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Otogenic brain abscess: diagnostic and treatment experience
International Congress Series 1240 (2003) 61 – 65
Otogenic brain abscess: diagnostic and treatment experience D. Djeric *, N. Arsovic, V. Djukic Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, Pasterova St. 2, 11000 Belgrade, Yugoslavia
Abstract The authors report 25 years of experience in diagnosing and treatment of patients with otogenic brain abscesses. The study comprised 42 patients, of whom 28 had cerebral and 14 cerebellar abscesses. Otogenic abscess is usually accompanied by meningitis (45%). Headache and fever usually suggested otogenic intracranial complications. In the middle ear, active chronic otitis with cholesteatoma was commonly present. Inflammatory process usually expanded into the endocranium destroying the middle ear walls. Computerized tomography (CT) is the most reliable way to diagnose brain abscess. The method can help localize abscess, plan the surgery and monitor the postoperative course. Neurological and ophthalmologic examinations are not always sufficient for detection of brain abscess. The authors suggest initial neurosurgical removal of abscess, which after improvement of general condition of the patient should be followed by radical otosurgical removal of the process from the ear. This group of patients is still associated with relatively high mortality: 18% for cerebral and 20% for cerebellar cases. D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. Keywords: Otogenic brain abscesses; Chronic otitis; Diagnosis; Treatment
1. Introduction Otitis media, acute or chronic, is a potentially dangerous disease, which may lead to fatal complications. Although antibiotics have played an important role in treatment of otitis and related complications in the last 45 years, otogenic intracranial complications persist as a difficult problem [1,2,8,9]. Meningitis is the most common intracranial complication, followed by otogenic brain abscesses while thrombosis of the lateral sinus * Corresponding author. Tel.: +381-11-643-694; fax: +381-11-36-14-952. E-mail address: [email protected] (D. Djeric). 0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)00806-9
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is fairly uncommon [3,4]. Mortality of otogenic brain abscesses remains relatively high [3,8,9,11].
2. Aim of the study The aim of the study was to investigate the mechanisms of development, diagnostic methods and treatment of these complications of otogenic brain abscesses.
3. Patients and methods The retrospective study covered 42 patients with otogenic brain abscess (28 cerebral and 14 cerebellar) treated from 1975 through 2000 at the ENT and Neurosurgical Hospitals in Belgrade. Medical records of the studied patients were analyzed for the occurrence of the middle ear inflammation, intracranial infection, diagnosis and mode of therapy.
4. Results During the last 25 years, 114 patients have been treated for otogenic intracranial complications at the Institute of Otorhinolaryngology and Maxillofacial Surgery, Belgrade. Meningitis was the most common complication (45.5%), followed by cerebral abscess (24.4%), cerebellar abscess (13.0%), while thrombosis of the lateral sinus was less common, and extradural and subdural abscesses occurred only exceptionally. In somewhat more than half of the patients (55%), one intracranial complication was present, but in 45% of them two or more intracranial complications were recorded. Meningitis was the most frequent finding in cases of multiple intracranial complications. Otogenic brain abscesses are usually associated with meningitis. Meningitis was present in 20 patients with cerebral abscess (71%), and in five (33%) patients with cerebellar abscess. Meningitis and thrombosis of the lateral sinus were more commonly associated with cerebellar abscess (41%), and less with cerebral abscess (10%). Only in five patients (18%) with cerebral abscess and three patients (26%) with cerebellar abscess was meningitis not associated. In our group of patients otogenic brain abscesses were more common in the third decade of life than in the second, while the frequency of the complication fell significantly in older age groups. Predominant clinical features were headache (92%), fever (91%), vomiting (68%); while vertigo, altered sesorium and photophobia were less common (38 and 30%, respectively). Active chronic otitis with cholesteatoma was most commonly present in patients with otogenic brain abscess, in cerebral abscess (84%) and in cerebellar abscess (80%). The pathological process in the middle ear cavities (cholesteatoma or granulations) was usually very extensive leading to wall destruction. During surgery, a bone destruction was found in 25 out of 28 patients with cerebral abscess and in 13 out of 14 patients with cerebellar
D. Djeric et al. / International Congress Series 1240 (2003) 61–65
63
Table 1 Findings in patients with otogenic brain abscess
Neurological
Abscess Meningitis Not evaluated TOTAL
Ophthalmologic papillary edema Normal Not evaluated TOTAL Radiological computerized tomography Magnetic resonance Arteriography Not studied TOTAL
Cerebrum
Cerebellum
11 15 2 28 16 8 4 28 18 1 7 2 28
7 7 – 14 4 8 2 14 10 – 1 3 14
abscess. In patients with cerebral abscess, the destruction usually occurred on the tympanic tegmen and prominence of the lateral semicircular canal (85%) and rarely on the lateral sinus wall (15%). Neurological examination of 28 patients with cerebral abscess evidenced the abscess in 11, while in 15, these findings suggested meningitis. This examination of patients with cerebellar abscess revealed papillary edema in four, while in eight, the fundus oculi finding was normal (Table 1). The diagnosis of otogenic brain abscess was most commonly established by computerized tomography (CT). It revealed cerebral abscess in 18 out of 28 patients, and cerebellar abscess in 10 out of 14 patients. Magnetic resonance imaging (MR) was used only in one case of cerebral abscess. Arteriography was the diagnostic tool in seven of 28 patient with cerebral and one out of 14 patients with cerebellar abscess. Radiographic diagnostic procedures were not used only exceptionally (Table 1). Radical tympanomastoidectomy was performed in all examined patients. In nine patients, revision surgery was done because the initial operation was not sufficiently Table 2 Mode and outcome of therapy of patients with brain abscess
Mode of treatment
Outcome of therapy
Mortality
Radical tympanomastoidectomy Revised operation Abscess extirpation Abscess drainage TOTAL Cured Died TOTAL Brain abscess Otogenic complications
Cerebrum
Cerebellum
28 7 24 4 28 23 5 28 5/28 (18%) 5/114 (4.4%)
14 2 10 4 14 11 3 14 3/14 (20%) 3/114 (2.6%)
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radical. Radical extirpation of abscess was performed in 24 out of 28 patients with cerebral abscess and in 10 out of 14 with cerebellar abscess. Drainage of the brain abscess was performed rarely (Table 2). Out of 28 patients with cerebral abscess, five (18%) died, while three (29%) died out of 14 patients with cerebellar abscess. The mortality rate was 18% for cerebral and 20% for cerebellar abscesses (the relation to otogenic intracranial complications was 4.4% (5/114) for cerebral and 2.6% (3/114) for cerebellar abscesses) (Table 2).
5. Discussion Otogenic brain abscesses imply accumulation of pus in the cerebrum or cerebellum developing after encephalitis caused by pyogenic microorganisms originating from inflammatory process in the middle ear cavity. This is a serious complication with high mortality. According to the data reported by several authors, introduction of antibiotic therapy resulted in drastic fall of associated mortality. Thus, in the preantibiotic era (1938 – 1950), the mortality was 35% to be substantially decreased to 5.7% between 1950 and 1960 [7]. Arseni [1] presented 386 patients with adjacent cerebral abscesses secondary to otorhinolaryngological infection. The cerebral abscess was most commonly an otogenic (86.5%), and rarely rhinogenic (12.2%) or tonsillary (1.3%). The annual risk of otogenic abscess of the brain is one in 1000 adults with active chronic otitis. The incidence of abscess is significantly higher in certain age groups, i.e. one in 200 between the ages of 20 and 40 [6,8]. It is important to point out that in some cases, young otologists have become less aware of these potentially catastrophic problems. The physician must understand these complications to recognize them quickly and treat them appropriately [10]. The diagnosis of brain abscess established clinically is not quite reliable. The disease is usually associated with severe meningitis, so that neurological examination usually detects only signs of meningitis. The brain abscess results in increased intracranial pressure, which should result in changes on the fundus oculi. However, experience shows that even in cases of brain abscess obstructed papilla need not be seen. The important role of CT in diagnosing of patients who were clinically suspected of having otogenic brain abscess was suggested by Mafee et al. [5]. Brain abscess therapy is conservative and surgical. Conservative therapy is similar to that of otogenic meningitis. Attitudes related to the mode of surgical removal of accumulated pus from the brain and sequence of the procedures (brain– ear). Therapeutic approach to brain abscess cannot be strictly schematized. Each case should be studied individually, and the therapeutic approach depends on surgical experience of the attending surgeon. Both oto- and neurosurgery are required. Accumulated collection of pus should be neurosurgically removed, after which, the primary cause of the infection in the ear should be also surgically extirpated. In deciding on the mode of therapy, the fact that prognosis depends on two factors, whether the infection is acute or chronic, and whether the patient is conscious or not [4,10], has to be considered. Abscess enucleation is the method of choice if certain conditions are fulfilled, but still pointing out that every generalization and schematization may be dangerous. Drainage
D. Djeric et al. / International Congress Series 1240 (2003) 61–65
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procedure should be considered in cases of abscess localized deep in the brain, or in functionally important regions so that the operation would result in major and irreversible neurological deficits or even death. After neurosurgical abscess removal from the brain, when the patient is good enough, ear surgery is undertaken which involves radical removal of chronic inflammation by an open surgery [6].
6. Conclusion Our present experiences have shown that an otogenic brain abscess is significantly more common in cases of chronic otitis with cholesteatoma. Inflammatory process usually extends into the endocranium directly destroying the bony walls of the middle ear. The abscesses occurred most frequently in the second and third decade of life. Clinical examinations, such as neurological and ophthalmologic examinations, are not sufficient for diagnosing brain abscess. CT scanning is the most reliable method for diagnosing brain abscess, determining optimum timing of the surgery and monitoring postoperative course. Out of 28 patients with cerebral abscess, radical-controlled removal was performed in 24, while drainage was performed in four cases. Out of 14 patients with cerebellar abscess, radical removal was performed in 10 and drainage in four cases. The associated mortality is still high: 18% for cerebral and 20% for cerebellar abscesses.
References [1] C. Arseni, A.V. Ciurea, Cerebral abscesses secondary to otorhinolaryngologoc infection. A study of 386 cases, Zentralbl. Neurochir. 49 (1988) 22 – 36. [2] P.J. Bradley, K.P. Manning, M. Shaw, Brain abscess secondary to otitis media, J. Laryngol. Otol. 98 (1984) 1185 – 1191. [3] J. Kangsqhark, N. Navacharoen, S. Fooanant, K. Ruckphaopunt, Intracranial complications of suppurative otitis media; 13 years experience, Am. J. Otol. 16 (1995) 104 – 109. [4] A. Kula, T. Ozatik, I. Topcu, Otogenic intracranial abscesses, Acta Neurochir. (Wien) 107 (1990) 140 – 146. [5] M.F. Mafee, G.E. Valvassori, A. Kumer, B.C. Levin, K.H. Siedentop, S. Roje, Otogenic intracranial inflammation. Role of CT, Otolaryngol. Clin. North Am. 21 (1988) 245 – 263. [6] A.J. Nissen, Intracranial complications of otogenic disease, Am. J. Otol. 2 (1980) 164 – 167. [7] J. Pennybacker, Discussions on intracranial complications of otogenic origin, Proc. R. Soc. Med. 54 (1960) 309 – 317. [8] J. Samuel, C.M. Fernandes, J.L. Steinberg, Intracranial otogenic complications: a persisting problem, Laryngoscope 96 (1986) 272 – 277. [9] B.S. Sharma, V.K. Khosla, V.K. Kak, V.K. Gupta, M.K. Tawari, S.N. Mithurya, A. Pathak, Multiple pyogenic brain abscesses, Acta Neurochir. 133 (1995) 36 – 43. [10] B. Singh, T.D. Maharaj, Radical mastoidectomy: its place in otitic intracranial complications, J. Laryngol. Otol. 107 (1993) 1113 – 1118. [11] A.M. Talyshinskii, Diagnostic evaluation of meningeal syndrome in otogenic intracranial complications and infection, Vestn. Otorinolaringol. 5 (1990) 48 – 52.
Otogenic brain abscess: diagnostic and treatment experience D. Djeric *, N. Arsovic, V. Djukic Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia, Pasterova St. 2, 11000 Belgrade, Yugoslavia
Abstract The authors report 25 years of experience in diagnosing and treatment of patients with otogenic brain abscesses. The study comprised 42 patients, of whom 28 had cerebral and 14 cerebellar abscesses. Otogenic abscess is usually accompanied by meningitis (45%). Headache and fever usually suggested otogenic intracranial complications. In the middle ear, active chronic otitis with cholesteatoma was commonly present. Inflammatory process usually expanded into the endocranium destroying the middle ear walls. Computerized tomography (CT) is the most reliable way to diagnose brain abscess. The method can help localize abscess, plan the surgery and monitor the postoperative course. Neurological and ophthalmologic examinations are not always sufficient for detection of brain abscess. The authors suggest initial neurosurgical removal of abscess, which after improvement of general condition of the patient should be followed by radical otosurgical removal of the process from the ear. This group of patients is still associated with relatively high mortality: 18% for cerebral and 20% for cerebellar cases. D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. Keywords: Otogenic brain abscesses; Chronic otitis; Diagnosis; Treatment
1. Introduction Otitis media, acute or chronic, is a potentially dangerous disease, which may lead to fatal complications. Although antibiotics have played an important role in treatment of otitis and related complications in the last 45 years, otogenic intracranial complications persist as a difficult problem [1,2,8,9]. Meningitis is the most common intracranial complication, followed by otogenic brain abscesses while thrombosis of the lateral sinus * Corresponding author. Tel.: +381-11-643-694; fax: +381-11-36-14-952. E-mail address: [email protected] (D. Djeric). 0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)00806-9
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D. Djeric et al. / International Congress Series 1240 (2003) 61–65
is fairly uncommon [3,4]. Mortality of otogenic brain abscesses remains relatively high [3,8,9,11].
2. Aim of the study The aim of the study was to investigate the mechanisms of development, diagnostic methods and treatment of these complications of otogenic brain abscesses.
3. Patients and methods The retrospective study covered 42 patients with otogenic brain abscess (28 cerebral and 14 cerebellar) treated from 1975 through 2000 at the ENT and Neurosurgical Hospitals in Belgrade. Medical records of the studied patients were analyzed for the occurrence of the middle ear inflammation, intracranial infection, diagnosis and mode of therapy.
4. Results During the last 25 years, 114 patients have been treated for otogenic intracranial complications at the Institute of Otorhinolaryngology and Maxillofacial Surgery, Belgrade. Meningitis was the most common complication (45.5%), followed by cerebral abscess (24.4%), cerebellar abscess (13.0%), while thrombosis of the lateral sinus was less common, and extradural and subdural abscesses occurred only exceptionally. In somewhat more than half of the patients (55%), one intracranial complication was present, but in 45% of them two or more intracranial complications were recorded. Meningitis was the most frequent finding in cases of multiple intracranial complications. Otogenic brain abscesses are usually associated with meningitis. Meningitis was present in 20 patients with cerebral abscess (71%), and in five (33%) patients with cerebellar abscess. Meningitis and thrombosis of the lateral sinus were more commonly associated with cerebellar abscess (41%), and less with cerebral abscess (10%). Only in five patients (18%) with cerebral abscess and three patients (26%) with cerebellar abscess was meningitis not associated. In our group of patients otogenic brain abscesses were more common in the third decade of life than in the second, while the frequency of the complication fell significantly in older age groups. Predominant clinical features were headache (92%), fever (91%), vomiting (68%); while vertigo, altered sesorium and photophobia were less common (38 and 30%, respectively). Active chronic otitis with cholesteatoma was most commonly present in patients with otogenic brain abscess, in cerebral abscess (84%) and in cerebellar abscess (80%). The pathological process in the middle ear cavities (cholesteatoma or granulations) was usually very extensive leading to wall destruction. During surgery, a bone destruction was found in 25 out of 28 patients with cerebral abscess and in 13 out of 14 patients with cerebellar
D. Djeric et al. / International Congress Series 1240 (2003) 61–65
63
Table 1 Findings in patients with otogenic brain abscess
Neurological
Abscess Meningitis Not evaluated TOTAL
Ophthalmologic papillary edema Normal Not evaluated TOTAL Radiological computerized tomography Magnetic resonance Arteriography Not studied TOTAL
Cerebrum
Cerebellum
11 15 2 28 16 8 4 28 18 1 7 2 28
7 7 – 14 4 8 2 14 10 – 1 3 14
abscess. In patients with cerebral abscess, the destruction usually occurred on the tympanic tegmen and prominence of the lateral semicircular canal (85%) and rarely on the lateral sinus wall (15%). Neurological examination of 28 patients with cerebral abscess evidenced the abscess in 11, while in 15, these findings suggested meningitis. This examination of patients with cerebellar abscess revealed papillary edema in four, while in eight, the fundus oculi finding was normal (Table 1). The diagnosis of otogenic brain abscess was most commonly established by computerized tomography (CT). It revealed cerebral abscess in 18 out of 28 patients, and cerebellar abscess in 10 out of 14 patients. Magnetic resonance imaging (MR) was used only in one case of cerebral abscess. Arteriography was the diagnostic tool in seven of 28 patient with cerebral and one out of 14 patients with cerebellar abscess. Radiographic diagnostic procedures were not used only exceptionally (Table 1). Radical tympanomastoidectomy was performed in all examined patients. In nine patients, revision surgery was done because the initial operation was not sufficiently Table 2 Mode and outcome of therapy of patients with brain abscess
Mode of treatment
Outcome of therapy
Mortality
Radical tympanomastoidectomy Revised operation Abscess extirpation Abscess drainage TOTAL Cured Died TOTAL Brain abscess Otogenic complications
Cerebrum
Cerebellum
28 7 24 4 28 23 5 28 5/28 (18%) 5/114 (4.4%)
14 2 10 4 14 11 3 14 3/14 (20%) 3/114 (2.6%)
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D. Djeric et al. / International Congress Series 1240 (2003) 61–65
radical. Radical extirpation of abscess was performed in 24 out of 28 patients with cerebral abscess and in 10 out of 14 with cerebellar abscess. Drainage of the brain abscess was performed rarely (Table 2). Out of 28 patients with cerebral abscess, five (18%) died, while three (29%) died out of 14 patients with cerebellar abscess. The mortality rate was 18% for cerebral and 20% for cerebellar abscesses (the relation to otogenic intracranial complications was 4.4% (5/114) for cerebral and 2.6% (3/114) for cerebellar abscesses) (Table 2).
5. Discussion Otogenic brain abscesses imply accumulation of pus in the cerebrum or cerebellum developing after encephalitis caused by pyogenic microorganisms originating from inflammatory process in the middle ear cavity. This is a serious complication with high mortality. According to the data reported by several authors, introduction of antibiotic therapy resulted in drastic fall of associated mortality. Thus, in the preantibiotic era (1938 – 1950), the mortality was 35% to be substantially decreased to 5.7% between 1950 and 1960 [7]. Arseni [1] presented 386 patients with adjacent cerebral abscesses secondary to otorhinolaryngological infection. The cerebral abscess was most commonly an otogenic (86.5%), and rarely rhinogenic (12.2%) or tonsillary (1.3%). The annual risk of otogenic abscess of the brain is one in 1000 adults with active chronic otitis. The incidence of abscess is significantly higher in certain age groups, i.e. one in 200 between the ages of 20 and 40 [6,8]. It is important to point out that in some cases, young otologists have become less aware of these potentially catastrophic problems. The physician must understand these complications to recognize them quickly and treat them appropriately [10]. The diagnosis of brain abscess established clinically is not quite reliable. The disease is usually associated with severe meningitis, so that neurological examination usually detects only signs of meningitis. The brain abscess results in increased intracranial pressure, which should result in changes on the fundus oculi. However, experience shows that even in cases of brain abscess obstructed papilla need not be seen. The important role of CT in diagnosing of patients who were clinically suspected of having otogenic brain abscess was suggested by Mafee et al. [5]. Brain abscess therapy is conservative and surgical. Conservative therapy is similar to that of otogenic meningitis. Attitudes related to the mode of surgical removal of accumulated pus from the brain and sequence of the procedures (brain– ear). Therapeutic approach to brain abscess cannot be strictly schematized. Each case should be studied individually, and the therapeutic approach depends on surgical experience of the attending surgeon. Both oto- and neurosurgery are required. Accumulated collection of pus should be neurosurgically removed, after which, the primary cause of the infection in the ear should be also surgically extirpated. In deciding on the mode of therapy, the fact that prognosis depends on two factors, whether the infection is acute or chronic, and whether the patient is conscious or not [4,10], has to be considered. Abscess enucleation is the method of choice if certain conditions are fulfilled, but still pointing out that every generalization and schematization may be dangerous. Drainage
D. Djeric et al. / International Congress Series 1240 (2003) 61–65
65
procedure should be considered in cases of abscess localized deep in the brain, or in functionally important regions so that the operation would result in major and irreversible neurological deficits or even death. After neurosurgical abscess removal from the brain, when the patient is good enough, ear surgery is undertaken which involves radical removal of chronic inflammation by an open surgery [6].
6. Conclusion Our present experiences have shown that an otogenic brain abscess is significantly more common in cases of chronic otitis with cholesteatoma. Inflammatory process usually extends into the endocranium directly destroying the bony walls of the middle ear. The abscesses occurred most frequently in the second and third decade of life. Clinical examinations, such as neurological and ophthalmologic examinations, are not sufficient for diagnosing brain abscess. CT scanning is the most reliable method for diagnosing brain abscess, determining optimum timing of the surgery and monitoring postoperative course. Out of 28 patients with cerebral abscess, radical-controlled removal was performed in 24, while drainage was performed in four cases. Out of 14 patients with cerebellar abscess, radical removal was performed in 10 and drainage in four cases. The associated mortality is still high: 18% for cerebral and 20% for cerebellar abscesses.
References [1] C. Arseni, A.V. Ciurea, Cerebral abscesses secondary to otorhinolaryngologoc infection. A study of 386 cases, Zentralbl. Neurochir. 49 (1988) 22 – 36. [2] P.J. Bradley, K.P. Manning, M. Shaw, Brain abscess secondary to otitis media, J. Laryngol. Otol. 98 (1984) 1185 – 1191. [3] J. Kangsqhark, N. Navacharoen, S. Fooanant, K. Ruckphaopunt, Intracranial complications of suppurative otitis media; 13 years experience, Am. J. Otol. 16 (1995) 104 – 109. [4] A. Kula, T. Ozatik, I. Topcu, Otogenic intracranial abscesses, Acta Neurochir. (Wien) 107 (1990) 140 – 146. [5] M.F. Mafee, G.E. Valvassori, A. Kumer, B.C. Levin, K.H. Siedentop, S. Roje, Otogenic intracranial inflammation. Role of CT, Otolaryngol. Clin. North Am. 21 (1988) 245 – 263. [6] A.J. Nissen, Intracranial complications of otogenic disease, Am. J. Otol. 2 (1980) 164 – 167. [7] J. Pennybacker, Discussions on intracranial complications of otogenic origin, Proc. R. Soc. Med. 54 (1960) 309 – 317. [8] J. Samuel, C.M. Fernandes, J.L. Steinberg, Intracranial otogenic complications: a persisting problem, Laryngoscope 96 (1986) 272 – 277. [9] B.S. Sharma, V.K. Khosla, V.K. Kak, V.K. Gupta, M.K. Tawari, S.N. Mithurya, A. Pathak, Multiple pyogenic brain abscesses, Acta Neurochir. 133 (1995) 36 – 43. [10] B. Singh, T.D. Maharaj, Radical mastoidectomy: its place in otitic intracranial complications, J. Laryngol. Otol. 107 (1993) 1113 – 1118. [11] A.M. Talyshinskii, Diagnostic evaluation of meningeal syndrome in otogenic intracranial complications and infection, Vestn. Otorinolaringol. 5 (1990) 48 – 52.