T Klenzner

Universitätsklinikum Düsseldorf, Düsseldorf, North Rhine-Westphalia, Germany

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Publications (106)99.03 Total impact

  • Julia Kristin · Robert Geiger · Peter Kraus · Thomas Klenzner
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    ABSTRACT: A 'third hand' is useful for holding the endoscope during surgery. The SOLOASSIST camera holder (AktorMed GmbH, Germany), which is used for abdominal surgery, is supposed to be modified for head and neck surgery. The aim of this study was to determine the intraoperative hand-held endoscopic range of motion for different surgical procedures and to define the required technical changes. The intraoperative movements of the hand-held endoscope during sinus surgery, rigid laryngoscopy, and lateral skull base surgery were measured and calculated. The endoscopic range of motion during surgery revealed diverse geometric bodies and volumes. For use in the ENT area, the system must be expanded by a manual release function for the driven axes and two additional lockable axes at the distal end of the arm. Intraoperative endoscopic range of motions in head and neck surgery are highly specific and, as expected, differ from the endoscopic movements in abdominal surgery. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.
    International Journal of Medical Robotics and Computer Assisted Surgery 02/2015; DOI:10.1002/rcs.1643 · 1.53 Impact Factor
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    ABSTRACT: The increasing amount of medical knowledge and necessity for time-effective teaching and learning have given rise to emerging online, or e-learning, applications. The base of the skull is a challenging anatomic area in the otorhinolaryngology (ORL) department-for both students and lecturers. Technology-enhanced learning might be an expedient approach to benefit both learners and lecturers. To investigate and create for advanced medical students a self-assessed adaptive e-learning application for the skull base within our curriculum of otolaryngology at the University Medical Center of Heinrich Heine University, Düsseldorf, Germany. Pilot approach with prospective evaluation of a newly implemented web-based e-learning simulation. The e-learning application (Student's Interactive Skull-Base Trainer) was made accessible as an elective course to a total of 269 enrolled medical students during the first 2 semesters after web launch. Spatiotemporal independent e-learning application for the skull base. Self-assessed evaluation with focus on general acceptance and personal value as well as usage data analysis. The application was well accepted by the learners. More than 80% of the participating students found the application to be a beneficial tool for enhancing their analytical and clinical problem-solving skills. Although the general matter of the skull base seemed to be of lesser interest, the concept of anchored instructions with the use of high-end, interactive, multimedia-based content was considered to be particularly suitable for this challenging topic. Most of the students would have appreciated an extension of optional e-learning modules. With this pilot approach we were able to implement a useful and now well-accepted tool for blended learning. We showed that it is possible to raise interest even in this very specialized subspecialty of ORL with overall individual learning benefit for the students. There is a demand for more e-learning and web-based simulation to support the existing curricula in a hybrid, blended way.
    JAMA Otolaryngology - Head and Neck Surgery 12/2014; 141(2). DOI:10.1001/jamaoto.2014.3041 · 1.79 Impact Factor
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    ABSTRACT: Lasers have been proven to be precise tools for bone ablation. Applying no mechanical stress to the patient, they are potentially very suitable for microsurgery on fragile structures such as the inner ear. However, it remains challenging to control the laser-bone ablation without injuring embedded soft tissue. In this work, we demonstrate a closed-loop control of a short-pulsed CO2 laser to perform laser cochleostomy under the monitoring of an optical coherence tomography (OCT) system. A foresighted detection of the bone-endosteum-perilymph boundary several hundred micrometers before its exposure has been realized. Position and duration of the laser pulses are planned based on the residual bone thickness distribution. OCT itself is also used as a highly accurate tracking system for motion compensation between the target area and the optics. During ex vivo experimental evaluation on fresh porcine cochleae, the ablation process terminated automatically when the thickness of the residual tissue layer uniformly reached a predefined value. The shape of the resulting channel bottom converged to the natural curvature of the endosteal layer without injuring the critical structure. Preliminary measurements in OCT scans indicated that the mean absolute accuracy of the shape approximation was only around 20 μm.
    BioMed Research International 09/2014; 2014:251814. DOI:10.1155/2014/251814 · 2.71 Impact Factor
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    ABSTRACT: For multiport image-guided minimally invasive surgery at the lateral skull base a quality management is necessary to avoid the damage of closely spaced critical neurovascular structures. So far there is no standardized method applicable independently from the surgery. Therefore, we adapt a quality management method, the quality gates (QG), which is well established in, for example, the automotive industry and apply it to multiport image-guided minimally invasive surgery. QG divide a process into different sections. Passing between sections can only be achieved if previously defined requirements are fulfilled which secures the process chain. An interdisciplinary team of otosurgeons, computer scientists, and engineers has worked together to define the quality gates and the corresponding criteria that need to be fulfilled before passing each quality gate. In order to evaluate the defined QG and their criteria, the new surgery method was applied with a first prototype at a human skull cadaver model. We show that the QG method can ensure a safe multiport minimally invasive surgical process at the lateral skull base. Therewith, we present an approach towards the standardization of quality assurance of surgical processes.
    BioMed Research International 07/2014; 2014:904803. DOI:10.1155/2014/904803 · 2.71 Impact Factor
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    ABSTRACT: Objective: Minimally invasive procedures minimize iatrogenic tissue damage and lead to a lower complication rate and high patient satisfaction. To date only experimental minimally invasive single-port approaches to the lateral skull base have been attempted. The aim of this study was to verify the feasibility of a minimally invasive multiport approach for advanced manipulation capability and visual control and develop a software tool for preoperative planning. Methods: Anatomical 3D models were extracted from twenty regular temporal bone CT scans. Collision-free trajectories, targeting the internal auditory canal, round window, and petrous apex, were simulated with a specially designed planning software tool. A set of three collision-free trajectories was selected by skull base surgeons concerning the maximization of the distance to critical structures and the angles between the trajectories. Results: A set of three collision-free trajectories could be successfully simulated to the three targets in each temporal bone model without violating critical anatomical structures. Conclusion: A minimally invasive multiport approach to the lateral skull base is feasible. The developed software is the first step for preoperative planning. Further studies will focus on cadaveric and clinical translation.
    BioMed Research International 07/2014; 2014:379295. DOI:10.1155/2014/379295 · 3.17 Impact Factor
  • Julia Kristin · Armin Kolmer · Peter Kraus · Robert Geiger · Thomas Klenzner
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    ABSTRACT: Endoscope holders are utilized by a variety of surgeons but are not commonplace in head and neck surgery. The SOLOASSIST active camera holder, which is currently used for abdominal surgery, will soon be adapted for head and neck surgery in collaboration with AKTORmed GmbH SOLO SURGERY (Barbing, Germany). In our pre-feasibility study, we analyzed the use of the existing endoscope holder on anatomical specimens during head and neck surgery. Based on these results, we are proceeding towards the development of a new endoscope holder for head and neck surgery. First, we drafted the technical concepts and discussed the advantages and disadvantages of the system. Then, we used anatomic specimens to measure the forces that occur intraoperatively during sinus surgery. Next, we designed a computer-aided design (CAD) model. Finally, we developed the first production prototype and used it for a frontal skull base procedure on an anatomical specimen. We present the three most promising concepts for a new holder. The resulting total force (F res = √(X 2 + Y 2 + Z 2)) was calculated to be 3.2 N during sinus surgery. We could observe all necessary intraoperative landmarks with the endoscope and its holder in a sinus and frontal skull base surgery. We developed a production prototype of a new endoscope holder and demonstrate satisfactory results in the use of anatomic specimens for skull base surgery.
    Archives of Oto-Rhino-Laryngology 04/2014; 272(5). DOI:10.1007/s00405-014-3052-0 · 1.55 Impact Factor
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    ABSTRACT: The objective of the study was to determine the temporal occurrence of cochlear obliteration following translabyrinthine vestibular schwannoma resection. A retrospective chart review, cross-sectional study, and sequential analysis of the time series were performed. The retrospective study included patients undergoing translabyrinthine resection for stage T1-T2 vestibular schwannoma from 2007 to 2010 without prior therapy and postoperative follow-up including MRI of the brain and the cerebellopontine angle. Already 3 months after surgery a radiographic labyrinthine change was observed in 66.7 %, a partial obstruction in 50 %, and an obstruction limited to the saccule in 16.7 %. Only 33.3 % of the patients showed an unchanged inner ear. In consideration of early cochlear obstruction after translabyrinthine vestibular schwannoma resection, temporary follow-up is necessary. Since the indications for cochlear implantation (CI) have been extended, especially concerning patients with single-side deafness, a simultaneous or early second-stage CI after tumour removal should be discussed.
    Archives of Oto-Rhino-Laryngology 01/2014; 272(4). DOI:10.1007/s00405-013-2877-2 · 1.55 Impact Factor
  • J Kristin · C Beutner · T Klenzner · F B Knapp
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    ABSTRACT: Granulomatosis with polyangiitis is characterized by vasculitis of small and medium sized vessels and non-caseating granulomas with head and neck symptoms in 95% of those affected. Cranial nerve palsies are rare; while, chronic rhinosinusitis and ear problems are common. We describe the serious course and the diagnostic challenge of a patient with granulomatosis with polyangiitis of bilateral mastoids and the right temporal lobe. Initially, the patient showed metachronous bilateral facial palsy with chronic mastoiditis. Repeated surgeries and rheumatologic examinations did not determine a diagnosis. The patient developed additional cranial nerve palsies. Due to progression into the temporal lobe, we removed the affected parts. After 6 months, the diagnosis was revealed by histology. Granulomatosis with polyangiitis is a diagnostic challenge. Persistent reevaluations were necessary for a final diagnosis and to limit the life-threatening disease. Once diagnosed, therapy began with the standard FAUCI-Scheme.
    B-ENT 01/2014; 10(3):231-5. · 0.08 Impact Factor
  • J Kristin · S E Baldus · J Schipper · T Klenzner
    Laryngo-Rhino-Otologie 12/2013; 93(3). DOI:10.1055/s-0033-1361172 · 0.84 Impact Factor
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    ABSTRACT: Objectives: To investigate the preservation of residual hearing in subjects who received the Nucleus Hybrid L24 cochlear implant. To investigate the performance benefits up to one year post-implantation in terms of speech recognition, sound quality, and quality of life. Design: Prospective, with sequential enrolment and within-subject comparisons. Post-operative performance using a Freedom Hybrid sound processor was compared with that of pre-operative hearing aids. Study sample: Sixty-six adult hearing-impaired subjects with bilateral severe-to-profound high frequency hearing loss. Results: Group median increase in air-conduction thresholds in the implanted ear for test frequencies 125-1000 Hz was < 15 dB across the population; both immediately and one year post-operatively. Eighty-eight percent of subjects used the Hybrid processor at one year post-op. Sixty-five percent of subjects had significant gain in speech recognition in quiet, and 73% in noise (≥ 20 percentage points/2 dB SNR). Mean SSQ subscale scores were significantly improved (+ 1.2, + 1.3, + 1.8 points, p < 0.001), as was mean HUI3 score (+ 0.117, p < 0.01). Combining residual hearing with CI gave 22-26 %age points mean benefit in speech recognition scores over CI alone (p < 0.01). Conclusions: Useful residual hearing was conserved in 88% of subjects. Speech perception was significantly improved over preoperative hearing aids, as was sound quality and quality of life.
    International journal of audiology 09/2013; 52(12). DOI:10.3109/14992027.2013.802032 · 1.84 Impact Factor
  • J Schipper · T K Hoffmann · T Klenzner · M Wagenmann
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    ABSTRACT: Spontaneous rhinoliquorrhea with or without meningo-encephaloceles in the region of the sphenoid sinus occurs very infrequently. It is not uncommon that the attempt of transnasal endoscopic duraplasty in this region leads to recurrence of the CSF leak. The existence of a lateral craniopharyngeal canal can be a possible explanation for these failures.Retrospective analysis of 23 patients with rhinoliquorrhea of different pathogenesis in the region of the frontal and central skull base that were treated with transnasal, video-endoscopic surgical procedures in our department between 2006 and 2011.2 of 23 patients with proven rhinoliquorrhea following a transnasal video endoscopic duraplasty procedure showed a recurrence of the CSF leak. The computertomographic analysis with respect to the current literature indicated the presence of a craniopharyngeal canal at the lateral side of the sphenoid sinus. This canal is also known in the literature as Sternberg's canal. In contrast to the other 21 treated cases there were no planar skull base defects of different pathogenesis in these 2 cases, but a ontogenetically bony canal. The canal can reopen spontaneously or due to an external mechanical impact.The closure of this bony canal requires a modified surgical procedure such as sufficient padding of the bony canal and its sealing by a vascularized pedicle flap in contrast to the ordinary planar bony skull base defects.
    Laryngo-Rhino-Otologie 05/2013; 92(6). DOI:10.1055/s-0033-1334887 · 0.84 Impact Factor
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    ABSTRACT: Optical coherence tomography (OCT) is a promising candidate for monitoring the bottom of the drilled channel during cochleostomy to prevent injury to the critical structure under the bone tissue. While the thickness of the overlaying bone tissue is changed during the drilling process, the wave front of the backscattered light is also altered, resulting in changing speckle patterns of the observed structures in the sequential historical scans. By averaging the different patterns in these scans, named history compounding, the speckles can be reduced and the detection of critical structure becomes much easier. Before averaging, the refractive index of bone tissue 𝑛𝑏 has to be compensated so that the speckles of the same structure in different historical scans can be aligned together. An accurate method for measuring the refractive index nb using OCT is presented. Experiments were conducted to evaluate history compounding and the new technique is proved to be an effective, flexible and intuitive speckle reduction technique for OCT guided cochleostomy as well as hard tissue ablation of other kind.
    Proceedings of SPIE - The International Society for Optical Engineering 01/2013; 8571. DOI:10.1117/12.2006979 · 0.20 Impact Factor
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    ABSTRACT: Lower cranial nerve schwannomas are benign tumors of the neurolemmocytes of the cranial nerves. Among children, cranial nerve schwannomas are extremely rare and are predominantly associated with neurofibromatosis (NF) type 2. The purpose of the current case report is to describe a unique giant extra- and intracranial foramen jugular schwannoma in a young boy with lower cranial nerve deficits and glossopharyngeal neuralgia syncope syndrome and to review the pertinent literature. In the current case report, we illustrate the course of disease in a 14-year-old boy with a 4-month history of recurrent syncope and a big bulge on the left side of his neck. Audiometry showed deafness of the left ear. Magnetic resonance imaging (MRI) demonstrated a giant unilateral dumbbell-shaped intra- and extracranial foramen jugular schwannoma with a volume of 156 cm3 causing severe brain stem compression and obstructive hydrocephalus. The tumor was removed completely in a two-step surgery. The tumor was confirmed during surgery to originate from the glossopharyngeal nerve. The histological examination revealed the characteristic features of a schwannoma. The MRI 3 months after the second surgery confirmed complete tumor removal. The genetic examination for NF was negative. Review of literature showed that dumbbell-shaped lower cranial nerve schwannomas in the childhood population are rare.
    Journal of Neurological Surgery. Part A: Central European Neurosurgery 10/2012; 74(1). DOI:10.1055/s-0032-1324802 · 0.61 Impact Factor
  • J Kristin · D Mucha · J Schipper · T Klenzner
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    ABSTRACT: The aim of this study was to evaluate a new navigation system (Fiagon GmbH) at the lateral skull base. We performed repeated measurements and registrations on titanium screws, which were attached to specific anatomical locations on 5 temporal bone specimens. The focus of the investigation is to determinate the Target Registration Error and a comparison of different registration methods. Use of the navigation system seems to be practicable at the lateral scull base. For a registration strategy with 3 onesided attached Fiducials the Target Registration Error is 0.8 mm on the surface of the mastoid and in the mastoid cavity. The measurements at the inner ear canal showed a mean deviation of greater than 1.6 mm. In the comparison of different registration methods the best results were found for registration on titanium screws attached on both sides of the head, followed by surface registration at the face including laterobasis followed by registration in the mastoid cavity only. The measured values correspond to our clinical expectations and can be used if the existing Target Registration Error is known and respected. An intra-operative imaging may allow the application of titanium screws for navigation (gold standard) within the same general anesthesia during surgery.
    Laryngo-Rhino-Otologie 02/2012; 91(5):306-10. DOI:10.1055/s-0031-1299755 · 0.84 Impact Factor
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    ABSTRACT: Allergic rhinitis symptoms of itching, sneezing, rhinorrhea, and nasal obstruction significantly decrease patients' quality of life. Compared with histamine and leukotriene receptor antagonists, the petasol butenoate complex Ze 339 displays pharmacologically distinct properties. In vitro it inhibits the biosynthesis of leukotrienes and mediator release from activated eosinophils. This study aimed to assess the efficacy and mode of action of Ze 339, desloratadine, and placebo on allergic rhinitis symptoms, nasal airflow, and local mediator levels after unilateral nasal allergen provocation. In this double-blind, randomized, crossover study 18 subjects with allergic rhinitis to grass pollen received Ze 339, desloratadine, and placebo for 5 days before nasal allergen challenge with grass pollen extract. Rhinomanometry, symptom assessment, and local inflammatory mediator measurement were performed during the 24 hours after allergen challenge. With Ze 339, the patient's time to recovery (5.4 ± 1.6 hours) from nasal obstruction after allergen challenge (time for return to 90% of baseline value ± SEM) was significantly shorter than with placebo (9.1 ± 2.3 hours, P = .035) and desloratadine (10.7 ± 2.5 hours, P = .022). Likewise, Ze 339's standardized symptom assessment for nasal obstruction (3.2 ± 1.3 hours) showed significantly faster relief (time for return to baseline value ± SEM compared with placebo, 8.3 ± 2.4 hours; P = .027) and desloratadine (4.5 ± 1.2 hours, P = .030). One interesting finding was that Ze 339 significantly reduced IL-8 and leukotriene B(4) levels in nasal secretions before challenge. When compared with desloratadine and placebo, Ze 339 shows better efficacy in relieving nasal obstruction symptoms and inhibiting critical components of the chemokine network and as such represents a novel symptomatic and possible prophylactic treatment for allergic rhinitis.
    The Journal of allergy and clinical immunology 06/2011; 127(6):1515-21.e6. DOI:10.1016/j.jaci.2011.02.045 · 11.48 Impact Factor
  • J Kristin · R Geiger · F B Knapp · J Schipper · T Klenzner
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    ABSTRACT: It has been shown that a third hand is useful for holding the endoscope during endoscopic surgery so that both hands of the surgeon are free for instrumentation. Experimental tests were performed with the mechatronic robotic camera holding system Soloassist on anatomical specimens in the area of the nose, nasopharynx and larynx. An ergonomic set-up and the practical application are easily possible. The third hand enables a still and clear picture without undesired camera movement and all instruments can be controlled by the surgeon. There would appear to be some room for improvement as the working area is limited due to an additional instrument. The camera holding system shows a very high velocity for head and neck surgery. Until the active holder can be used regularly in clinical practice in the field of head and neck surgery, more technical modifications have to be implemented.
    HNO 06/2011; 59(6):575-81. · 0.58 Impact Factor
  • T Klenzner
    HNO 06/2011; 59(6):568-9. DOI:10.1007/s00106-011-2288-x · 0.58 Impact Factor
  • J. Kristin · R. Geiger · F.B. Knapp · J. Schipper · T. Klenzner
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    ABSTRACT: HintergrundBei der Anwendung endoskopischer Verfahren hat sich gezeigt, dass für die Führung eines Endoskops eine „3.Hand“ wünschenswert ist, um beide Hände zum Instrumentieren zur Verfügung zu haben. Material und MethodeZur Untersuchung, ob ein Einsatz des Kameraführungsarms „Soloassist“ in der Kopf-Hals-Chirurgie möglich ist, wurden Versuche am anatomischen Kopfpräparat im Bereich der Nase, des Nasopharynx und des Larynx durchgeführt und hinsichtlich Machbarkeit sowie Workflow untersucht. ErgebnisDie Verwendung zeigt sich ergonomisch und schnell durchführbar. Die „3.Hand“ ermöglicht ein ruhiges Bild ohne ungewollte Kamerabewegungen, wobei der Operateur alle Instrumente einschließlich des Endoskops führt. Eine Lageänderung des Op.-Tisches wird automatisch auf das System übertragen. Verbesserungswürdig erscheint der zur Verfügung stehende Arbeitsraum, der durch das zusätzliche im Situs befindliche Instrument limitiert ist, und die hohe Geschwindigkeit des Systems für die Kopf-Hals-Chirurgie. SchlussfolgerungDie Anwendung war durchführbar, jedoch müssen vor der routinemäßigen Anwendung in der Kopf-Hals-Chirurgie noch technische Änderungen wie z.B. die Geschwindigkeitsanpassung erfolgen. BackgroundIt has been shown that a third hand is useful for holding the endoscope during endoscopic surgery so that both hands of the surgeon are free for instrumentation. Material and methodsExperimental tests were performed with the mechatronic robotic camera holding system Soloassist on anatomical specimens in the area of the nose, nasopharynx and larynx. ResultsAn ergonomic set-up and the practical application are easily possible. The third hand enables a still and clear picture without undesired camera movement and all instruments can be controlled by the surgeon. There would appear to be some room for improvement as the working area is limited due to an additional instrument. The camera holding system shows a very high velocity for head and neck surgery. ConclusionUntil the active holder can be used regularly in clinical practice in the field of head and neck surgery, more technical modifications have to be implemented. SchlüsselwörterEndoskopisches Operieren–Aktive Kameraführung–Mechatronischer Haltearm–Automatische Endoskopführung–Soloassist KeywordsEndoscopic surgical procedure–Active camera holder–Mechatronic holder–Endoscope guidance–Soloassist
    HNO 06/2011; 59(6):575-581. DOI:10.1007/s00106-011-2273-4 · 0.58 Impact Factor
  • A Aschendorff · T Klenzner · S Arndt · R Beck · C Schild · L Röddiger · W Maier · R Laszig
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    ABSTRACT: The aim of our study was to evaluate results of insertion following cochlear implantation with Contour™ and Contour Advance™ electrode arrays in adult patients and to analyze individual insertion results for three experienced surgeons. We performed a retrospective analysis of postoperative 3D volume tomography results in 223 adult patients. The intracochlear electrode position was evaluated to be in scala tympani, scala vestibuli or with a dislocation from one scala to the other. Surgical methods were analyzed and assigned to the different surgeons. We observed a significant increase for scala tympani insertions from initially 33% to 84% and a reduction in dislocations from scala tympani to scala vestibuli from 71% with the Contour™ electrode to 22% with the Contour Advance™ electrode. Results for the different surgeons varied individually with regard to scala tympani insertion rates and dislocation rates over time. 3D Volume tomography offers an important method for postoperative quality control following cochlear implant surgery. The intracochlear electrode position could be determined in all cases. We were able to identify individual learning curves for insertion results. Controlling the insertion quality serves as a feedback of surgical results and may be helpful for improving surgical quality and thus rehabilitation results.
    HNO 05/2011; 59(5):448-52. DOI:10.1007/s00106-011-2319-7 · 0.58 Impact Factor
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    ABSTRACT: Chondrosarcomas are rare tumors of the head and neck. Nevertheless, they display the most common non-epithelial malignancy of the larynx. Between 1999 and February 2010 we treated six patients with laryngeal chondrosarcoma. The group included two female and four male patients ranging in age from 54 to 82 years. An 82-year-old female patient died 3 months after diagnosis and tracheostomy due to other underlying diseases. An 82-year-old male patient underwent primary radiation therapy. In the other patients, we performed a modified hemilaryngektomy in three cases and a laryngectomy in one. In those four cases, there were no signs of recurrent disease 50, 85, 87 and 95 months after surgery, respectively. There were no local or distant metastases. Chondrosarcomas of the larynx are slow growing neoplasms. Metastases occur in less than 3% of cases. Complete resection is the therapy of choice. Function-preserving surgical approaches should be favoured.
    HNO 04/2011; 59(4):352-9. DOI:10.1007/s00106-010-2243-2 · 0.58 Impact Factor

Publication Stats

814 Citations
99.03 Total Impact Points


  • 2008–2014
    • Universitätsklinikum Düsseldorf
      Düsseldorf, North Rhine-Westphalia, Germany
  • 2007–2014
    • Heinrich-Heine-Universität Düsseldorf
      Düsseldorf, North Rhine-Westphalia, Germany
  • 2004–2007
    • Universitätsklinikum Freiburg
      • Department of Ear, Nose and Throat Medicine
      Freiburg an der Elbe, Lower Saxony, Germany
    • Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e.V.
      Freiburg, Baden-Württemberg, Germany
  • 1999–2007
    • University of Freiburg
      • Department of Pathology
      Freiburg, Baden-Württemberg, Germany
  • 2006
    • Evangelische Hochschule Freiburg, Germany
      Freiburg, Baden-Württemberg, Germany