[Curriculum "Tracheostomy management in dysphagia therapy"]. / Curriculum "Trachealkanülenmanagement in der Dysphagietherapie".

The number of tracheotomized patients with dysphagia and their need for treatment are continuously increasing in clinical and community settings. The revised version of the directive on home care and community-based intensive care of the Federal Joint Committee (G-BA) requires that tracheotomized patients are regularly evaluated with the aim of identifying and promoting the therapeutic potential after hospital discharge. Dysphagia treatment plays a crucial role as without improvement of severe dysphagia there is practically no possibility for decannulation. Tracheotomized patients with dysphagia are treated by speech and language therapists (SLT); however, the contents of tracheostomy management (TM) are not obligatory in the speech and language therapeutic training curricula, so that there is a need for further education and treatment standards must be secured. Therefore, the German Interdisciplinary Society for Dysphagia (DGD) in cooperation with the participating German medical and therapeutic societies developed a postgraduate curriculum for TM. This should serve as the basis for contents in TM and qualification of therapists within the framework of the delegation of medical services. The goals of the TM curriculum are the definition of theoretical and practical contents of TM, the qualification to perform TM according to current standards of care and quality assurance. The curriculum defines two qualification levels (user and trainer), entry requirements, curricular contents, examination and qualification criteria as well as transitional regulations for SLTs already experienced in TM.

[Curriculum "Tracheostomy management in dysphagia therapy"]. / Curriculum "Trachealkanülenmanagement in der Dysphagietherapie".

The number of tracheotomized patients with dysphagia and their need for treatment are continuously increasing in clinical and community settings. The revised version of the directive on home care and community-based intensive care of the Federal Joint Committee (G-BA) requires that tracheotomized patients are regularly evaluated with the aim of identifying and promoting the therapeutic potential after hospital discharge. Dysphagia treatment plays a crucial role as without improvement of severe dysphagia there is practically no possibility for decannulation. Tracheotomized patients with dysphagia are treated by speech and language therapists (SLT); however, the contents of tracheostomy management (TM) are not obligatory in the speech and language therapeutic training curricula, so that there is a need for further education and treatment standards must be secured. Therefore, the German Interdisciplinary Society for Dysphagia (DGD) in cooperation with the participating German medical and therapeutic societies developed a postgraduate curriculum for TM. This should serve as the basis for contents in TM and qualification of therapists within the framework of the delegation of medical services. The goals of the TM curriculum are the definition of theoretical and practical contents of TM, the qualification to perform TM according to current standards of care and quality assurance. The curriculum defines two qualification levels (user and trainer), entry requirements, curricular contents, examination and qualification criteria as well as transitional regulations for SLTs already experienced in TM.

[Statement on the lower age limit for outpatient adenotomies and tonsillotomies]. / Stellungnahme zur Altersuntergrenze bei der ambulanten Durchführung von Adenotomien und Tonsillotomien.

At the beginning of 2023, there have been significant changes to the regulations for outpatient surgery in Germany, which were set out in a trilateral self-administration agreement between the umbrella association of statutory health insurance companies, the German Hospital Association and the Federal Association of Statutory Health Insurance Physicians. Among other things, a catalog stated circumstances under which an operation should not be carried out on an outpatient basis or should only be carried out with doubt. This catalog explains the patient's age: up to the first year of life, inpatient performance of a service can be justified. This formulation in itself means that children from one year of age on should regularly undergo outpatient surgery.In the german scientific societies for otolaryngology, head and neck surgery as well as for anesthesiology and intensive care medicine, doubts arose as to whether this age limit could also be scientifically justified for operations in the throat such as adenotomy or tonsillotomy.A search was carried out in international guidelines and in the international literature and the statements were evaluated. The results of this literature search were discussed with representatives of the Pediatric Otorhinolaryngology Working Group (AG PädHNO) of the German Society for Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC) and the scientific working group for pediatric anesthesia (WAKKA) of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) in conferences.The consensus revealed that a strict age limit of the first year of life is not appropriate for the outpatient performance of adenotomies and tonsillotomies. First of all, specifying a strict age limit is questionable because, regardless of age, a number of other medical and social factors influence the responsible performance of outpatient operations. Furthermore, the age limit of one year is not considered appropriate in view of literature, guidelines and practical experience in the international area. The assessment of the literature and the consideration of the implementation in the international area make an age limit in the range of 2-3 years seem more appropriate.This review provides the responsible doctors with a variety of insights, aspects and arguments so that they can make their decision to carry out these operations on an outpatient or inpatient basis appropriately and responsibly.

[Recognition function for the Freiburg monosyllabic test in noise with a signal to noise ratio (SNR) of 5 dB]. / Die Verständlichkeitskurve für den Freiburger Einsilbertest im Störschall mit einem Signal-Rausch-Abstand (SNR) von 5 dB.

OBJECTIVE: The Freiburg monosyllabic test (FBE) has been an important German speech audiometry test for years. It is nowadays also used to assess the benefit of hearing aids in noise (FBE-S). This study investigates hearing in noise using the FBE at different sound pressure levels and a signal to noise ratio of 5 dB to generate a recognition curve. METHODS: In autumn 2018, 60 normal-hearing German native speakers (age 18-31 years) participated in the study at the military hospital in Hamburg. Using one FBE test list, speech intelligibility was measured from sound pressure levels of 15 to 90 dB in 5­dB steps with a noise level 5 dB lower in each case. Subsequently, the average of all intelligibility rates and 95% confidence intervals (CI) were determined. RESULTS: Participants comprised 29 female and 31 male subjects. Average age was 24.32 years (±3.29 years). The fixed effects analysis of variance with recognition as the dependent variable demonstrated a highly significant correlation between the levels of sounds/noise and the intelligibility of speech (p < 0.0001). The average intelligibility rates with 95% CI and the frequency distributions were presented tabularly and graphically. CONCLUSION: In comparison to the normative curve, the FBE­S recognition curve is shifted to the right. The average values of the FBE­S reach the saturation area at a volume of 70/65 dB with an intelligibility rate of 90% (for comparison: the point of saturation for 100% intelligibility of the FBE without noise is reached at 55 dB). Using these averaged values of the FBE­S enables better interpretation of individual results without and with hearing aids. In the future, the benefit of hearing aids should be measured at lower noise levels than it is today.

[Everyday relevance of APHAB questions : Influence on answer frequency]. / Alltagsrelevanz der APHAB-Fragen : Einfluss auf die Beantwortungshäufigkeit.

BACKGROUND: The Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire measures subjective hearing impairment in different situations. Recently, a survey demonstrated that some APHAB questions were answered more rarely than others. This study aims to evaluate the everyday relevance of each APHAB question and investigate whether this relevance for daily life influences answer frequency. METHODS: Between July 2016 and November 2017, 517 hearing impaired patients from 11 ENT practices in Schleswig-Holstein, Germany, were evaluated using the APHAB. In parallel, the everyday relevance of each APHAB question for the subjects was assessed on a four-step scale (often/sometimes/rarely/never). The answers were listed in a cross table and statistically analyzed. RESULTS: The average age of all subjects was 67.4 years (±14.0 years); 45.3% were female and 54.7% were male. One APHAB question (no. 21) was answered noticeably less often than the others. Overall, five types of distribution for the everyday relevance of APHAB questions could be determined. Using the χ2-test, no correlation between the frequency of answers and their everyday relevance could be detected (p < 0.001). CONCLUSION: No correlation between everyday relevance and answer frequency was detected. However, the five types of distribution could be used for an individual interpretation of single APHAB answers. In the future, a possible influence of everyday relevance on ranking within a specific APHAB answer should be investigated.

[The adaptive Freiburg monosyllabic test in noise : Development of a procedure and comparison of the results with the Oldenburg sentence test]. / Die adaptive Messung des Freiburger Einsilbertests im Störschall : Entwicklung einer Messmethode und Vergleich der Ergebnisse mit dem Oldenburger Satztest.

BACKGROUND: Whereas sentence tests are commonly performed using an adaptive procedure, this method has not yet been transferred to the Freiburg monosyllabic speech test, the most important word test. When using different procedures, a comparison of results between sentence and word tests is not possible. Therefore, an adaptive procedure which has proven itself in sentence tests was transferred to the Freiburg monosyllabic test in noise. The results of the new procedure were compared to the standard of sentence tests, i.e., the Oldenburg sentence test. METHODS: The adaptive Freiburg monosyllabic speech test and the Oldenburg sentence test were applied in 40 otologically normal subjects in a randomized order. Results were analyzed with respect to time requirements, possible gender differences, the influence of test order, and correlation of test results. RESULTS: The time required for the adaptive Freiburg monosyllabic speech test was significantly higher than for the Oldenburg sentence test. No significant impact of gender or test order could be shown. The mean signal-to-noise ratio for 50% speech discrimination of the Oldenburg sentence test was significantly smaller than for the adaptive Freiburg monosyllabic speech test. No correlation could be shown between the results of the two tests CONCLUSION: The Freiburg monosyllabic test can not only be used for quantifying discrimination loss in percentage terms, but also to measure the 50% speech recognition threshold with an adaptive algorithm. However, the procedure of the adaptive Freiburg monosyllabic test is more time consuming than that of the Oldenburg sentence test. Concerning a possible missing correlation between the results for 50% speech discrimination, further studies with hearing-impaired persons are needed.

[Dependency of APHAB score in the ECu subscale on age, gender and subjective hearing loss : Hearing aid fitting in two subjective hearing loss groups]. / Abhängigkeit des APHAB-Werts in der ECu-Skala von Alter, Geschlecht und objektivem Hörverlust : Hörgeräteerstversorgung in 2 subjektiven Hörverlustgruppen.

OBJECTIVE: The Abbreviated Profile of Hearing Aid Benefit (APHAB) determines subjective impairment by hearing loss in four situations before and after hearing aid fitting. The first part (APHABu) of the questionnaire can be used independently of hearing aid fitting. Previous research has demonstrated that the answers in the ECu subscale for hearing under easy conditions are concentrated in two groups: one with subjectively better, one with subjectively worse hearing. This study aimed to investigate in a large collective whether there are differences between these two groups in terms of age, gender, and individual hearing loss. PATIENTS AND METHODS: The data of 1755 patients were analyzed, whose APHAB answers and pure-tone thresholds had been collected during hearing aid fitting. Group 1 had an average ECu score ≤37.5%; in group 2 it was ≥67.5%. The individual hearing losses was determined. Statistical analysis was performed using Mann-Whitney U, χ2, Spearman, and Pearson tests. RESULTS: The 616 members of group 1 were significantly younger (68.7 vs. 73.0 years) and comprised more females (53.9 vs. 46.1%) than the 1139 members of group 2. Hearing was frequency specific in group 1, and hearing loss as classified using standard audiograms and according to the three-frequency table was significantly lower in group 1 than in group 2, CONCLUSION: The distribution with two maximums in the ECu subscale can be explained by individual differences in terms of age and hearing loss, in part also by gender. The lower absolute number of patients in group 1 could be explained by the still relatively late fitting of hearing aids in general.

[Management of acute vertigo and dizziness : Patients in emergency departments in Germany]. / Primärversorgung von akutem Schwindel : Patienten in Notfallambulanzen in Deutschland.

BACKGROUND: Dizziness and vertigo are some of the most common reasons for seeking medical help. Acute dizziness and vertigo require interdisciplinary cooperation. New diagnostic methods (the video head impulse test) and modern algorithms (HINTS: head impulse test/nystagmus [direction changing]/test-of-skew) are increasingly used in case of the acute vestibular syndrome in emergency care. METHODS: In a survey on the management and participation of the ENT specialist area, the authors interviewed 168 German ENT clinics during the spring of 2017 using an online survey. RESULTS: Of the 168 departments, 100 departments participated in the survey. The specialties with first medical contact in cases with acute vertigo were ENT (48%), neurology (32%), and internal medicine (17%). Most of the patients were hospitalized. Patients with acute dizziness were referred most commonly to the ENT (62%) and neurology (16%) departments for further therapy, rarely, to internal medicine wards. For emergency diagnostic workup, the video head impulse test is frequently used in ENT (72%). CONCLUSIONS: In acute vertigo syndromes, the ENT physician has a special role and responsibility in the interdisciplinary workup, since ontological disorders are the most common cause. In any case, an ENT consultation is recommended. In German emergency departments, otorhinolaryngologists use modern diagnostic tools and algorithms such as the video head pulse test and HINTS to objectify peripheral vestibulopathy or identify central causes. Thus, this is a contribution to improving medical care.

[APHAB scores for individual assessment of the benefit of hearing aid fitting]. / APHAB-Scores zur individuellen Beurteilung des Nutzens von Hörgeräteversorgungen.

OBJECTIVE: The Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire measures subjective hearing impairment on four different subscales pertaining to different listening situations. Using a very large patient cohort, this study aims to show how answers are distributed within the four subscales before and after hearing aid fitting, and what benefit the patients experience. The results are discussed on the basis of the available literature. PATIENTS AND METHODS: Between April 2013 and March 2016, 35,000 APHAB questionnaires from nine German statutory health insurance providers were evaluated. The average values before and after hearing aid fitting, as well as the benefit, were determined for all four APHAB subscales and analyzed graphically. RESULTS: The results of the subjective evaluation of hearing impairment before and after hearing aid fitting and the resultant benefit were plotted by percentile distribution graphs and boxplots. The data were analyzed statistically. There was no overlap of the interquartile ranges before and after hearing aid fitting in any of the APHAB subscales. In three scales (EC, BN and RV), the median improvement after hearing aid fitting was nearly 30 percentage points. In the AV subscale, this value was slightly negative. DISCUSSION: The percentile distribution graphs used in this study allow individual evaluation of subjective hearing impairment before and after hearing aid fitting, as well as of the resultant benefit, on the background of a huge database. Additionally, it is demonstrated why presentation as boxplots and the average benefit values calculated from these is problematic.

Associations between the probabilities of frequency-specific hearing loss and unaided APHAB scores.

The Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire reports subjective hearing impairments in four typical conditions. We investigated the association between the frequency-specific probability of hearing loss and scores from the unaided APHAB (APHABu) to determine whether the APHABu could be useful in primary diagnoses of hearing loss, in addition to pure tone and speech audiometry. This retrospective study included database records from 6558 patients (average age 69.0 years). We employed a multivariate generalised linear mixed model to analyse the probabilities of hearing losses (severity range 20-75 dB, evaluated in 5-dB steps), measured at different frequencies (0.5, 1.0, 2.0, 4.0, and 8.0 kHz), for nearly all combinations of APHABu subscale scores (subscale scores from 20 to 80%, evaluated in steps of 5%). We calculated the probability of hearing loss for 28,561 different combinations of APHABu subscale scores (results available online). In general, the probability of hearing loss was positively associated with the combined APHABu score (i.e. increasing probability with increasing scores). However, this association was negative at one frequency (8 kHz). The highest probabilities were for a hearing loss of 45 dB at test frequency 2.0 kHz, but with a wide spreading. We showed that the APHABu subscale scores were associated with the probability of hearing loss measured with audiometry. This information could enrich the expert's evaluation of the subject's hearing loss, and it might help resolve suspicious cases of aggravation. The 0.5 and 8.0 kHz frequencies influenced hearing loss less than the frequencies in-between, and 2.0 kHz was most influential on intermediate degree hearing loss (around 45 dB), which corresponded to the frequency-dependence of speech intelligibility measured with speech audiometry.

[Gaps of Evidence in ENT-Surgery - a Qualitative Survey]. / Qualitative Umfrage zur Identifizierung von Evidenzlücken in der HNO-Heilkunde.

INTRODUCTION: As in other disciplines, the burgeoning knowledge in ENT medicine long ago surpassed our ability to adequately absorb it and maintain a proper overview. This can give rise to actual or assumed knowledge gaps that can impede the progress of the discipline and evidence-based treatment of patients. Clinics and medical practices also hold to traditional doctrines that shape day-to-day medicine, without these schools being challenged based on evidence. METHODS: Between February and June 2015, 160 ENT clinics, including 34 university hospitals, and 2,670 ENT practices took part in a two-arm online survey on existing or perceived evidentiary gaps in ENT medicine using a previously development questionnaire. The survey used for half the participants was open in form; the other half were given a closed survey with systematics of the field for orientation. The survey was augmented with additional data such as the number of publications and focus areas in the clinics and the age and type of practice of the established physicians. RESULTS: The return rate from the clinics was 39.7%; the return rate of the closed surveys was 29.3%. Of the physicians in medical practice, 14.6% responded to the closed and 18.6% to the open survey. There were no major differences between the two forms of survey. Otological and oncological issues comprised approximately 30% of the list of answers from clinics. Corresponding questions were formulated regarding the current diagnostic and therapeutic problems, such as with stage-related tumor treatment or implantable hearing aids. Diagnostic procedures, e.g., special new procedures in audiology and vestibulogy, dominated the surveys from the practices. However clinics and practices alike cited marginal areas of the discipline that are of daily relevance. DISCUSSION: The cited knowledge gaps then needed to be verified or refuted and clarified based on research of the literature as to whether the existing evidence actually reached healthcare providers in the form of guidelines, publications, conferences or continuing training for application in daily practice. Other steps would include prioritizing future research, evidence mapping, deciding on further systematic reviews, and targeted studies in conjunction with procuring third-party funding and in cooperation with patient associations. The knowledge thus gained should ultimately be transferred in improved form for application in daily clinical practice. Ten questions of key importance each needed to be formulated for the hospitals and practices.

[Evidence and Evidence Gaps - an Introduction]. / Evidenz und Evidenzlücken - eine thematische Einführung.

BACKGROUND: Treating patients requires the inclusion of existing evidence in any health care decision, to be able to choose the best diagnosis or treatment measure or to make valid prognosis statements for a particular patient in consideration of the physician's own expertise.The basis are clinical trials, the results of which are ideally gathered in systematic reviews, rated, summarized and published. In addition to the GCP (Good Clinical Practice)-compliant planning, conducting and analysis of clinical studies it is essential, that all study results are made publicly available, in order to avoid publication bias. This includes the public registration of planned and discontinued trials. HISTORY: In the last 25 years, the evidence-based medicine (EbM) has increasingly found its way into clinical practice and research. Here EbM is closely associated with the names Archibald Cochrane and David Sackett. In Germany, both the German Cochrane Centre (DCZ) and the network of evidence-based medicine (DNEbM) were established approximately 15 years ago. In the international Cochrane Collaboration clinicians and other scientists like statisticians interdisciplinary work side by side to develop the methods of evidence-based medicine and to address the topics of evidence generation and processing as well as the transfer of knowledge. Challenge: Existing evidence primarily serves doctors to support their decision-making, but is also the basis for providing scientific proof for a health care intervention's benefit to patients and ultimately payers/health insurances. The closure of existing evidence gaps requires substantial human and financial resources, a complex organizational structure and can only succeed with the involvement of clinical and methodological expertise and specific knowledge in the field of clinical research. In addition, the knowledge must be transferred into practice, using journals, guidelines, conferences, databases, information portals with processed evidence and not least the medical education of students.One problem is the wealth of information, so that in clinical practice there may be gaps in knowledge of actual evidence. Usually it still takes several years until new knowledge is fully implemented in daily practice. OBJECTIVES: The German Society of Otolaryngology, Head and Neck Surgery (DGHNOKHC) and the German professional association of otolaryngologists (BVHNO) have a vested interest in supporting their members in the generation, processing and dissemination of evidence, and to foster the transfer of knowledge into practice. This includes the areas of diagnosis, treatment, prognosis and prevention as well as drug therapies or the application of medical devices or surgical procedures. Crucial is the regular determination of existing evidence gaps, including in the area of already established procedures, which must be followed by a prioritization of research questions and subsequent conduct of clinical research. Only with combined efforts even large trials can be performed, to test therapies and diagnostics for example, also after approval under everyday conditions. Methods, Results and Vision: The executive committees of DGHNOKHC and BVHNO have together founded the German Clinical Trials Unit for Ear, Nose and Throat medicine, Head and Neck Surgery (DSZ-HNO) to assist their members in the identification of evidence gaps and the planning and conduct of systematic reviews and clinical trials. The first projects have been started, including a BMBF(German Ministry for education and research)-funded clinical trial for the treatment of sudden hearing loss and a survey to detect evidence gaps in Otolaryngology. It seems both reasonable and feasible to provide a structure such as a jointly-run study center for doctors in hospitals and medical practices to assist in clinical research and to anchor the principles of evidence-based medicine in daily life.

[The Influence of Hearing Loss Represented by Standard Audiogram Types to Unaided APHAB Scores]. / Die Abhängigkeit von APHABu-Scores von Hörverlusten in Standardaudiogrammen.

BACKGROUND: Questionnaires as the APHAB (Abbreviated Profile of Hearing Aid Benefit) are besides pure-tone and speech-audiometry the third method of diagnostics in audiology. Up to now there has been no research on the influence of individual hearing loss, represented by standard audiograms, on the scores of the unaided APHAB (APHABu) done with a big number of subjects. This study will investigate whether there does exist such a relationship or not. METHODS: A total of 2 745 records provided by a database were analysed. First, the subjects' audiograms (air conduction) were allocated to 7 standardised audiogram types. By using a multivariant mixed linear model a potential connection was examined between these standard audiograms and particular APHABu scores for its four subscales: EC - ease of communication, BN - background noise, RV - reverberation, AV - aversiveness of sounds. RESULTS: There was no evidence for a dependency between any type of hearing loss dependence and unaided APHAB-scores. The values on the EC-scale vary between 49.8 and 58.0, on the BN-scale between 45.3 and 46.6, on the RV-scale between 44.4 and 52.4, and on the AV-scale between 47.6 and 50.1. DISCUSSION: This result confirms earlier studies with other questionnaires. Therefore, the APHABu can be used as an initial instrument for the diagnostics of individual hearing loss independently on whether hearing aids will be fitted subsequently or not.

[Multicenter trial for sudden hearing loss therapy - planning and concept]. / Multizentrische Studie zur Hörsturztherapie - Planung und Konzeption.

Systemic steroids are widely used worldwide as a standard of care for primary therapy of idiopathic sudden sensorineural hearing loss (ISSHL). The German ISSHL guideline recommends high-dose steroids for primary therapy of ISSHL, without evidence from randomized controlled trials (RCTs). The rationale for the treatment of ISSHL using high dose steroids is only based on retrospective cohort studies.This article describes the planning and initiation of a multicenter, national, randomized, controlled clinical trial entitled Efficacy and safety of high dose glucocorticosteroid treatment for idiopathic sudden sensorineural hearing loss - a three-armed, randomized, triple-blind, multicenter trial (HODOKORT). This clinical trial aims to compare standard dose with two types of high-dose steroids for primary systemic therapy with respect to their efficacy in improving hearing, and thus communication ability, in patients with idiopathic sudden sensorineural hearing loss.This study is funded by the "Clinical Trials with High Patient Relevance" research program in the health research framework of the German Federal Ministry of Education and Research. It is one of two studies by the German Study Center of Clinical Trials of the German Society of Otorhinolaryngology, Head and Neck Surgery (DSZ-HNO). Planning and initiation was done in cooperation with the DSZ-HNO, the Coordination Center of Clinical Trials of the Martin-Luther-University Halle-Wittenberg, and the Study Center of the University Hospital Freiburg.

[The influence of current social, medical, and political trends on the future of otorhinolaryngology]. / Auswirkungen aktueller Trends in Gesellschaft, Medizin und Politik auf die Zukunft der HNO-Heilkunde.

BACKGROUND: All medical specialties are changing permanently, including otorhinolaryngology. Analyzing trends in social changes, medical progress, and political decisions will allow the effects of these on ENT medicine to be at least partially anticipated. TRENDS: Demographic changes and medical progress lead to an increasing demand for medical treatments. In addition, increasing numbers of female physicians are observed, as are many changes in the lifestyles of young physicians. Medical treatment will develop toward more individualized therapies in the future. ENT surgery will become a more ambulatory medical specialty. Driven by political decisions, digital medicine will become more important. Particular services once provided by physicians will be delegated to non-physician professionals. DISCUSSION: The lack of physicians and the progress in medicine require better networking between in- and outpatient services in the future. The potential of such collaborations is currently not completely realized. However, these developments will also increase the cost of health care. CONCLUSION: These trends will develop otorhinolaryngology into a conservative and surgical ambulatory care driven medical specialty. Embedded in decentralized networks and cooperations, and supported by IT technologies and specialized non-physician professionals, ENT physicians will work in hospitals as well as in practices on a permanent basis. Nevertheless, the question of funding these changes has yet to be clarified.