Toward the development of a supported employment program for individuals with high-functioning autism in Germany.

Human-human interactions are of central relevance for the success in professional and occupational environments, which also substantially influence quality of life. This is especially true in the case of individuals with high-functioning autism (HFA), who experience deficits in social cognition that often lead to social exclusion and unemployment. Despite good education and high motivation, individuals with HFA do not reach employment rates that are substantially higher than 50 %. This is an alarmingly high rate of unemployment considering that the United Nations have recently emphasized the inclusion of handicapped persons as a mandatory human right. To date, the specific needs of autistic persons with respect to their working environment are largely unexplored. It remains moreover an open question how support systems and activities, including newly developed communication devices for professional environments of individuals with HFA, should look like. The German health and social care systems are not adequately prepared for the proper support of this population. This leads us to suggest that supported employment programs should be developed for adults with HFA that specifically address their needs and requirements. Such programs should comprise (1) the adequate assessment of HFA, including a neuropsychological profile and an individual matching of persons' preferences with requirements of the working place, (2) on-the-job coaching activities that include systematic communication and interaction training, and (3) instruction of non-autistic peers, including colleagues and supervisors, about weaknesses and strengths of HFA.

Effective head and neck tumor markers. The continuing quest.

To evaluate the clinical value of two serologic tumor markers, squamous cell carcinoma-associated antigen and plasma lipid-bound sialic acid, for identifying cancers of the head and neck, plasma specimens were obtained from patients receiving care for untreated newly diagnosed cancers of the head and neck, routine surveillance for recurrence, or treatment for chronic nonmalignant otolaryngologic conditions. Using identical methods at two institutions, levels of both markers were determined blind to diagnoses for patients with biopsy-proven cancers of the head and neck (n = 134) and for those defined as cancer free based on clinical evaluation for 6 months (n = 140). Disease status was determined blind to tumor marker level results. Cancer prevalence was 48.9%. Applying standard normal limits used alone, plasma lipid-bound sialic acid test sensitivity was 63.4% and specificity was 77.9%. For squamous cell carcinoma-associated antigen alone, test sensitivity was 27.6% and specificity was 85.0%. Neither test alone appears sensitive enough to effectively detect early cancers of the head and neck. When the results of both tests in series combination were positive, sensitivity was 18.7% and specificity was 95.0%. If either was positive in parallel combination, sensitivity was 72.4% and specificity was 68.0%. Further evaluation is required that applies different definitions of normal and determines longitudinal changes with disease status.

Histology of Isshiki thyroplasty type I.

Isshiki thyroplasty type I, an open surgical procedure to medialize the true vocal cord, has been proposed as an alternative to Teflon injection in selected cases of recurrent nerve paralysis or vocalis muscle atrophy. This operation was performed in a man with a mediastinal tumor and a paralyzed vocal cord in an intermediate position. He died 1 month later, and his larynx and recurrent nerve were studied histologically. The gross and microscopic changes in the larynx caused by this operation are discussed, and the pathologic changes in the recurrent nerve leading to the paralysis are examined.

Anatomic foramina in the thyroid cartilage: incidence and implications for the spread of laryngeal cancer.

Anatomic openings in the posterosuperior portion of the thyroid lamina of the larynx were first described in the 19th century. In the present study of 121 coronally sectioned larynges, such openings were found in 47 (39%), appearing bilaterally in 15 and unilaterally in 32. In a separate study of 69 cadaver larynges, the openings were found in 39 (57%), appearing bilaterally in 16 and unilaterally in 23. In 51 laryngectomy specimens removed for squamous cell cancer and showing foramina, tumor was not observed to invade or traverse the foramen in a single case, even in those specimens with tumor overlying the foramen and displaying framework invasion at other sites. Invasion by cancer through the foramen appears to be prevented by a layer of fibroelastic tissue overlying the medial surface of the foramen, parallel to the inner surface of the thyroid lamina. This layer of fibroelastic tissue may represent perichondrium.

Prolonged intubation vs. tracheotomy: complications, practical and psychological considerations.

The charts of 52 adult patients who underwent tracheotomy (49 after intubation) were reviewed to identify early complications of both endotracheal intubation and tracheotomy. The complication rate of endotracheal intubation was 57%, and of tracheotomy, 14%. None of the complications of tracheotomy was serious. Sixty critical-care nurses were surveyed about their attitudes regarding prolonged endotracheal intubation and tracheotomy. A large majority preferred tracheotomy for patients who require airway support, for several reasons. First, they felt that tracheotomy patients were more comfortable and, therefore, required less sedation and restraint. Second, the patients could communicate more effectively. Third, airway care was simplified. Ninety-two percent of nurses stated that they would prefer a tracheotomy for themselves or a loved one if more than 10 days of ventilatory support were required. We conclude that tracheotomy can be performed safely in this group of patients, and that it offers significant practical and psychological benefits compared to prolonged endotracheal intubation.

Vocal cord mobilization by posterior laryngoplasty.

Laryngeal obstruction due to fixation of the vocal cords by scar tissue in the posterior commissure is a serious complication of endotracheal intubation. Until recently, operative procedures, including unilateral arytenoidectomy, were recommended for the relief of such obstruction. Because arytenoidectomy adversely affects voice quality, alternative procedures designed to open the airway by restoring vocal cord mobility have been attempted with some success. We report our experience with six consecutive patients, five of whom had previously required tracheotomy for relief of airway obstruction from posterior glottic stenosis. In all patients, the operative procedure included a midline thyrotomy, excision of the posterior commissure scar tissue, and stenting. Vocal cord motion returned to normal or near normal in all six patients, and all have been decannulated. Subjective evaluation of voice quality was the same or improved postoperatively. Our experience suggests that restoration of an adequate airway in patients with posterior glottic stenosis can be achieved without sacrificing an arytenoid cartilage and voice quality.

The use of topical oral antibiotics in head and neck prophylaxis: is it justified?

Systemic antibiotic therapy is widely used for prophylaxis in major head and neck surgery, but the efficacy of topical oral antibiotic therapy has not been adequately investigated. A pilot, placebo-controlled, double-blind crossover study using six healthy adult male volunteers was performed to assess the influence of topical clindamycin on oral flora. Samples of saliva were cultured for aerobic and anaerobic bacteria immediately before, and at 1- and 4-hour intervals after, rinsing the mouth with a solution of either placebo or clindamycin. Quantitative analysis demonstrated significantly reduced levels of both aerobic and anaerobic bacteria after use of the topical antibiotic at both the 1- and 4-hour intervals. It is postulated that topical clindamycin, by reducing concentrations of oral flora, may also reduce the incidence of regional infection following major upper aerodigestive tract surgery.

Speaking rate of adventitiously deaf male cochlear implant candidates.

No objective group data on speaking rate or speaking duration have been reported on the speech of adventitiously profoundly hearing-impaired adults. Results of the present study showed that speaking rate, i.e., number of syllables per second, was significantly slower and speaking duration was significantly longer for 25 adventitiously profoundly hearing-impaired adult male cochlear implant candidates than for 10 normal-hearing control subjects. The factors of length of time since onset of profound hearing loss and hearing aid use did not significantly affect speaking rate. Based on these objective data, a rationale and method are presented for aural rehabilitation of the profoundly hearing-impaired who exhibit speaking rate abnormalities.

Speaking fundamental frequency of postlingually profoundly deaf adult men.

We investigated the speaking fundamental frequency (F0) of 21 postlingually profoundly sensorineurally deaf men. Results indicated that speaking F0 was significantly higher for the deaf group than for normal-hearing, age-matched men. Neither duration of profound deafness nor hearing aid usage affected speaking F0 values significantly. The findings of the present study provide a baseline for determining the effects of rehabilitation.

Voice intensity of prospective cochlear implant candidates and normal hearing adult males.

Voice intensity in 19 prospective cochlear implant candidates, all adventitiously profoundly sensorineurally deaf adult males, was investigated. For the first time with objective data, it was shown that such deaf subjects spoke with significantly increased voice intensity and with greater intensity fluctuations than normal hearing male speakers. Neither length of time of profound deafness nor history of hearing aid use significantly affected voice intensity. Based on quantitative data, rehabilitation of voice intensity problems in the adventitiously deaf is indicated.

Immediate effects of cochlear implantation on voice quality.

Seminal quantitative group acoustic data are presented on voice quality changes following electrical stimulation (ES) of the auditory nerve via a single-channel cochlear implant (CI). It was found that the fundamental frequency (Fo) of our patients was significantly lower after the first day of ES, while intensity and speaking duration were not significantly different from pre-CI values. These results suggest that the CI provides enough frequency information less than 300 Hz to permit immediate and independent alterations in voice Fo towards normal-hearing speakers values. Our findings also indicate that intensity and speaking duration require additional time before differences found become significant. Longitudinal data are still needed to determine if Fo continues to lower and if intensity and/or speaking duration change significantly to approximate values observed in normal-hearing individuals.

Reacquisition of contrastive stress in an adventitiously deaf speaker using a single-channel cochlear implant.

Acoustic correlates of contrastive stress, i.e., fundamental frequency (F0), duration, and intensity, and listener perceptions of stress, were investigated in a profoundly deaf subject (RS) pre/post single-channel cochlear implant and longitudinally, and compared to the overall patterns of age-peer profoundly deaf (JM) and normally hearing subjects (DL). The stimuli were a group of general American English words in which a change of function from noun to verb is associated with a shift of stress from initial to final syllable, e.g., CON'trast versus conTRAST'. Precochlear implant, RS was unable to produce contrastive stress correctly. Hearing one day post-stimulation resulted in significantly higher F0 for initial and final stressed versus unstressed syllables. Four months post-stimulation, RS maintained significantly higher F0 on stressed syllables, as well as generalization of significantly increased intensity and longer syllable duration differences for all stressed versus unstressed syllables. Perceptually, listeners judged RS's contrastive stress placement as incorrect precochlear implant and as always correct post-cochlear implant. JM's contrastive stress was judged as 96% correct, and DL's contrastive stress placement was 100% correct. It was concluded that RS reacquired all acoustic correlates needed for appropriate differentiation of contrastive stress with longitudinal use of the cochlear implant.

Markedly delayed postoperative malignant hyperthermia.

Malignant hyperthermia (MH) may be triggered by exposure to commonly employed anesthetic agents and muscle relaxants, and often manifests itself during the period of anesthesia. Delayed-onset MH occurring one to four hours postoperatively has been described in isolated case reports. A case of delayed-onset MH occurred 11 hours following routine tonsillectomy and adenoidectomy. The patient demonstrated tachypnea, tachycardia, hyperthermia, and metabolic acidosis. Prompt intravenous administration of dantrolene sodium was therapeutic. Serial serum creatine phosphokinase evaluation verified the diagnosis of MH. The implications of delayed-onset MH and the importance of preoperative screening for potentially susceptible individuals are discussed.

Computed tomography of Körner's septum and petrosquamosal suture.

The petrosquamosal suture and septum are formed at the junction of the petrosal and squamosal bones. The suture crosses the temporal bone obliquely in an anteroposterior direction. Anteriorly, its anatomy is complex due to the convergence of two other bones: the sphenoid and the tympanic. Posteriorly, the petrosquamosal (Körner's) septum has a distinctive appearance on computed tomography (CT). While the anterior attachment of the septum can be used as a guide during surgery, the surgeon must also be aware preoperatively that large septa on CT can be mistaken for the medial mastoid wall. Prior to CT, Körner's septum has been used as a roentgenographic landmark to determine cholesteatoma extension. We now propose that the septum can also be used as a gauge for squamomastoid sclerosis.