Laryngeale Obstruktion bei therapieresistenter obstruktiver Schlafapnoe

Zusammenfassung

Die obstruktive Schlafapnoe (OSA) ist durch eine Verlegung des oberen Atemwegs im Schlaf gekennzeichnet; am häufigsten verschließt sich der Atemweg auf Höhe des Weichgaumens bzw. des Oropharynx. Obstruktionen auf laryngealer Ebene sind deutlich seltener, sie können jedoch zu einer therapieresistenten nächtlichen Atemwegsobstruktion führen (laryngeale OSA). Die Diagnose der laryngealen OSA wird im Rahmen einer medikamentös induzierten Schlafendoskopie (MISE) gestellt; die Therapie besteht aus einer Teilresektion der Epiglottis. Präsentiert wird der Fall eines 66-jährigen männlichen Patienten mit schwergradiger OSA, bei dem eine konservative Therapie mithilfe des „continuous positive airway pressure" (CPAP) auch unter Ausschöpfung aller technischen Möglichkeiten nicht erfolgreich war. Die respiratorischen Ereignisse ließen sich nicht vollständig beseitigen, und die Therapie wurde vom Patienten nicht toleriert. Unter dem Verdacht auf eine laryngeale OSA wurde eine MISE durchgeführt. Hierbei zeigte sich eine Obstruktion auf Ebene des hyperplastischen Zungengrundes mit einer konsekutiven Dorsalverlagerung der Epiglottis, die bei Inspiration auf den Kehlkopfeingang angesaugt wurde. Bei passiver Vorverlagerung des Unterkiefers (Esmarch-Manöver) richtete sich die Epiglottis auf, und die laryngeale Obstruktion war beseitigt. Aufgrund der Antikoagulation mit Rivaroxaban wurde von einer operativen Therapie abgesehen, und es ergab sich die Indikation zur Therapie mit einer Unterkieferprotrusionsschiene (UPS). Mithilfe einer laborgefertigten UP-Testschiene mit ca. 70 %igem Vorschub konnte bereits eine Reduktion der respiratorischen Ereignisse erzielt werden. Durch die Kombination mit einer CPAP-Therapie war die komplette Beseitigung der Atmungspausen festzustellen. Der dargestellte Fall zeigt, dass eine laryngeale Obstruktion bei therapieresistenter OSA als Auslöser in Betracht gezogen werden sollte. Eine MISE bestätigt in solchen Fällen die Diagnose. Die Versorgung mithilfe einer UPS kann eine Alternative zur chirurgischen Therapie darstellen, und eine Kombinationstherapie kann in zunächst therapieresistenten Fällen eine Lösung herbeiführen.

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Erratum to: The laminar organization of the motor cortex in monodactylous mammals: a comparative assessment based on horse, chimpanzee, and macaque

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Metabolomics and neuroanatomical evaluation of post-mortem changes in the hippocampus

Abstract

Understanding the human brain is the ultimate goal in neuroscience, but this is extremely challenging in part due to the fact that brain tissue obtained from autopsy is practically the only source of normal brain tissue and also since changes at different levels of biological organization (genetic, molecular, biochemical, anatomical) occur after death due to multiple mechanisms. Here we used metabolomic and anatomical techniques to study the possible relationship between post-mortem time (PT)-induced changes that may occur at both the metabolomics and anatomical levels in the same brains. Our experiments have mainly focused on the hippocampus of the mouse. We found significant metabolomic changes at 2 h PT, whereas the integrity of neurons and glia, at the anatomical/ neurochemical level, was not significantly altered during the first 5 h PT for the majority of histological markers.

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Modulation of APOE and SORL1 genes on hippocampal functional connectivity in healthy young adults

Abstract

Apolipoprotein E (APOE) and sortilin-related receptor (SORL1) genes act on the same metabolic pathway and have been associated with Alzheimer's disease (AD) characterized by hippocampal impairment. Although the effects of APOE on hippocampal resting-state functional connectivity (rsFC) have been reported, the main effects of SORL1 and SORL1 × APOE interactions on hippocampal rsFC in healthy subjects remain largely unknown. Here, we systematically investigated the main effects of SORL1 rs2070045, and APOE, and their interaction effects on hippocampal rsFC in healthy young adults. The main effect of APOE showed that risk ε4 carriers had decreased positive hippocampal rsFC with the precuneus/posterior cingulate cortex and subgenual anterior cingulate cortex, and increased positive hippocampal rsFC with the sensorimotor cortex compared with non-ε4 carriers. The main effect of SORL1 showed that risk G-allele carriers had decreased positive rsFC between the hippocampus and middle temporal gyrus compared with TT carriers. No significant additive interaction was observed. Instead, significant SORL1 × APOE non-additive interaction was found in negative rsFC between the hippocampus and inferior frontal gyrus. Compared with subjects with TT genotype, SORL1 G-allele carriers had a stronger negative rsFC in APOE ε4 carriers, but a weaker negative rsFC in APOE non-ε4 carriers. These findings suggest that SORL1 and APOE genes modulate different hippocampal rsFCs and have a complex interaction. The SORL1- and APOE-dependent hippocampal connectivity changes may at least partly account for their association with AD.

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Effects of aging on $$T_{1}$$ T 1 , $$T_{2}^{*}$$ T 2 ∗ , and QSM MRI values in the subcortex

Abstract

The aging brain undergoes several anatomical changes that can be measured with Magnetic Resonance Imaging (MRI). Early studies using lower field strengths have assessed changes in tissue properties mainly qualitatively, using \(T_{1}\) - or \(T_{2}^{*}\) - weighted images to provide image contrast. With the development of higher field strengths (7 T and above) and more advanced MRI contrasts, quantitative measures can be acquired even of small subcortical structures. This study investigates volumetric, spatial, and quantitative MRI parameter changes associated with healthy aging in a range of subcortical nuclei, including the basal ganglia, red nucleus, and the periaqueductal grey. The results show that aging has a heterogenous effects across regions. Across the subcortical areas an increase of \(T_{1}\) values is observed, most likely indicating a loss of myelin. Only for a number of areas, a decrease of \(T_{2}^{*}\) and increase of QSM is found, indicating an increase of iron. Aging also results in a location shift for a number of structures indicating the need for visualization of the anatomy of individual brains.

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Non-neurogenic SVZ-like niche in dolphins, mammals devoid of olfaction

Abstract

Adult neurogenesis has been implicated in brain plasticity and brain repair. In mammals, it is mostly restricted to specific brain regions and specific physiological functions. The function and evolutionary history of mammalian adult neurogenesis has been elusive so far. The largest neurogenic site in mammals (subventricular zone, SVZ) generates neurons destined to populate the olfactory bulb. The SVZ neurogenic activity appears to be related to the dependence of the species on olfaction since it occurs at high rates throughout life in animals strongly dependent on this function for their survival. Indeed, it dramatically decreases in humans, who do not depend so much on it. This study investigates whether the SVZ neurogenic site exists in mammals devoid of olfaction and olfactory brain structures, such as dolphins. Our results demonstate that a small SVZ-like region persists in these aquatic mammals. However, this region seems to have lost its neurogenic capabilities since neonatal stages. In addition, instead of the typical newly generated neuroblasts, some mature neurons were observed in the dolphin SVZ. Since cetaceans evolved from terrestrial ancestors, non-neurogenic SVZ may indicate extinction of adult neurogenesis in the absence of olfactory function, with the retention of an SVZ-like anatomical region either vestigial or of still unknown role.

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Mtss1 promotes maturation and maintenance of cerebellar neurons via splice variant-specific effects

Abstract

Efficient coupling of the actin cytoskeleton to the cell membrane is crucial for histogenesis and maintenance of the nervous system. At this critical interface, BAR (Bin–Amphiphysin–Rvs) proteins regulate membrane bending, shown to be instrumental for mobility and morphogenesis of individual cells. Yet, the systemic significance of these proteins remains largely unexplored. Here, we probe the role of a prominent member of this protein family, the inverse-BAR protein Mtss1, for the development and function of a paradigmatic neuronal circuit, the cerebellar cortex. Mtss1-null mice show granule cell ectopias, dysmorphic Purkinje cells, malformed axons, and a protracted neurodegeneration entailing age-dependent motor deficits. In postmitotic granule cells, which transiently express Mtss1 while they migrate and form neurites, Mtss1 impinges on directional persistence and neuritogenesis. The latter effect can be specifically attributed to its exon 12a splice variant. Targeted re-expression of Mtss1 in Mtss1-null animals indicated that these pathologies were largely due to cell type-specific and intrinsic effects. Together, our results provide a mechanistic perspective on Mtss1 function for brain development and degeneration and relate it to structural features of this protein.

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Blocking effects in non-conditioned goal-directed behaviour

Abstract

A great deal of our goal-directed behaviour depends on stimulus–response (S–R) associations, which can be established through conditioning or explicit instructions. For conditioned and reward maximizing behaviour, it has been shown that redundant information will no longer be taken into account once those associations have been formed ("blocking effect"). Following from this, new aspects will not be included in a pre-established association unless they improve behaviour. Opposing this, influential action control theories state that all kinds of information may be taken into account during action selection, thus denying the possibility of blocking redundant "surplus" information from non-conditioned goal-directed behaviour. We probed these contradicting predictions by asking two groups of healthy young adults to perform a redundant and a non-redundant version of a stop-change task in a counter-balanced order. Using behavioural and electrophysiological data, we demonstrate that contradicting current theories, blocking seems to be a general mechanism which also applies to non-conditioned goal-directed behaviour. Specifically, we show that the complexity of response selection processes associated with medial frontal cortical activity is altered by blocking. This was reflected by faster responses and smaller central P3 amplitudes originating in the ACC (BA24/BA32). Preceding attentional processes were not affected. Contradicting current views, our ability to ignore information that hampers an expedient unfolding of goal-directed behaviour is quite limited. Prior experiences have a much larger influence on which input we consider for response formation. This offers a functional explanation for why it can be hard to alter (inefficient) behaviour once it has been established.

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Aus der Gutachtenpraxis: Was der medizinische Gutachter über technische Akustik und Lärmmesstechnik wissen sollte

Laryngo-Rhino-Otol 2017; 96: 478-484
DOI: 10.1055/s-0043-104094

© Georg Thieme Verlag KG Stuttgart · New York

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Singultus – Diagnostik und Therapie

Laryngo-Rhino-Otol 2017; 96: 446-455
DOI: 10.1055/s-0043-104086

Der Schluckauf (Singultus) ist ein reflektorischer Bewegungsablauf mit diffus im Thorax verteilten Afferenzen und Efferenzen und kontrovers diskutierter funktioneller Relevanz. In seiner physiologischen Form handelt es sich um eine meist spontan sistierende Bagatellbeschwerde, die nur selten zum Arztkontakt führt. Ein anhaltender quälender Singultus kann jedoch zu einer erheblichen Beeinträchtigung der Lebensqualtiät führen. Ein solcher chronischer Singultus wird im Allgemeinen durch eine Dauer von mehr als 48 h definiert. Häufigste zugrundeliegende Erkrankung ist der gastroösophageale Reflux. Die weiteren Ursachen für einen chronischen Singultus sind vielfältig und betreffen multiple Organsysteme mit zum Teil schwerwiegenden Grunderkrankungen. In einigen Fällen können sich auch neurologische Erkrankungen mit einem Schluckauf präsentieren, zum Teil ist er sogar das einzige Symptom im Rahmen der Erstmanifestation. In der zerebralen Bildgebung findet sich dann häufig eine Läsion der Medulla oblongata. Eine Neuromyelitis optica und ein ischämischer Hirninfarkt mit Wallenbergsyndrom sind 2 häufigere zugrundeliegende neurologische Erkrankungen, aber auch andere entzündliche und vaskuläre Erkrankungen und Tumorerkrankungen des zentralen Nervensystems sind beschrieben. Für ein optimales evidenzbasiertes Management der Diagnostik und Therapie des chronischen Singultus gibt es keine hinreichenden Daten. Die Suche nach der Grunderkrankung erfordert oft ein interdisziplinäres Vorgehen von Internisten, Neurologen und HNO-Ärzten. Bereits vor Abschluss der Diagnostik oder bei nicht behebbarer Ursache kann eine symptomatische Therapie erforderlich sein. Der anhaltende Schluckauf stellt auch ein häufiges Problem in der onkologischen Palliativversorgung dar. Die medikamentöse Therapie des Singultus ist oft diffizil. Protonenpumpenhemmer oder Prokinetika bei gastroösophagealer Ursache bzw. Baclofen mit oder ohne Gabapentin bei anderer Ursache gehören dabei zu den Mitteln der ersten Wahl. Weitere Alternativen sind andere Antikonvulsiva, Neuroleptika, Antidepressiva und Kalziumantagonisten. Für den therapierefraktären Verlauf stehen grundsätzlich auch invasive Verfahren wie z. B. die selektive Phrenicusblockade zur Verfügung. Insgesamt wären mehr Studien zum Singultus wünschenswert, um der therapeutischen und diagnostischen Herausforderung gerecht zu werden, die dieses Symptom für Neurologen darstellen kann.
[...]

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Leserbrief von Prof. Dr. med. Dr. med. dent. Dr. h. c. Ralf Siegert

Laryngo-Rhino-Otol 2017; 96: 440-441
DOI: 10.1055/s-0043-103502

© Georg Thieme Verlag KG Stuttgart · New York

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Fragen für die Facharztprüfung

Laryngo-Rhino-Otol 2017; 96: 497-498
DOI: 10.1055/s-0043-104095

© Georg Thieme Verlag KG Stuttgart · New York

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Antwort auf den Leserbrief

Laryngo-Rhino-Otol 2017; 96: 441-442
DOI: 10.1055/s-0037-1606176

© Georg Thieme Verlag KG Stuttgart · New York

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Einlage eines tracheobronchialen Bifurkationsstents zur Behandlung ­malignombedingter tracheobronchialer Stenosen und Fisteln

Laryngo-Rhino-Otol 2017; 96: 443-444
DOI: 10.1055/s-0043-104092

© Georg Thieme Verlag KG Stuttgart · New York

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Laryngopharyngeale Refluxerkrankung (LPRD) bei Kindern

Laryngo-Rhino-Otol 2017; 96: 485-496
DOI: 10.1055/s-0043-109188

Zwischen 5 und 20 % aller Kinder leiden an einer gastroösophagealen Refluxerkrankung (GERD), die zu Erosionen, Ulzera und Metaplasien der Ösophagusschleimhaut führen kann. Überwindet der Mageninhalt in pathologischer Häufigkeit und Intensität auch den kindlichen oberen Ösophagussphinkter, liegt eine laryngopharyngeale Refluxerkrankung (LPRD) vor. Die mit einer kindlichen LPRD assoziierten Symptome und Folgeerkrankungen sind äußerst vielfältig.LPRD in children is characterized by symptoms, clinical findings, and sequelae caused by the reflux of gastric acid, bile acid or refluxate containing pepsin beyond the esophagus. For diagnostic procedures and therapy of gastroesophageal reflux disease (GERD) in children and adults widely accepted guidelines have been established. However, diagnosis and therapy of LPRD in children remains a continuous issue of inter- and intradisciplinary discussions. Although both GERD and LPRD in children are reflux-induced diseases, these two entities are different in symptoms, cause, diagnostic procedures, and therapy. Thus, the terms GERD and LPRD are not eligible to be used as synonyms.Otorhinolaryngologists are becoming more and more involved in the management of children with suspicious LPRD. With flexible transnasal laryngopharyngoscopy being one of the most important diagnostic tools for LPRD detection, otorhinolaryngologists play an important role in the interdisciplinary diagnostic network of physicians treating children with suspected LPRD. The present article highlights age-dependent clinical symptoms, diagnostic tools, differential diagnoses, and adequate therapy for pediatric LPRD.
[...]

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Chirurgie der inneren Nase

Laryngo-Rhino-Otol 2017; 96: 499-502
DOI: 10.1055/s-0043-104090

© Georg Thieme Verlag KG Stuttgart · New York

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Targeted radiotherapy limits side effects of breast cancer treatment

Breast cancer patients who have radiotherapy targeted at the original tumour site experience fewer side effects five years after treatment than those who have whole breast radiotherapy, and their cancer is just as unlikely to return, according to trial...

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'This is our journey:' Melissa Bishop and her ailing coach race on toward their goals - National Post

National Post

'This is our journey:' Melissa Bishop and her ailing coach race on toward their goals National Post Janet said it sometimes feels like they've been dealt a bad hand, since Fairall had beaten cancer of the larynx just prior to the London Olympics. "It seemed like we'd just overcome a hurdle and we got hammered back down again," Janet said. "For me ... and more »

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A comparative assessment of antiproliferative properties of resveratrol and ethanol leaf extract of Anogeissus leiocarpus (DC) Guill and Perr against HepG2 hepatocarcinoma cells

Epidemiological and experimental evidences have shown cancer as a leading cause of death worldwide. Although the folklore use of plants as a reliable source of health-restoring principles is well-documented, t...

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Erratum to: Severely deranged vital signs as triggers for acute treatment modifications on an intensive care unit in a low-income country

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