with that of other centers with such a long-term experience. Thanks to the recent development of other minimally invasive or conservative methods, ESWL may be used not only as a primary unique modality but also in combination or as a secondary modality after transoral removal of submandibular stones; in this regard, the availability of different modalities, though time-consuming and relatively expen-

N. A. Daikhes, H. Sh. Davudov, I. I. Matela Federal Research Clinical Center of ENT of Russia Objectives: The aim of our research is to study immunological parameters of the peripheral blood of patients with laryngeal papillomatosis during diagnostics of the illness and after a certain period of time after the tumor ablation and also examination of ablated tissues for human papilloma virus. Participants of the study are 49 patients with laryngeal papilloma: 34 men and 15 women aged from 19 to 64. Malignization of the papilloma occurred with 16 out of 49 patients. From adverse effects it is necessary to note that 12 patients developed laryngeal papillomatosis and its malignization on the background of smoking. 2 patients had malignization detected during pregnancy. Methods: All patients were prescribed to have immunological, histological study and the examination of the ablated tissues done for the papilloma virus of 6, 11, 16 and 18 types by polymerase chain reaction. Results: On studying of the immunity level all patients showed different disturbances, for the most part, depression of T-cell chain of lymphocytes: reduction of Thelpers and natural killers, several patients showed reduction and increase of IgA, IgG and IgM and also depression of the functional activity of B and T lymphocytes. Five patients with the papilloma malignization had the human papilloma virus—18 type. In two cases laryngeal papillomatosis was developed from childhood in men, in the rest cases—malignization of ﬂat cell papilloma. Conclusions: It is necessary to reveal the presence of 16 and 18 type papillomavirus in samples of laryngeal papilloma and papillomatosis to suspect possibility of future malignization.

HP 272 Monitoring vocal perturbations in running speech: objectives—technical challenges—perspectives Jean Schoentgen Universite´ Libre de Bruxelles, CP 165/51, 50, Av. F.-D. Roosevelt, B-1050 Brussels, Belgium Vocal perturbations refer to deviations of the glottal cycle lengths from strict cycle-to-cycle periodicity. The causes include jitter, shimmer, and turbulence noise. Acoustic cues summarizing vocal perturbations are correlates of perceived roughness and breathiness. Known difﬁculties are that existing analysis methods occasionally fail to track vocal perturbations accurately, if these exceed a critical size, as well as that the analysis is often restricted to stable fragments of sustained speech sounds. An argument in favour of analyzing running speech is that the variable conditions under which vocal fold vibration must take place constitute a greater challenge to a speaker’s larynx. The presentation therefore concerns speech analysis methods that accurately detect and measure vocal perturbations in any speech material, whatever the severity of the disorder. Experiments have shown that the (Pearson) correlation between perceived abnormality (grade) and acoustic cues that quantify vocal perturbations is better than 0.8 for four matched sentences and vowels [a] produced by a corpus of dysphonic speakers. The ability to track vocal perturbations in connected speech as reliably as in sustained sounds offers novel opportunities, such as monitoring speakers at risk in their professional setting.

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HNS - Head and Neck Surgery, Larynx and Others

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