Round-Window Vibroplasty: Systematic Review and Meta-Analysis of Audiological Effectiveness With Different Round-Window Coupling Techniques.

OBJECTIVE: Active middle ear implants can be directly coupled to the round-window (RW) membrane via RW Vibroplasty. The objectives of this systematic review were to summarize data on different RW coupling techniques and to investigate their effect on audiological and safety outcomes using meta-analyses. DATABASES REVIEWED: PubMed (MEDLINE), Cochrane Library, and Embase (DIMDI). METHODS: All publications reporting on audiological outcomes in human patients after RW Vibroplasty were included. Two independent reviewers carried out screening and data extraction. Meta-analyses and meta-regression were used to evaluate the potential effects of surgical and demographic parameters on primary audiological outcomes. Adverse events were extracted and tabulated for qualitative analysis. RESULTS: Fourteen different combinations of surgical coupling parameters were identified in 61 included publications. Overall, data from 23 publications could be used for meta-analyses. Significantly better aided sound-field thresholds were reported for RW Vibroplasty performed without a dedicated coupler and using fascia as interponate, compared with RW Vibroplasty with an RW coupler or without an interponate. These effects were not found in other outcomes (i.e., functional gain, word recognition score). Reporting of adverse events was relatively heterogeneous, with 32 explicit mentions of revision surgery after the loss of coupling efficacy. CONCLUSION: There are numerous publications investigating the effectiveness of coupling active middle ear implants to the RW membrane. However, studies are typically undersampled and of low evidence level. Using meta-analyses, weighted means, and qualitative analyses enabled a summary of the existing literature on audiological and safety outcomes after RW Vibroplasty. Individual selection of the most appropriate coupling modality with standardized intraoperative measurement and careful patient follow-up may be considered key factors for achieving effective RW coupling.

Functional Outcomes and Quality of Life after Cochlear Implantation in Patients with Long-Term Deafness.

Background: Hearing-related quality of life (QoL) after cochlear implantation (CI) is as important as audiological performance. We evaluated the functional results and QoL after CI in a heterogeneous patient cohort with emphasis on patients with long-term deafness (>10 years). Methods: Twenty-eight patients (n = 32 implanted ears, within n = 12 long-term deaf ears) implanted with a mid-scala electrode array were included in this retrospective mono-centric cohort study. Speech intelligibility for monosyllables (SIM), speech reception thresholds (SRT50) and QoL with Nijmegen Cochlear Implant Questionnaire (NCIQ) were registered. Correlation of SIM and QoL was analyzed. Results: SIM and SRT50 improved significantly 12 months postoperatively up to 54.8 ± 29.1% and 49.3 ± 9.6 dB SPL, respectively. SIM progressively improved up to 1 year, but some early-deafened, late implanted patients developed speech understanding several years after implantation. The global and all subdomain QoL scores increased significantly up to 12 months postoperatively and we found a correlation of SIM and global QoL score at 12 months postoperatively. Several patients of the "poor performer" (SIM < 40%) group reported high improvement of hearing-related QoL. Conclusions: Cochlear implantation provides a benefit in hearing-related QoL, even in some patients with low postoperative speech intelligibility results. Consequently, hearing-related QoL scores should be routinely used as outcome measure beside standard speech understanding tests, as well. Further studies with a prospective multi-centric design are needed to identify factors influencing post-implantation functional results and QoL in the patient group of long-term deafness.

[Emergencies in ear, nose and throat medicine]. / Notfälle in der Hals-, Nasen- und Ohrenheilkunde.

Emergencies in ear, nose and throat medicine in the preclinical setting are common. Due to the narrow anatomical conditions, relocation or bleeding in this area can quickly lead to an emergency situation. In this article, the most important causes of bleeding, shortness of breath and trauma are to be presented and the corresponding treatment briefly outlined.

Long-term audiological benefit with an active transcutaneous bone-conduction device: a retrospective cohort analysis.

PURPOSE: To evaluate long-term audiological, surgical and safety outcomes of a complex patient cohort treated with an active transcutaneous bone-conduction device (tBCD). METHODS: This retrospective, monocentric cohort analysis involves 31 adults with conductive (CHL) and mixed hearing loss (MHL). For outcome analysis, study results were divided into short-term follow-up data (< 12 months) and long-term follow-up data (> 12 months). RESULTS: 31 patients with a total person-time of 90.4 years and an average number of 3.2 ± 1.5 preoperatively performed surgeries on the implanted side were investigated. Mean BCD-aided PTA4 thresholds were significantly lower than unaided PTA4AC before surgery (64.7 ± 16.1 dB HL; CHL 50.6 ± 10.6 dB HL; MHL 72.8 ± 12.8 dB HL) and did not change between short-term (42.3 ± 13.1 dB HL; CHL 35.8 ± 6.8 dB HL; MHL 45.2 ± 14.3 dB HL) and long-term (43.4 ± 10.0 dB HL; CHL 35.8 ± 4.3 dB HL; MHL 48.1 ± 9.6 dB HL) follow-up periods. Speech intelligibility in the Freiburg monosyllables test at 65 dB improved significantly, from 16.3 ± 21.5% (CHL 26.8 ± 19.0%; MHL 8.7 ± 20.5%) in the unaided condition to 82.7 ± 15.5% (CHL 90.0 ± 12.2%; MHL 79.4 ± 16.3%) in the short-term and 85.5 ± 13.2% (CHL 93.8 ± 7.9%; MHL 79.5 ± 13.3%) BCD-aided in the long-term follow-up periods. Ten minor procedure-related and 6 implant-related (5 minor, 1 major) AEs occurred over the total follow-up period. CONCLUSION: The device provides satisfactory audiological and speech benefit over long-term follow-up periods, up to 7 years. Explant rates were very low, while the overall rate of manageable AEs was high in this complex patient cohort. The device is considered a safe and effective option in the long-term hearing rehabilitation of patients with CHL and MHL.

Comparison of Clinical Examination and Various Imaging Modalities in the Diagnosis of Head and Neck Cancer.

Introduction Squamous cell Carcinoma of the Head and Neck (HNSCC) is the most common tumor entity of malignant processes in the head and neck area. Due to the metastasizing behavior of these tumors, the staging is indispensable for the treatment planning and requires imaging techniques, which are sensitive, specific, and as far as possible cost-effective, to benefit ultimately the patient and to ensure optimal care. Objectives The aim of the present study is to compare the clinical examination including palpation, ultrasound and computed tomography (CT)/magnetic resonance imaging (MRI) for the diagnosis of neck metastases to make the correct indication for a neck dissection. Methods Data from 286 patients with HNSCC were analyzed for neck metastases to determine which diagnostic tool is the best to answer the question if a neck dissection is necessary or not. Each study method was examined retrospectively by comparing sensitivity, specificity, the positive/negative predictive value, the positive likelihood ratio and the diagnostic accuracy. Results The ultrasound showed a sensitivity of 91.52%, a specificity of 61.67%, a positive/negative predictive value of 76.65%/84.09%, a positive likelihood ratio of 2.39 and a diagnostic accuracy of 78.95%. The clinical examination showed a sensitivity of 75.76%, a specificity of 66.12%, a positive/negative predictive value of 75.30%/66.67%, a positive likelihood ratio of 2.24 and a diagnostic accuracy of 71.68%. The CT/MRI showed a sensitivity of 78.66%, a specificity of 62.50%, a positive/negative predictive value of 74.14%/68.18%, a positive likelihood ratio of 2.10 and a diagnostic accuracy of 71.83%. Radiographically, ultrasound, as well as the clinical examination, could be judged to be free from radiation load and side effects from the contrast medium. The high dependence on the investigator when using ultrasound made reproducibility of the results difficult. Conclusions It could be shown that ultrasound was the diagnostic tool with the highest sensitivity, positive/negative predictive value, positive likelihood ratio and diagnostic accuracy by detecting and interpreting metastases in the head and neck region correctly. Whether a neck dissection should be performed depends to a large extent on the ultrasound findings.

Comparison of Clinical Examination and Various Imaging Modalities in the Diagnosis of Head and Neck Cancer

Abstract Introduction Squamous cell Carcinoma of the Head and Neck (HNSCC) is the most common tumor entity of malignant processes in the head and neck area. Due to the metastasizing behavior of these tumors, the staging is indispensable for the treatment planning and requires imaging techniques, which are sensitive, specific, and as far as possible cost-effective, to benefit ultimately the patient and to ensure optimal care. Objectives The aim of the present study is to compare the clinical examination including palpation, ultrasound and computed tomography (CT)/magnetic resonance imaging (MRI) for the diagnosis of neck metastases to make the correct indication for a neck dissection. Methods Data from 286 patients with HNSCC were analyzed for neck metastases to determine which diagnostic tool is the best to answer the question if a neck dissection is necessary or not. Each study method was examined retrospectively by comparing sensitivity, specificity, the positive/negative predictive value, the positive likelihood ratio and the diagnostic accuracy. Results The ultrasound showed a sensitivity of 91.52%, a specificity of 61.67%, a positive/negative predictive value of 76.65%/84.09%, a positive likelihood ratio of 2.39 and a diagnostic accuracy of 78.95%. The clinical examination showed a sensitivity of 75.76%, a specificity of 66.12%, a positive/negative predictive value of 75.30%/66.67%, a positive likelihood ratio of 2.24 and a diagnostic accuracy of 71.68%. The CT/MRI showed a sensitivity of 78.66%, a specificity of 62.50%, a positive/negative predictive value of 74.14%/68.18%, a positive likelihood ratio of 2.10 and a diagnostic accuracy of 71.83%. Radiographically, ultrasound, as well as the clinical examination, could be judged to be free from radiation load and side effects from the contrast medium. The high dependence on the investigator when using ultrasound made reproducibility of the results difficult. Conclusions It could be shown that ultrasound was the diagnostic tool with the highest sensitivity, positive/negative predictive value, positive likelihood ratio and diagnostic accuracy by detecting and interpreting metastases in the head and neck region correctly. Whether a neck dissection should be performed depends to a large extent on the ultrasound findings.

Patient-reported long-term benefit with an active transcutaneous bone-conduction device.

PURPOSE: To evaluate the long-term benefits in hearing-related quality of life, patient satisfaction and wearing time of patients rehabilitated with an active transcutaneous bone-conduction device. Adverse events and audiological outcomes are reported as secondary outcomes. METHODS: This retrospective, mono-centric cohort analysis involves 16 adults with conductive or mixed hearing loss with a mean device experience of 51.25 months. Patient-reported outcome measures were assessed using the short version of the Speech, Spatial and Qualities of Hearing Scale (SSQ12-B) and the German version of the Audio Processor Satisfaction Questionnaire (APSQ). Audiological outcomes as well as incidence of adverse events were obtained from patients´ charts. RESULTS: The hearing-related quality of life improved significantly within all subscales of the SSQ12-B scoring a mean overall of 2.95 points. Patient satisfaction measured with the APSQ scored 8.8 points on average. Wearing times differed considerably and patients with lower levels of education seemed to use their device longer compared to patients with academic education. Eight minor adverse events were documented, all of which resolved during follow-up. The mean gain in word recognition score at the last follow-up measured at 65 dB was 75.9%, while speech reception threshold was lowered by 35.1 dB. CONCLUSION: Even after several years, patients report significant benefits in hearing-related quality of life and device satisfaction. In combination with a low rate of minor adverse events and significantly improved audiological outcomes, the device is considered as a comfortable and effective option in hearing rehabilitation.

Etiology and therapy of delayed facial paralysis after middle ear surgery.

PURPOSE: This review focuses on the etiology, incidence and therapy of delayed paralysis of the facial nerve (DFP) after different types of middle ear surgery. METHODS: Retrospective review of studies published in English from 1970 until 2019 reporting DFP after tympanoplasty, tympanomastoid surgery, stapedotomy and stapedectomy. The search used the databases of PubMed, Scopus and Cochrane Library. Studies reporting from adult patients and DFP onset after 48 h after surgery were included. Studies dealing with iatrogenic or preexisting facial palsy and case reports were excluded. The initial literature search resulted in 52 studies. The relevance of the publications was verified using title, abstract and full-text analysis. Data were analyzed with descriptive statistics using median, simple sum and statistical significance. RESULTS: Ten studies having 12,161 patients could be included in this review. The incidence of DFP after the middle ear surgeries varies between 0.2 and 1.9%. The surgical stress of the middle ear surgeries is the main trigger for the development of DFP and leads to a virus reactivation and/or neuronal edema. Patients with a dehiscence of the facial canal have a significantly higher probability for a DFP. The recommended therapy of DFP based on the data of the therapy of Bell's palsy, consists of the administration of a steroid. For patients having a case history of previous viral infections, an antiviral prophylaxis is recommended. CONCLUSION: Overall, DFP has a very good prognosis, with mostly complete healing with appropriate therapy. Viral reactivation is the most favored genesis of DFP. Immunization or antiviral prophylaxis is recommended to those patients being at risk for a viral reactivation.

Aspirin sensitivity and chronic rhinosinusitis with polyps: a fatal combination.

Aspirin-exacerbated respiratory disease (AERD) refers to aspirin sensitivity, chronic rhinosinusitis (CRS), nasal polyposis, asthma, eosinophil inflammation in the upper and lower airways, urticaria, angioedema, and anaphylaxis following the ingestion of NSAIDs. Epidemiologic and pathophysiological links between these diseases are established. The precise pathogenesis remains less defined, even though there is some progress in the understanding of several molecular mechanisms. Nevertheless, these combinations of diseases in patients classified by AERD constitute a fatal combination and may be difficult to treat with standard medical and surgical interventions. This paper reviews in brief the epidemiology, clinical features, diagnosis, molecular pathogenesis, and specific therapies of patients classified by AERD and postulates future attempts to gain new insights into this disease.

Evaluation and development of a predictive model for ultrasound-guided investigation of neck metastases.

Ultrasound investigations for the correct identification of lymph node metastases depend on the experience and qualifications of the investigator; thus, model that provides better preoperative evaluation is desired. Data from 290 patients with an upcoming neck dissection were analyzed to compare the preoperative ultrasound assessment of neck metastases with the pathologically proven postoperative neck status. In total, 364 data sets with 200 malignant and 164 benign lymph nodes were explored. The minimal and maximal transverse diameters and their ratio were shown to be especially good parameters for sensitivity, whereas the echostructure and the presence of a hilum were good for specificity. A model incorporating the evaluated markers is presented. The model provides better judgement of neck lymph nodes in a more objective manner. Using logistic regression, five parameters were identified to predict metastases.

Perioperative intensity-modulated brachytherapy for refractory orbital rhabdomyosarcomas in children.

PURPOSE: To evaluate the feasibility and toxicity of perioperative intensity-modulated brachytherapy (IMBT) as well as functional outcome in children with therapy-refractory orbital rhabdomyosarcomas (RMS). PATIENTS AND METHODS: Since 1993, children with therapy-refractory orbital RMS have been treated by a multidisciplinary approach combining function-preserving, mostly R1 tumor resection and perioperative IMBT at the University Hospital of Schleswig-Holstein, Germany. All children with orbital RMS, who were enrolled in this multidisciplinary treatment protocol between 1993 and 2002, were prospectively assessed with respect to evaluation of side effects and functional outcome. RESULTS: Ten children (six boys, four girls) were included. Median age was 6.5 years (range, 1-19 years) at the beginning of our treatment and 6.0 years (range 1-17 years) at diagnosis. All children were in Intergroup Rhabdomyosarcoma Study Group (IRSG) group III and had embryonal subtype. Estimated 5-year survival was 62% +/- 18%. There was no radiation-related toxicity grade 3 or 4 observed. The eyes were primarily preserved in all cases. One child underwent secondary orbital exenteration 10 months after completion of IMBT. Visual acuity could be preserved apart from one child developing significant visual deterioration due to radiation cataract grade 2. The cosmetic results were good or very good in eight and moderate in two children. Four children died of their disease. CONCLUSION: This interdisciplinary, individually tailored and function-preserving treatment procedure has proven to be a well-tolerated therapeutic option in cases with refractory orbital RMS. It provides both improvement of local tumor control and quality of life.

Association between human beta defensin expression and cholesteatoma formation.

OBJECTIVE: To investigate an association between human beta defensin (hBD) expression and cholesteatoma formation. METHODS: hBD-2 mRNA expressions were assessed in healthy external acoustic meatus skin organ cultures before and after stimulation with Pseudomonas aeruginosa. In addition, hBD-1 and hBD-2 protein production of stimulated and non-stimulated external acoustic meatus skin was visualized by immunohistochemistry. Furthermore, hBD-1 and hBD-2 mRNA expression was analyzed in 25 external acoustic meatus skin, 29 cholesteatoma, and 18 non-cholesteatoma control samples. Non-stimulated meatal tissue preparation did not express hBD-2, whereas incubation with P. aeruginosa demonstrated hBD-2 induction. RESULTS: The hBD-1 mRNA expression was detected in cholesteatoma (14/17), meatal skin, and middle ear mucosa (11/18). hBD-2 mRNA expression was shown in eight cholesteatoma (28.5%) and in three middle ear mucosa tissue samples (37.5%). CONCLUSION: Our data suggest constitutional hBD-1 and inducible hBD-2 expression in chronic middle ear infection and cholesteatoma. Failure of hBD-1 and hBD-2 expression might dispose to exacerbation of cholesteatoma disease. The organ culture model of the external acoustic meatus skin is effective in order to evaluate germ stimulation experiments.

Defensin and chemokine expression patterns in the palatine tonsil: a model of their local interaction.

Defensins and chemokines are an essential part of the immune response mechanisms in the head and neck mucosa. This work investigates their correlation and their expression pattern in tonsillar disease. Forty-four tonsil tissue samples were obtained from patients who underwent tonsillectomy between 1998 and 1999 for chronic tonsillitis with (n =9) and without (n =25) inflammatory infiltrates and hyperplasia of the tonsil (n =10). Defensin (hBD-1, hBD-2, HNP-1 and HNP-4) and chemokine (RANTES, eotaxin, eotaxin-2, MCP-3, MCP-4 and IL-8) mRNA expressions were analyzed by SQRT-PCR. HNP-4 and eotaxin-2 expressions were positively correlated (P <0.05) in the acute tonsillitis group. HBD-2 and MCP-3 expressions were positively correlated in the hyperplastic tonsils group. Within all groups together, HNP-4 and RANTES expressions were highly positively correlated (P <0.01), and HNP-1 and hBD-2 were positively correlated with IL-8 expressions. Immunohistochemistry demonstrated eotaxin-1 as well as IL-8 production to be predominantly located within the lymphoid follicles and submucosa. RANTES production was shown in the epithelial lining and perivascular tissue. The expression of hBD-1 and hBD-2 was limited to the epithelial lining. Our data support an association between the innate and acquired immune systems on the defensin-chemokine level. The finding of positively correlated hBD-2 and IL-8 expression is biologically relevant because of the proximity of hBD-2 (epithelium) and IL-8 (submucosa) release, as well as the synergistic support of the Th1 system. In addition, our data suggest RANTES as a first-line mediator of perivascular leukocyte recruitment.

Separation of beta2-transferrin by denaturing gel electrophoresis to detect cerebrospinal fluid in ear and nasal fluids.

BACKGROUND: Cerebrospinal fluid (CSF) leakage is a critical condition with a substantial risk of meningitis. We investigated the use of transferrin isoform analysis as a diagnostic marker for detection of CSF leakage in fluid samples. METHODS: We analyzed 241 samples from patients with CSF leakage, most commonly presenting as otorrhea or rhinorrhea, by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) with subsequent Western blotting and immunostaining for transferrin. Tears, saliva, nasal fluid, and ear secretions (20 samples each) were analyzed in parallel, and normal human serum served as a control in each experiment. We compared the minimum volume of added CSF that could be detected in secretions by our assay with the minimum volume detected by the prostaglandin-D synthase (beta-trace) test. CSF was admixed with blood in different proportions to determine the influence of blood contamination on the transferrin pattern. RESULTS: In all CSF samples, beta1- and beta2-transferrin were present in nearly equal amounts. In tears and ear secretions, beta2-transferrin migrated in the gel in the same manner as in CSF, but its concentration was noticeably lower than that of beta1-transferrin, a difference that allowed a clear distinction from the transferrin pattern of CSF. In saliva, both transferrin isoforms were also present but could be distinguished from those of other fluids by electrophoretic migration pattern rather than relative concentrations. With the beta-trace test, a minimum of 5 microL of CSF was needed for detection, whereas our beta2-transferrin assay yielded a signal of comparable intensity with a minimum of 2 microL of CSF. CONCLUSION: Analysis of the transferrin microheterogeneity pattern by SDS-PAGE for the identification of CSF leakage is a highly sensitive and specific method that merits consideration as a routine technique.

Impact to the head increases cochlear implant reimplantation rate in children.

OBJECTIVE: To describe the outcome of cochlear implantation in children and to discuss the cause and management of cochlear reimplantation. STUDY DESIGN: Retrospective chart review. METHODS: The medical records of 110 patients younger than 18 years of age, who underwent cochlear implantation at the Department of ORL, Head and Neck Surgery, of the University of Kiel, Germany, were reviewed for demographics, complications, and history of revision surgery. The patients had previously had implantation with either Nucleus (including the Contour) devices or MED-EL devices. RESULTS: Length of use before cochlear explanation ranged from 4 days to 3.9 years. Reimplantation was caused by traumatic device failure, wrong electrode insertion and infection of implanted area. Results indicated a reimplantation rate of 5.4% in children compared to 0.8% in adults, mostly resulting from the greater risk of children receiving an impact to the head. Postoperative performance data showed no decrease in scores taken before failure. CONCLUSIONS: Though young children who are developing their motor skills are probably at greater risk of a cochlear reimplantation resulting from device failure following head trauma, surgical revision with reimplantation can be performed safely and without decrement to performance.

Human beta-defensin-2 in oral cancer with opportunistic Candida infection.

Candida albicans (CA) is a frequent opportunistic pathogen in cancer patients. Usually, human surfaces are protected, apart from physical barriers, by the production of human beta-defensins (hBD). hBD-2 shows a potent antimicrobial activity against CA. We therefore investigated whether CA induces hBD-2 expression in primary oral cells and if immunosuppressive betamethasone alters hBD-2 expression. Additionally, we studied, whether a lack of hBD-2 expression could explain opportunistic infection of tonsillar cancer. Primary oral epithelial cells and fibroblasts were stimulated with Candida albicans in a time- and dose-dependent manner with or without betamethasone preincubation. Total RNA from oral cells and specimens was isolated and hBD-2 expression was analyzed by semiquantitative RT-PCR. Our data demonstrate that opportunistic CA induced hBD-2 expression in a time- and dose-dependent manner, suggesting hBD-2 to be a fast antifungal, epithelia-derived immune response. Treatment with glucocorticoid could lead to diminished innate immunity based on suppression of inducible AP. Malignant transformation induces alteration of hBD-2 expression and leads to a reduced hBD-2 expression and subsequentially to Candida colonization on oral SCCs.