Thomas Wilhelm

Objective: Currently no data exist on what distance from facial nerve (FN) it is safe to perform bipolar cautery (BC) in parotid surgery, although frequently performed.Methods: The degree of damage was measured using continuous intraoperative neuromonitoring (cIONM, NIM™ 3, Medtronic) in 16 Wistar rats. Amplitude drop of at least 50% (A₅₀) or a loss of signal (LOS) in the cIONM was defined as harmful; BC was performed in power range 20–60 W.Results: BC ≤30 W did not cause LOS (0/14 nerves). When applying 35 W, A₅₀ occurred at 4 mm from FN and LOS was noted in 1 of 5 nerves. BC at a power of 40 to 60 W demonstrated LOS in all nerves (12/12) at a 5 mm distance.Conclusion: BC up to 30 W can be safely applied up to 3 mm distance from FN. 40 to 60 W should be avoided and used only at a distance of over 6 mm from FN.Level of Evidence: NA/animal study. Laryngoscope, 135:1120–1126, 2025

Purpose Facial palsy (FP) is the most significant complication of parotidectomy. Currently, the use of intermittent intraoperative neuromonitoring (iIONM) in parotid surgery facilitates nerve detection, which is paramount to nerve protection. Continuous IONM (cIONM), as applied in thyroid surgery, enables real-time information on electrophysiological nerve status through continuous nerve stimulation, thereby allowing consequent amplitude analysis. To date, the application of cIONM in parotid surgery has not been noted in literature. Methods We performed parotidectomies with anterograde facial nerve visualization using cIONM in 32 consecutive patients in a prospective study (German Register of clinical studies—DRKS 00011051) during the period October 2016 to January 2020. After the facial trunk had been exposed, an atraumatic stimulation electrode was placed and the nerve was stimulated at 3 Hz, at a low threshold (0.62 ± 0.06 mA), for the entire duration of the preparation. Selected electrophysiological parameters were collected and compared to postoperative facial nerve function, measured by the House-Brackmann grading system. Results In the post hoc analysis, a significant correlation between a drop in amplitude (< 50% of the “baseline” amplitude) and postoperative FP was recorded (p = 0.001). True positive prediction of FP was noted in 14 out of 16 patients and true negative in 10 out of 16. The sensitivity was 87.5% (AUC 0.75), with a high negative predictive value of 83.3%. Conclusion cIONM has significant value in predicting postoperative FP in parotidectomy. Future development of an acoustic/optic warning system in IONM devices could prevent nerve injury in real time.

The treatment guidelines for basal cell carcinoma (BCC) postulate complete surgical excision using microscopically controlled resection (MOHS) as the gold standard. The need to obtain a small safety margin in the complex anatomical area of the head and neck is very challenging due to the individual characteristics (localization, histology, and size) of tumors and the fact that the postoperative loss of quality of life depends on the surgical defect size. The R1 status is histopathologically defined when the safety margin is less than 1 mm even if there are no tumor cells actually infiltrating the resection margin. Therefore, some studies have already favored a watch-and-wait-strategy in R1 situations. We aimed to evaluate the outcome and recurrence rate of resected BCCs of the head and neck, especially in a histologically proven R1 situation. The outcomes of all resected BCCs observed during a 5-year period (January 2009–December 2013) in a tertiary care center were analyzed. Our standard operating procedure was microscopically controlled surgical excision with reresections until an R0 situation was achieved. In selected patients, an R1 status has been accepted after at least two resections. From the included 191 BCCs, the R1 status was accepted as the final result in 46 (24.1%) cases which had surgically clear margins and were closely followed-up. From 54 patients in the R0 and 40 patients in the R1 group who completed the follow-up (2.4 ± 0.4 years), we observed 0 and 2 local recurrences, respectively (p = 0.19). In cases where frequent follow-up can be secured and the surgical area is delicate, a surgical closure at R1 status can be justified as the recurrence rate is not significantly higher compared with R0. All procedures involving human participants in this study were performed in accordance with the ethical standards of the Institutional and/or National Research Committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study passed an evaluation of the Ethical Committee of the Saxonian Chamber of Physicians. Data handling was in accordance with national data protection laws and the anonymity of the patients was secured. Informed consent regarding the data analysis was obtained from all individual participants included in the study by means of the treatment contract. This study was approved by the Ethical Committee of the Saxonian Chamber of Physicians (approval no.: EK-BR-103/18–1, 08.01.2019). Data handling was in accordance with national data protection laws. ^* Petar Stankovic and Robert Bock are both first authors since the idea, conception, and execution of the project derives from them both. Article published online: 07 November 2022 © 2022. Thieme. All rights reserved. Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

Objectives: Epistaxis is the most common otolaryngological emergency and one-third of epistaxis patients regularly take low-dose acetylsalicylic acid (ASA) for the prevention of cardiovascular disease (CVD). The shift in contemporary guidelines identifies little benefit of ASA intake in patients who have not previously had an infarction. Existing evidence confirms ASA intake as a factor for severe epistaxis, while the evidence concerning its impact on recurrence is ambiguous. There are no available studies which justify the administration of these drugs nor are there any studies correlating the effects of these drugs to the SCORE2 CVD risk stratifying scale. Study design: A retrospective analysis of all admitted epistaxis patients in a tertiary academic hospital for the 10 year period 2011 to 2021. Methods: Patient data were analysed using the hospital information software. A recurrence was defined as an epistaxis episode requiring hospital readmittance for at least one night. Patients taking anticoagulants were excluded (N = 421). Results: 444 patients were included: 246 were taking ASA and 198 were not (NoASA). ASA patients had more frequent recurrence in general (p = 0.03), more recurrences per patient (p = 0.002), and more changes in bleeding localisation (p = 0.04). Recurrence in the ASA group was associated with lower haemoglobin values (HR 0.62, p < 0.0001), while surgery (HR 6.83, p < 0.0001) was associated with recurrence in the NoASA group. ASA patients had a statistically significant (r 0.33, p = 0.032) correlation between the total number of epistaxis recurrences and SCORE2. The indication for drug intake was highly questionable in as much as 40% of ASA patients. Follow-up time was 5.27 years. Conclusions: Epistaxis patients taking prophylactic ASA are significantly more burdened by recurrence, because they have more frequent recurrences, a greater number of recurrences per patient, and more changes in bleeding localisations when compared to control patients. The drug indication is questionable in up to 40% of ASA patients, exposing them unnecessarily to recurrence. Level of evidence: 4.

Background: Primary radio(chemo)therapy [R(C)T] is a treatment option for advanced oropharyngeal squamous cell carcinoma (OSCC). Nevertheless, early diagnostics of treatment failure is problematic. Cytokeratin fragment 19 (CYFRA 21-1), an established marker in the management of pulmonary cancer, might be helpful here. Hence, in this study the impact of CYFRA 21-1 as an indicator for treatment failure and tumor recurrence (TR) in OSCC after R(C)T was analyzed. Patients and Methods: The data of 77 patients with advanced OSCC and R(C)T were retrospectively examined. For determination of CYFRA 21-1 at the time of diagnosis and after R(C)T, an electrochemiluminescence immunoassay was used. Tumor residuals and tumor recurrence were pathologically verified after detection by radiological imaging and endoscopy. The mean follow-up was 44.4 months. Results: After R(C)T, 48 (62%) patients showed locoregional control and 29 (38%) patients experienced locoregional failure. No statistical difference in the CYFRA 21-1 level between groups both before (p=0.75) and after R(C)T (p=0.85) was found. Nevertheless, in cases of TR in follow-up, the CYFRA 21-1 level was significantly higher (p≤0.01). The occurrence of TR was significantly associated with a CYFRA 21-1 elevation at this time (p≤0.01). However, CYFRA 21-1 failed to show a suitable discriminative ability for TR (area under the curve=0.57). Conclusion: In OSCC, CYFRA 21-1 does not seem to be a useful marker for locoregional failure after R(C)T. Nevertheless, a higher level immediately after R(C)T and in the further course of the disease may be associated with TR in individual patients.

Objective Epistaxis is the most common otolaryngological emergency and up to one third of patients in treated on an inpatient basis take oral anticoagulants (OAC). Direct oral anticoagulants (DOAC), an OAC subgroup, have been on the market since 2010 and are being increasingly prescribed due to the cardiologic and hematologic guidelines that favour them over vitamin K antagonists (VKA), the older of the OAC subgroups. The present study aims to investigate which subgroup of epistaxis patients taking OACs has a more favourable outcome. Design/Setting A systematic review and meta-analysis were performed according to the PRISMA 2020 statement using the PubMed and Cochrane Library databases. Continuous data was analysed and standardized mean difference (SMD) was calculated according to Hedges’ g. Dichotomous data was analysed and the Mantel-Haenszel method was applied to establish the odds ratio (OR). Heterogeneity was assessed according to the I² statistics. Main Outcome/Results A total of 8 reports covering 1390 patients were included in the final synthesis. The pooled analysis demonstrated significantly shorter hospital stays in the DOAC group (SMD= -0.22, 95% CI -0.42 to -0.02, P= .03) and a significantly higher rate of posterior bleeding in the VKA group (OR= .39, 95% CI .23 to .68, P= .001). No statistically significant differences with regard to recurrence rates, admission rates, the need for transfusion, or surgical intervention (P= .57, .12, .57 and .38 respectively) were found. Conclusion According to this meta-analysis, epistaxis patients taking DOACs have a more favourable outcome than patients taking VKAs.

Die plastische Rekonstruktion onkologischer, anorektaler Defekte ist aufgrund der erheblichen bakteriellen Kontamination, einer neoadjuvanten Radio-Chemotherapie sowie den anatomisch sehr schwierigen Bedingungen häufig kompliziert und führt zu einer prolongierten Hospitalisation der Patienten. Einen Goldstandard für die plastische Rekonstruktion gibt es nicht. Wir stellen eine Patientin vor, welche nach der Diagnose eines distalen Rektumkarzinoms mit Infiltration des Anus und der Scheidenhinterwand eine radikale Tumorexzision mit Rektum-, Anus- und Vaginateilresektion erhielt, wobei es postoperativ zu einer schweren nekrotisierenden Infektion kam. Es resultierte ein großflächiger, tiefreichender vollschichtiger Weichteildefekt des kleinen Beckens und der Perinealregion. Wir präsentieren eine retrospektive klinische Beurteilung und Fotodokumentation einer Rekonstruktion der Vagina, des kleinen Beckens sowie des Gesäßes durch eine bilaterale M.-gracilis- und M.-gluteus-Lappenplastik. Plastic reconstructions of oncological anorectal defects often prove to be very difficult and lead to prolonged hospitalisation due to severe bacterial contamination, neoadjuvant radiotherapy and chemotherapy and difficult anatomical conditions. There is no common standard for plastic reconstruction in such cases. We present a patient diagnosed with distal rectal cancer with infiltration of the anus and vagina, who underwent radical tumour resection of the rectum and anus as well as partial resection of the vagina. A severe necrotising infection occurred post-surgery, which resulted in an extensive defect of the pelvis and perineal region. This article provides a retrospective clinical evaluation and photographic documentation of the reconstruction of the vagina, pelvis and perineal region with a bilateral gracilis and gluteus muscle flap. Received: 27 July 2020 Accepted: 29 June 2021 Publication Date: 23 September 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Seit der erfolgreichen Entwicklung und klinischen Einführung der transoral-endoskopischen Thyreoidektomie (TOET) 2008 und 2009 sind einigen Modifikationen des Zugangs publiziert worden, von denen der rein vestibuläre Zugang (TOETVA) die weiteste Verbreitung gefunden hat. Dieses hat aber neben der bekannten meist passageren Schädigung des N. mentalis neue spezifische Komplikationsmöglichkeiten: neben Hautperforationen vor allem eine Schädigung des R. marginalis mandibulae n. facialis. Wir haben daher in einer anatomischen Studie an zwei Präparaten sowie einer Ultraschalluntersuchung an 20 Probanden untersucht ob es gefährliche und sichere Inzisionen im Bereich des anterior-vestibulären Zugangs gibt. Hierbei zeigte sich, dass sowohl in Hinblick auf vaskuläre als auch neurale Strukturen eine laterale Inzision zirka 5 bis 10 mm von der vestibulären Umschlagfalte sowie die anteriore Inzision etwa 5 mm von dieser das geringste Risiko von akzidentellen Komplikationen verspricht. Bei Beachtung der vorgeschlagenen Inzisionsorte ist der vestibuläre Zugangs bei der TOET eine sichere Alternative zum sublingualen Zugangsweg. Publication Date: 10 June 2020 (online) © . © Georg Thieme Verlag KG Stuttgart · New York

Hintergrund Die Entwicklung des intraoperativen Neuromonitorings (IONM) blieb in den letzten Dekaden bei der Parotischirurgie eingeschränkt, obwohl sich diese Methode bei der Schilddrüsen- und Kleinhinrbrückenchirurgie mit dem Einsatz des kontinuierlichen IONM (cIONM) als nutzbringend bewiesen hatte. Hier wurden die Paresenraten durch die Erkennung von Mustern der drohenden Nervenverletzung gesenkt. In dieser Studie zum cIONM bei der Parotischurgie sollten die Parameter zur Erkennung von Schädigungen sowie die Sicherheit untersucht werden. Methoden Die prospektive Studie wurde beim dt. Register für klinische Studien registriert (DRKS-ID: DRKS00011051, http://www.drks.de). 40 Patienten mit präoperativ normaler Fazialisfunktion (House-Brackmann I) die sich einer primären Parotisoperation von 2016 bis 2018 unterzogen, wurden durch das cIONM mit der Saxophonelektrode® (AVALANCHE XT, Dr. Langer Medical, Waldkirch) gemonitort. Als Kontrollgruppe dienten die Patienten, die zuvor unter intermittierendem IONM (iIONM) operiert wurden. Ergebnisse Eine Hälfte der operierten Patienten hatten eine frühe Fazialisparese (fFP) welche sich bei 39 von 40 Patienten binnen 6 Monaten völlig erholte. Es bestand keinen statistisch signifikanten Unterschied im Vergleich zur iIONM-Gruppe (p = 0,11). Eine Korrelation wurde weder für Stimulationspegel (p = 0,74) noch die Stimulationsdauer (p = 0,51) und fFP gefunden. Schlussfolgerung Das cIONM mit der Saxophonelektrode® bei der Parotischirurgie kann sicher durchgeführt werden. Zukünftige Entwicklungen der Methode könnten die fFP-Rate durch Erkennung von Mustern der drohenden Nervenverletzung reduzieren. Publication Date: 10 June 2020 (online) © . © Georg Thieme Verlag KG Stuttgart · New York