Discrepancy of the subjective perception of the nasal appearance between independent individuals and patients undergoing functional rhinoplasty (fRPL).

PURPOSE: Satisfaction with the nasal appearance is a crucial outcome parameter in functional rhinoplasty (fRPL). The visual analogue scale is a suitable instrument not only for the preoperative patient assessment, but also as a patient-reported outcome measure in fRPL. In this study, we analyzed whether a high discrepancy in the preoperative subjective perception of the nasal appearance between patients and other individuals predicts a lower level of satisfaction with the postoperative result and hence a worse outcome of fRPL. METHODS: Standardized facial pictures of patients (n = 80) who underwent fRPL were taken preoperatively, 3 and 12 months postoperatively. In addition, patients were asked to complete the German version of the Utrecht Outcome Assessment Questionnaire in Aesthetic Rhinoplasty (D-OAR). The standardized facial pictures of the patients were presented to surgeons as well as to examiners without a medical background, and they were asked to evaluate the patients' nasal appearance using the visual analogue scale. RESULTS: The external evaluation of patient's nasal appearance was 1.7 points higher in median than the patient's subjective perception (range -5.7-7.00). A large discrepancy between self- and external estimation significantly correlates with higher D-OAR values (r = 0.539, p < 0.001). Patients with high scores in the D-OAR trick questions, indicating a body dysmorphic disorder, show a significant larger discrepancy between the external- and the self-assessment (2.8 ± 0.5 vs. 1.4 ± 0.3, mean ± SEM, p = 0.017). CONCLUSIONS: Large discrepancies between the self and external assessment of the nasal appearance are associated with a high-perceived influence of the appearance of the nose on the quality of life in patients undergoing functional rhinoplasty. That might be an indicator for unrealistic expectations concerning the postoperative outcome. Knowledge about this factor helps to identify the need for intensive discussion about possibilities and limitations of the planned procedure to avoid postoperative dissatisfaction.

Anamnesis as a Prognostic Factor in Cochlear Implantation in Adults.

INTRODUCTION: This study aims to analyze possible preoperative factors taken from the medical history that may assist the otolaryngologist in counseling an adult patient before cochlear implantation (CI). OBJECTIVE: Analysis of preoperative factors taken during the initial patient presentation for a possible prognostic role in the auditory rehabilitation outcome. METHODS: A cohort of 232 (272 CI implantations) postlingually deafened adults was evaluated in this study. Hearing results at 1, 2, and up to 3 years postoperatively were compared with various preoperative factors: living status, cause of deafness, gender, side of implantation, residual hearing, and duration of deafness. Postoperative hearing performance was measured based on the German Freiburg monosyllabic word test and the Oldenburg sentence test. RESULTS: Duration of deafness showed a negative correlation to word recognition and a positive correlation to increased speech reception threshold in sentence testing. A significant decline in hearing outcome was shown starting around the second decade of deafness. Residual hearing as defined in our cohort and side of implantation showed limited benefit in speech understanding. Living status, gender, and cause of deafness did not show any prognostic value. CONCLUSION: In this retrospective review it could be shown that simple case history information can only provide limited prognostic insight before CI. The duration of deafness is the most reliable anamnestic factor present on initial patient evaluation.

Prognostic factors in cochlear implantation in adults: Determining central process integrity.

The purpose of this study is to examine various preoperative factors that can play a role in the auditory rehabilitation outcome of cochlear implant (CI) recipients. In order to determine the level of integrity of central processing preoperatively, special attention was given to residual hearing, duration of deafness, and cochlear nerve diameter as prognostic factors. A cohort of 232 (272 CI implantations) postlingually deafened adults was evaluated in this study. Hearing results at 1, 2 and up to 3 years postoperatively were compared with various preoperative factors: promontory stimulation testing, residual hearing, duration of deafness, and magnetic resonance imaging of the cochlear nerve. Postoperative hearing performance was measured based on the German Freiburg monosyllabic word test and the Oldenburg sentence test. Postoperative hearing performance showed a significant improvement in each consecutive year after implantation. Duration of deafness showed a negative correlation to word recognition and a positive correlation to increased signal-to-noise-ratio in sentence testing. A significant decline in hearing outcome was shown starting around the second decade of deafness corresponding to 66% of life spent in deafness. MR imaging of cochlear nerve diameter shows a positive correlation of larger nerve diameter to better speech understanding. Promontory stimulation testing did not show any prognostic value. In this retrospective review it could be shown that there is an intricate interaction in the preoperative variables: duration of deafness - as well as the ratio of life spent in deafness; residual hearing; and cochlear nerve diameter.

Influence of the Subjective Body Image on the Outcome of Functional Rhinoplasty.

Improvement of nasal breathing is considered to be the major aspect of functional rhinoplasty (fRPL). Nevertheless, simultaneous aesthetic modifications can be required to achieve sufficient functional enhancement. Thus, the aim of this study was to assess the influence of the subjective perception of the nasal appearance on the outcome of fRPL. Patients undergoing fRPL were asked to complete the German version of the Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty (D-OAR) preoperatively, 1, 3 and 12 months after surgery. The patients' satisfaction with the procedure's result was determined using a five-point Likert scale 1, 3 and 12 months after rhinoplasty. In total, 87 patients (42 males and 45 females) with a median age of 25 years undergoing fRPL were included in this study. Compared to males, females showed diminished VAS scores (4.03 ± 2.02 vs 2.71 ± 1.96, p = 0.006) and higher D-OAR scores during preoperative outpatient consultation (13.34 ± 5.00 vs 16.07 ± 5.62, p = 0.020). An increase in the VAS score and a decrease in the D-OAR score were observed independent of gender post-operatively. Significant correlations between the patients' satisfaction and the D-OAR score at each time point of assessment were demonstrated, whereas no significant correlation between the post-operative patients' satisfaction and the initial D-OAR score could be identified. These results demonstrate the importance of body image and the subjective perception of the nasal appearance in particular in patients undergoing fRPL which should be taken into consideration of surgeons preoperatively. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Adaption and validation of the nasal obstruction symptom evaluation scale in German language (D-NOSE).

BACKGROUND: Questionnaires have proven their worth in detecting changes in quality of life after medical interventions. The Nasal Obstruction Symptom Evaluation scale (NOSE) is a reliable and valid tool to identify restrictions of quality of life in patients with nasal problems. The aim of this prospective study was the validation of the German version of the NOSE scale (D-NOSE). METHODS: Adaption of the NOSE in German language was performed by forward and backward translation process. Patients undergoing functional septorhinoplasty were asked to complete the D-NOSE preoperatively, one, three or twelve months after surgery. Healthy volunteers served as controls. Reliability, validity and responsiveness of the D-NOSE were determined. RESULTS: The D-NOSE showed a good internal consistency as well as good inter-item, item-total correlation and a satisfactory test-retest reliability. The convincing validity of the adapted NOSE scale was approved by good construct validity and an excellent discriminant validity. Furthermore, a high sensitivity to identify clinical changes due to an intervention indicates a good responsiveness of the D-NOSE. CONCLUSIONS: The adapted German version of the NOSE questionnaire (D-NOSE) is an appropriate and validated tool to assess the influence of nasal obstruction in quality of life in German speaking patients.

Development and Validation of a Brief Four-Component Questionnaire to Identify Patient's Motivation to Undergo Functional Rhinoplasty.

Outcome of functional rhinoplasty depends on different domains such as functional and aesthetic improvement. The aim of this study was to develop a brief and comprehensible questionnaire to identify patient motivation to undergo rhinoplasty and to measure the outcome of an intervention within a short time during outpatient consultation. Patients undergoing rhinoplasty were asked to complete the Rhinoplasty Outcome Evaluation (ROE) questionnaire, the Nasal Obstruction Symptom Evaluation (NOSE) scale, and the Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty (OAR) preoperatively, as well as one, three, and twelve months postoperatively. Patient satisfaction after surgery was assessed at postoperative consultations using a five-point Likert scale. Principle component analysis was performed to reveal the main domains, which were detected by the different questionnaires. Items with the strongest loading on a factor were identified by correlation matrix. Influence of the nasal appearance on the quality of life, troubles with nasal breathing, subjective perception of nasal appearance, and the wish for modification or alteration were found to be the four important domains of the questionnaires. The questions with the strongest loading on these domains were compiled and the four-component questionnaire (4CQ) was developed. The 4CQ is a very effective instrument to obtain a comprehensive impression of the varied determinants representing the major motifs to undergo functional rhinoplasty within a short time. The preoperative assessment of the 4CQ allows an estimation concerning the expected outcome.

Predictors of hearing recovery in patients with severe sudden sensorineural hearing loss.

BACKGROUND: Sudden sensorineural hearing loss (SSHL) is a disease, which severely affects the patient's social and relational life. The underlying pathomechanisms have not been finally clarified yet and outcome is not predictable. METHODS: We conducted a retrospective study in order to identify parameters that influence hearing recovery. The data base contains results of basic otoneurological tests and clinical parameters of 198 patients with idiopathic SSHL of at least 60 dB in at least four frequencies, diagnosed and treated at the University Hospital of Münster, Germany, between 1999 and 2015. Hearing recovery was measured by pure tone audiometry. RESULTS: Multivariate linear and logistic regression analyses indicate that the chance as well as the magnitude of hearing recovery is higher for patients with normal caloric testing than for patients with pathological caloric testing. However, for the subgroup of patients who attained a hearing recovery, the caloric testing result was not found to influence the magnitude. Instead, the magnitude was noticeably lower for patients within this subgroup who had a previous hearing loss. Furthermore, we found indications that the magnitude is higher for men than for women and that receiving a high-dose steroid therapy is associated with a higher chance and magnitude of a hearing recovery. CONCLUSIONS: We conclude that SSHL associated with disorders of the vestibular system or previous hearing loss represent special sub-entities of SSHL that may be caused by unique pathophysiological mechanisms and are associated with worse outcome. Furthermore, our data support the importance of elevated dosage of steroids in SSHL therapy.

Cochlear Implantation in the Elderly: Does Age Matter?

OBJECTIVE: To compare the outcome of hearing rehabilitation in younger versus older adult cochlear implant recipients. Analysis of surgical and postoperative complications, as well as the number of auditory therapy sessions in the two age groups. STUDY DESIGN: Individual retrospective cohort study. METHODS: A cohort of 145 postlingually deafened adults was evaluated in this study. The patients were divided into two age groups based on the age at implantation: Group I, 18 to 69 years; and Group II, 70 and older. Postoperative hearing performance was measured based on the German Freiburg monosyllabic word test (FM) and the Oldenburg sentence test (OLSA). RESULTS: Postoperative hearing evaluation results in both groups plateaued and remained constant after 12 months of implantation. The results remained constant at the 2 and 3-year time intervals. There was a significant difference in complications arising after cochlear implantation. Group II showed more cases of vertigo and dysgeusia. The number of auditory therapy sessions in both groups was similar. CONCLUSION: Cochlear implantation in the elderly is highly effective; the postoperative hearing performance is at the same level as younger adult recipients. Complex hearing tasks, such as hearing in background noise, requires an equally long time for comprehension. The recovery period of vestibular dysfunction after surgery may be longer in the elderly. Auditory therapy rehabilitation is not more time consuming in the elderly compared with the younger counterparts.

Association Between Facial Nerve Monitoring With Postoperative Facial Paralysis in Parotidectomy.

IMPORTANCE: Electrophysiologic facial nerve monitoring is becoming an established intraoperative aid to assist the surgeon in facial nerve trunk or branch location and dissection. Limited studies have addressed the postoperative outcomes of parotid surgery with and without monitoring. OBJECTIVE: To examine the influence of intraoperative facial nerve monitoring on postoperative facial nerve function and procedure duration in parotid surgery. DESIGN, SETTING, AND PARTICIPANTS: An 8-year retrospective review of parotidectomies performed at the Department of Otorhinolaryngology-Head and Neck Surgery, University of Münster. The study analyzed 120 patients undergoing parotidectomy without monitoring from January 1, 1988, to December 31, 1991, and 147 patients undergoing parotidectomy with monitoring from January 1, 2003, to December 31, 2006. The patients were further subdivided in partial parotidectomy (PP) (n = 222) and total parotidectomy (TP) (n = 45) groups. An evaluation of operative time was performed to test the hypothesis of shorter duration of surgery with facial nerve monitoring. Final follow-up was completed on December 31, 2008, and data were analyzed from June 1 to December 31, 2013. MAIN OUTCOMES AND MEASURES: Comparison of the incidence of facial nerve dysfunction and operative time between the PP and TP subgroups with and without monitoring. RESULTS: A total of 267 patients (127 men [47.6%] and 140 women [52.4%]; mean [SD] age, 51.3 [17.6] years; range, 3-90 years) were included in the analysis. A significant reduction in postoperative facial nerve dysfunction with the use of nerve monitoring could be seen in the PP group (46 of 99 without monitoring [46.5%] vs 18 of 123 with monitoring [14.6%]; P = .001). A similar finding was evident in the TP group when comparing moderate and severe nerve dysfunction (9 of 21 without monitoring [42.9%] vs 2 of 24 with monitoring [8.3%]; P = .01). The mean (SD) operative time in the PP subgroup without nerve monitoring was 115.3 (37.8) minutes; with nerve monitoring, 110.1 (33.6) minutes. The mean (SD) operative time in the TP subgroup without nerve monitoring was 134.5 (50.4) minutes; with nerve monitoring, 158.3 (56.3) minutes. There was no statistical difference between these groups. CONCLUSIONS AND RELEVANCE: Facial nerve monitoring in primary parotid surgery for benign and malignant disease does not necessarily reduce the operative time, but the rate of transient postoperative facial nerve dysfunction or the grade of palsy is reduced.

Outcome measures in stapes surgery: postoperative results are independent from preoperative parameters.

The aim of this study was to compare audiometric results before and after stapes surgery and identify potential prognostic factors to appropriately select patients with otosclerosis who will most likely benefit from surgery. We enrolled 126 patients with otosclerosis (162 consecutive ears) in our study who underwent stapes surgery between 2007 and 2012 at our institution. Preoperative and postoperative data including pure-tone audiometry, speech audiometry, stapedial reflex audiometry and surgical data were analyzed. The average preoperative air-bone gap (ABG) was 28.9 ± 8.6 dB. Male patients and patients older than 45 years of age had greater preoperative ABGs in comparison to females and younger patients. Postoperative ABGs were 11.2 ± 7.4 dB. The average ABG gain was 17.7 ± 11.1 dB. Preoperative audiometric data, age, gender and type of surgery did not influence the postoperative results. Stapes surgery offers predictable results independent from disease progression or patient-related factors. While absolute values of hearing improvement are instrumental in reflecting audiometric results of a cohort, relative values better reflect individual's audiometric data resembling the patient's benefit.

Clinicopathological characteristics of carcinoma from unknown primary in cervical lymph nodes.

Carcinoma in cervical lymph nodes of unknown origin represents a rare clinical entity where optimal diagnostic and therapeutic management is still a widely debated issue. Molecular classification of these metastases is thus of utmost importance. We analyzed the expression of eight basic molecular markers in 26 metastases from unknown primaries, 31 metastases from overt primaries and their associated primaries. Medical records of the respective patients were reviewed for main clinicopathological parameters. The expression rates showed no significant differences between the two tumor entities, neither in absolute terms nor in comparison among the parameters. Surprisingly, patients with metastases from unknown primary demonstrated improved progression-free survival (p = 0.046) despite advanced age (p = 0.029), advanced nodal stage (p = 0.006) and higher incidence of extracapsular spread (p = 0.045) compared to patients with metastases from overt primaries. Presence of extracapsular spread was associated with increased expression of epidermal growth factor receptor in metastases from overt primaries (p = 0.035) and reduced expression of matrix metalloproteinase-2 in metastases from unknown primary (p = 0.031). We thus conclude that cervical metastases from unknown and overt primaries show similarities in their molecular profile, but fundamental differences in clinical parameter.