[Effects of the SARS-CoV­2 pandemic on the otolaryngology university hospitals in the field of research, student teaching and specialist training]. / Auswirkungen der SARS-CoV­2-Pandemie auf die universitäre Hals-Nasen-Ohren-Heilkunde im Bereich der Forschung, Lehre und Weiterbildung.

BACKGROUND: From spring 2020, SARS-CoV­2 began to spread worldwide, with what is now known as the first wave of the pandemic, starting in March 2020. This resulted in restructuring and shift of resources at many hospitals. The aim of our work was to detect the effects of the pandemic on the german Oto-Rhino-Laryngology (ORL) university hospitals in terms of research, student teaching and further specialist training. MATERIAL AND METHODS: The chairmen of the 39 ORL university hospitals in Germany were asked about the effects of the pandemic on research, student teaching and ORL specialist training (residency) in the period from March to April 2020 using a structured online survey. RESULTS: All 39 chairmen took part in the survey. Of these, 74.4% (29/39) stated that their research activities had deteriorated as a result of the pandemic. In 61.5% (24/39) pandemic-related research issues were addressed. All hospitals reported a restriction for in-house teaching and 97.5% (38/39) introduced new digital teaching methods. During the observation period, 74.4% of the chairmen did not see ORL specialist training (residency)at risk. CONCLUSION: Our results provide an insight into the heterogeneous effects of the pandemic. The fast processing of pandemic-related research topics and the introduction of innovative digital concepts for student teaching impressively demonstrates the great innovative potential and the ability of the ORL university hospitals to react quickly in order to maintain their tasks in research, student teaching and ORL specialist training in the best possible way even during the pandemic.

[Characterization of a closed-set logatome test : Documentation of audiometric data: discrimination function and reproducibility]. / Charakterisierung eines geschlossenen Logatomtests : Erhebung audiometrischer Kenndaten: Diskriminationsfunktion und Reproduzierbarkeit.

BACKGROUND: Logatomes, nonsensical combinations of consonants and vowels, are suitable for a precise capture and analysis of individual phonemes as fundamental modules of speech in audiometric diagnostics. OBJECTIVE: The aim of this prospective study was to capture the audiometric characteristics of a closed-set logatome test. The slope of the discrimination function at the speech reception threshold (SRT) and the reproducibility were analyzed. MATERIAL AND METHODS: A set of 102 intensity varied and randomized logatomes were presented in the form of consonant-vowel-consonant to 25 hearing unimpaired adults. The measurements were performed in a free field setting and were each repeated after a 2-week interval. The subjects were requested to repeat the heard logatome in a closed response test of 10 items per sound item on a touchscreen. RESULTS: The slope of the mean discrimination function at the SRT was on average 4%/dB; however, the mean discrimination function slope was steeper for the initial consonant than for the final one. The differences of the test and retest results at the SRT showed a standard deviation of 13% for consonants. These differences were normally distributed. There were no significant differences between test and retest. CONCLUSION: The slope of the discrimination function at the SRT appeared to be shallow but was comparable to established word tests. Finally, there was no evidence of a learning effect in the retest, which emphasizes the low redundancy of the speech material and makes it an attractive complementary option to routine audiometric diagnostics.

[Effects of the SARS-CoV-2 pandemic on the otorhinolaryngology university hospitals in the field of medical care]. / Auswirkungen der SARS-CoV-2-Pandemie auf die universitäre Hals-Nasen-Ohrenheilkunde im Bereich der Krankenversorgung.

INTRODUCTION: Since December 2019, the SARS-CoV-2 virus has been rapidly spreading worldwide. In Germany, an exponential increase in the number of infections was registered at the beginning of March 2020 and led to a call of the Ministry of Health to create more capacity for intensive medical treatment in hospitals. The aim of the present study was to determine the effects of the SARS-CoV-2 pandemic on Oto-Rhino-Laryngology (ORL) university hospitals regarding patient care. MATERIALS AND METHODS: An online survey was sent out to all chairmen of the 39 ORL university hospitals in Germany. The answers to the questions referred to the defined period from March 15th to April 15th 2020 and were carried out using the online survey tool "SurveyMonkey". 87 questions focused on general information, health care, and structural effects in the respective institution. RESULTS: All chairmen of the 39 university hospitals in Germany participated in the survey. The collected data prove the considerable impact on organizational, structural and medical aspects of patient care. For example, the surveyed clinics reported a decrease in outpatient cases by 73.8 % to 26.2 ±â€Š14.2 % and in surgical treatments by 65.9 % to 34.1 ±â€Š13.9 %. In contrast, emergency treatment remained unchanged or even increased in 80 % of the facilities and surgical treatment of emergency patients remained unchanged or even increased in more than 90 %. Emergency outpatient and surgical treatment of patients was provided throughout the pandemic in all facilities. In total, about 35 000 outpatients and about 12 000 surgical cases were postponed. As a result of the acute structural changes, the potential danger of falling below current treatment standards was seen in individual areas of patient care. DISCUSSION: The assessment of the impact of the SARS-CoV-2 pandemic is heterogeneous. The majority of the chairmen are critically aware of the risk of falling below current medical treatment standards or guidelines. In the phase of an exponential increase in the number of infections, significant changes in treatment processes had to be accepted for understandable reasons. However, with the currently significantly reduced number of infections, falling below treatment standards and guidelines should not be allowed to remain constant and tolerated. SUMMARY: This study shows a differentiated picture with regard to the effects of the SARS-CoV-2 pandemic on outpatient, inpatient and operative patient care at the ORL university hospitals in Germany and illustrates the importance of these institutions for ensuring patient care during this critical phase.

Speech audiometry and data logging in CI patients : Implications for adequate test levels.

BACKGROUND: As part of postoperative cochlear implant (CI) diagnostics, speech comprehension tests are performed to monitor audiological outcome. In recent years, a trend toward improved suprathreshold speech intelligibility in quiet and an extension of intelligibility to softer sounds has been observed. Parallel to audiometric data, analysis of the patients' acoustic environment can take place by means of data logging in modern CI systems. OBJECTIVES: Which speech test levels reflect the individual listening environment in a relevant manner and how can these be reflected in a clinical audiometric setting? PATIENTS AND METHODS: In a retrospective analysis, data logs of 263 adult CI patients were evaluated for sound level and the listening situation (quiet, speech in quiet, noise, speech in noise, music, and wind). Additionally, monosyllabic word comprehension in quiet was analyzed in experienced CI users at presentation levels of 40-80 dB. RESULTS: For the sound level in the acoustic environment of postlingually deafened adult CI users, data logging shows a maximum occurrence of speech signals in the range of 50-59 dB. This demonstrates the relevance of everyday speech comprehension at levels below 60 dB. CONCLUSION: Individual optimization of speech intelligibility with a CI speech processor should not be performed in the range of 65-70 dB only, but also at lower levels. Measurements at 50 dB currently seem to be a useful addition.

[Speech audiometry and data logging in CI patients : Implications for adequate test levels. German version]. / Sprachaudiometrie und Datalogging bei CI-Patienten : Überlegungen zu geeigneten Sprachpegeln.

BACKGROUND: As part of postoperative cochlear implant (CI) diagnostics, speech comprehension tests are performed to monitor audiological outcome. In recent years, a trend toward improved suprathreshold speech intelligibility in quiet and an extension of intelligibility to softer sounds has been observed. Parallel to audiometric data, analysis of the patients' acoustic environment can take place by means of data logging in modern CI systems. OBJECTIVES: Which test levels reflect the individual listening environment in a relevant manner and how can these be reflected in a clinical audiometric setting? PATIENTS AND METHODS: In a retrospective analysis, data logs of 263 adult CI patients were evaluated for sound level and the listening situation (quiet, speech in quiet, noise, speech in noise, music, and wind). Additionally, monosyllabic word comprehension in quiet was analyzed in experienced CI users at presentation levels of 40-80 dB. RESULTS: For the sound level in the acoustic environment of postlingually deafened adult CI users, data logging shows a maximum occurrence of speech signals in the range 50-59 dB. This demonstrates the relevance of everyday speech comprehension at levels below 60 dB. CONCLUSIONS: Individual optimization of speech intelligibility with a CI speech processor should not be performed in the range of 65-70 dB only, but also at lower levels. Measurements at 50 dB currently seem to be a useful addition.

32 years of experience with CO2 -LASER-assisted treatment for Zenker's Diverticulum - an update of 227 patients treated in Kiel.

OBJECTIVES: To underline the value of the microendoscopic CO2 -LASER-assisted treatment (MEDCO2 ) for Zenker's diverticulum by investigating a large patient cohort treated in a single medical centre. DESIGN: Retrospective cohort study of consecutive patients. SETTING: Department of Otorhinolaryngology, Head and Neck Surgery, Christian-Albrechts-University Kiel, Germany. PARTICIPANTS: A total of 227 patients with Zenker's diverticulum were treated by MEDCO2 , and the results were compared with those reported in the literature for the open transcervical approach (OTA) and the endoscopic staple-assisted oesophagodiverticulostomy (ESED). OUTCOME MEASUREMENTS: Data assessment regarding preoperative symptoms, perioperative management, morbidity, mortality and longtime results. Comparison of results with data from the literature regarding MEDCO2 , ESED and OTA. RESULTS: Operation duration: 25 min median; morbidity: 4.7%; mortality: 0%; mediastinitis: 0.9%; hospitalisation: 7 days; feeding tube dependency: 4 days; recurrence rate: 6.1%. Rise of body temperature above 38°C and 39°C in 36.7% and 12.2% of cases on first postoperative day, respectively. CONCLUSIONS: The results identify MEDCO2 as superior in comparison with ESED and OTA concerning the treatment for Zenker's diverticulum especially in terms of excellent long-term functional results and a low morbidity and mortality. The short operation time qualifies MEDCO2 as specifically suitable for the treatment of the characteristic patient cohort with Zenker's diverticulum, namely the elderly, whereas OTA should be reserved for cases with sophisticated or impossible endoscopic exposure of the pouch. The occurrence of perioperative fever can be managed with a systemic antibiotic and antipyretic medication. Although a mediastinitis as major complication is a rare event, the early introduction of its diagnosis with CT scans and consecutive therapy including thoracotomies can be lifesaving.

[The Freiburg monosyllable word test in postoperative cochlear implant diagnostics]. / Der Freiburger Einsilbertest in der postoperativen CI-Diagnostik.

BACKGROUND: The Freiburg monosyllable word test represents a central tool of postoperative cochlear implant (CI) diagnostics. OBJECTIVES: The objective of this study is to test the equivalence of different word lists by analysing word comprehension. For patients whose CI has been implanted for more than 5 years, the distribution of suprathreshold speech intelligibility outcomes will also be analysed. PATIENTS AND METHODS: In a retrospective data analysis, speech understanding for 626 CI users word correct scores were evaluated using a total of 5211 lists with 20 words each. RESULTS: The analysis of word comprehension within each list shows differences in mean and in the kind of distribution function. There are lists which show a significant difference of their mean word recognition to the overall mean. The Freiburg monosyllable word test is easy to administer at suprathreshold speech level for CI recipients, and typically has a saturation level above 80 %. CONCLUSION: The Freiburg monosyllable word test can be performed successfully by the majority of CI patients. The limited balance of the test lists elicits the conclusion that an adaptive test procedure with the Freiburg monosyllable test does not make sense. The Freiburg monosyllable test can be restructured by resorting all words across lists, or by omitting individual words of a test list to increase the reliability of the test. The results show that speech intelligibility in quiet should also be investigated in CI recipients al levels below 70 dB.

Prospective evaluation of malignant cell seeding after percutaneous endoscopic gastrostomy in patients with oropharyngeal/esophageal cancers.

BACKGROUND AND STUDY AIMS: Insertion of a percutaneous endoscopic gastrostomy (PEG) is standard care for many patients with oropharyngeal (ENT) and esophageal malignancies in order to ensure enteral feeding. The current pull-through insertion technique involves direct contact with the tumor and case reports have demonstrated the presence of metastases at insertion sites. The aim of the current study was to prospectively evaluate the risk of malignant cell seeding and the development of abdominal wall metastases after PEG placement. PATIENTS AND METHODS: A total of 50 consecutive patients with ENT/esophageal tumors were included. After PEG placement (40 pull-through technique, 10 direct insertion), brush cytology was taken from the PEG tubing and the transcutaneous incision site. A second cytological assessment was performed after a follow-up period of 3 - 6 months. RESULTS: In total, 26 patients with ENT cancer, 13 with esophageal cancer, and one with esophageal infiltration of lung cancer underwent pull-through PEG placement with no immediate complications. Cytology following brushing of tubing and incision sites demonstrated malignant cells in 9 /40 cases (22.5 %). Correlation analyses revealed a higher rate of malignant seeding in older patients and in those with higher tumor stages. At follow-up, cytology was undertaken in 32 /40 patients who had undergone pull-through PEG placement. Malignant cells were present in three on cytology, resulting in a metastatic seeding rate of 9.4 %. CONCLUSION: This study showed that malignant cells were present in 22.5 % of patients immediately after pull-through PEG placement; local metastases were verified at follow-up in 9.4 %, all of which were from esophageal squamous cell carcinoma. This risk is particularly high in the older age group and in patients with higher tumor stages. Therefore, pull-through PEG placement should be avoided in these patients and direct access PEG favored instead.

Clinically relevant asymmetry of bispectral index during recovery from anaesthesia for ear-nose-throat surgery in adults and children.

This study investigates the incidence of clinically relevant asymmetry in bispectral index readings from different sides of the skull (using two monitors) during ear-nose-throat surgery in 42 adults and 46 children. A unilateral increase or decrease > 10% from baseline was defined as an 'asymmetry'. Asymmetry followed by movement after stimulation was defined as a 'clinically relevant asymmetry'. Asymmetry occurred in 39 out of 42 adults (93%) and in 20 out of 46 children (44%) during surgery and in 24 out of 42 adults (57%) and in 17 out of 46 children (37%) during recovery. Clinically relevant asymmetry was observed in 5 out of 42 adults (12%) and 6 out of 46 children (13%). The incidence of asymmetry was higher in adults during surgery (p = 0.0002). In conclusion, clinically relevant bispectral index asymmetry has been observed in > 10% of paediatric and adult anaesthesia and may have clinical implications. You can respond to this article at http://www.anaesthesiacorrespondence.com.

[A rare tumour of the auricle]. / Ein seltener Ohrmuscheltumor.

We report on a patient suffering from a mesenchymal tumour located at the antihelix. Histopathology of the tissue specimens derived from this lesion reported a myofibroblastic sarcoma, a rare tumour entity with a slight predominance of occurrence in the area of the head and neck. Grading of these tumours can be challenging since benign as well as malign phenotypes have been described. Therefore, beside complete resection of the lesion additional radiotherapy should be discussed individually.

[Functional organ preservation in laryngeal and hypopharyngeal cancer]. / Funktionserhaltende Therapie des Kehlkopf- und des Hypopharynxkarzinoms.

The principles of open vs. laser microsurgical approaches for partial resections of the larynx are described, oncological as well as functional results discussed and corresponding outcomes following primary radiotherapy are opposed. Over the last decade, the endoscopic partial resection of the larynx has developed to an accepted approach in the treatment of early glottic and supraglottic carcinomas thus leading to a remarkable decline in the use of open surgery. Comparing the various surgical approaches of laryngeal partial resections, the oncological outcome of the patients, as far as survival and organ preservation are concerned, are comparable, whereas functional results of the endoscopic procedures are superior with less morbidity. The surgical procedures put together, are all superior to radiotherapy concerning organ preservation. Transoral laser microsurgery has been used successfully for vocal cord carcinomas with impaired mobility or fixation of the vocal cord, supraglottic carcinomas with infiltration of the pre- and/or paraglottic space as well as for selected hypopharyngeal carcinomas. It has been well documented that laser microsurgery achieves good oncological as well as functional results with reasonable morbidity. However, patients with those tumours have been successfully treated by open partial resections of the larynx at medical centres with appropriate expertise. The initially enthusiastic assessment of study results concerning the efficacy of various protocols of chemoradiation with the intent of organ preservation for laryngeal and hypopharyngeal carcinomas are judged more cautious, today, due to recent reports of rather high rates of late toxicity complications.

Severe impaired respiratory ciliary function in Wegener granulomatosis.

OBJECTIVE: The pathogenesis of granulomatous inflammation in the respiratory tract and autoimmunity in Wegener granulomatosis (WG) are poorly understood. Since mucociliar clearance represents the first major line of defence in the respiratory tract and its breakdown facilitates chronic inflammation, we investigated ciliary beat frequency (CBF) in WG. METHODS: Nasal epithelial cells were obtained from 30 patients with WG with involvement of the upper respiratory tract, 12 patients with other inflammatory rheumatic disease and 10 healthy controls. CBF was measured at 5 and 24 h after collection. RESULTS: were correlated with clinical data. Results: CBF was significantly reduced in WG compared to disease and healthy controls after 5 and 24 h. In WG, CBF almost stagnated after 24 h. Reduction of CBF correlated with the cumulative number of immunosuppressive agents in WG, but not in disease controls. No correlation was found between CBF impairment and cyclophosphamide levels, disease extent, disease activity, disease duration, serological and microbiological findings, or inflammation markers. CONCLUSION: CBF is severely impaired in WG, potentially influenced by immunosuppressive treatment. To what extent CBF impairment and subsequent barrier dysfunction are caused by other factors still has to be elucidated. Supportive measures to improve mucociliary clearance should be discussed in patients with WG.

Olfactory dysfunction in Wegener's granulomatosis.

Necrotizing granulomatous inflammation of the upper respiratory tract is one of the hallmarks of Wegener's granulomatosis (WG), which may explain the reason for olfactory dysfunction in WG. However, a systematic analysis using modem olfactory testing tools has not been performed and potential causes of dysfunction at different levels of olfactory information processing remain obscure so far. In this study a group of 76 WG-patients was examined with sniffin'sticks screening 12, odour threshold (T)/discrimination (D)/identification (I) TDI-score, active anterior rhinomanometry and a standardized questionnaire for olfactory function. WG-patients were aware of their olfactory dysfunction, as proven by psychophysiological test results. An altered olfactory function was significantly correlated to local administration of mupirocin and to the time interval between first diagnosis and study entry. None of the other variables had a statistical significant effect on the olfactory dysfunction.

Head and neck manifestations of Wegener's granulomatosis.

Wegener's Granulomatosis (WG) is a necrotizing granulomatous angiitis that presents the classic ELK triad of ear, nose, throat (E), lung (L), and kidney (K) involvement. Its potential rapid and fatal outcome makes the early recognition--before irreversible organ involvement occurs--mandatory. The aetiology is still unknown. Today, immunosuppressive therapy makes WG a treatable disease with a chronically relapsing course. The otorhinolaryngologist plays an important role in early diagnosis of WG, because in up to 95% of the patients initial WG symptoms are observed in the head and neck region. The majority of these patients show nasal or sinunasal involvement. Common manifestations are sinusitis, crusting of the nose, and development of saddle nose deformity. Other head and neck problems are middle and inner ear symptoms and subglottic stenosis. Follow up and activity assessment of the disease are also important roles to play for the otorhinolarygologist.

The effect of an adjuvant mistletoe treatment programme in resected head and neck cancer patients: a randomised controlled clinical trial.

The effect of an adjuvant mistletoe extract treatment was tested in a prospective, randomised controlled clinical trial involving 477 patients with head and neck squamous cell carcinoma. The patients were stratified into two treatment groups that underwent surgery or surgery followed by radiotherapy and both groups were randomised for additional treatment with mistletoe extract. Patients treated with a mistletoe lectin-1 (ML-1) standardised mistletoe preparation had no lower risk of local/locoregional recurrences, distant metastases or second primaries. In the main analysis based on 202 patients treated with surgery and 275 patients treated with surgery and radiotherapy the adjusted hazard ratio for the disease-free survival (DFS) was 0.959 (95% confidence interval (CI) 0.725-1.268). The 5-year survival rates of patients from the mistletoe group were no better than the survival rates of patients from the control group. Furthermore, no significant changes in the cellular immune reaction or in quality of life could be detected. We conclude that the used mistletoe preparation has no indication in the adjuvant treatment of patients with head and neck cancer.

p16 alterations and retinoblastoma protein expression in squamous cell carcinoma and neighboring dysplasia from the upper aerodigestive tract.

The progression potential of preinvasive epithelial lesions is usually evaluated by assessing the degree of histologic dysplasia. We examined p16, retinoblastoma protein (pRb), and proliferating cell nuclear antigen (PCNA) immunophenotypes in 57 cases of previously untreated squamous cell carcinoma (SCC) of the upper digestive tract and in the neighboring normal and dysplastic epithelia. Tissue samples were examined for homozygous deletion of exon 2 of the p16 gene using polymerase chain reaction (PCR) analysis. The PCNA index increased with increasing grade of dysplasia. The pRb protein was expressed in 89% of the samples of SCCs and in the neighboring dysplasias and carcinoma in situ (CIS). In cases with a lack of pRb expression, corresponding preinvasive lesions were also negative. Lack of p16 expression was found in 82% of SCCs. The prevalence of p16 expression decreased with increasing grade of dysplasia. Molecular analysis of the p16 gene showed homozygous deletion in 37% of SCCs, 33% of CIS, and 15% of the samples of normal epithelia. Our data indicate that inactivation of p16 may play an important role in early head and neck carcinogenesis, whereas the mutation of Rb may be an infrequent event. The p16 immunophenotype might be a biomarker for an increased risk of progression in squamous dysplasia.

p53 and MDM2 protein expression in squamous cell carcinoma and neighboring dysplasia from the upper aerodigestive tract.

BACKGROUND: The identification of genetic changes in preinvasive epithelial lesions may provide markers for a better assessment of the progression potential. MATERIALS AND METHODS: p53, MDM2 and PCNA immunophenotypes were examined in 57 cases of squamous cell carcinoma (SCC) of the upper aerodigestive tract and the adjacent normal and dysplastic epithelia. RESULTS: PCNA index increased with increasing grade of dysplasia. p53 protein was expressed in 35% and MDM2 protein in 33% of SCCs. The p53 protein was expressed in 89% of mild and moderate and in 93% of severe dysplasia and carcinoma in situ adjacent to p53-positive SCCs. The MDM2 protein was expressed in 30% of mild and moderate and in 54% of severe dysplasia and carcinoma in situ adjacent to MDM2-positive SCCs. Preinvasive lesions adjacent to negative SCCs stained negative. CONCLUSIONS: p53 protein was detected more frequently in preinvasive lesions than MDM2 protein and seems to be of greater value as a biomarker.

Overexpression of the human myosin-binding protein-C1 mRNA in laryngeal squamous cell carcinoma cells.

BACKGROUND: To compare gene expression patterns between laryngeal squamous cell carcinoma (SCC) cells and their normal phenotypes to identify genes showing differential expression. MATERIALS AND METHODS: Messenger RNA was isolated from both kinds of cells, reversely transcribed and subjected to differential display reverse transcription (DDRT)-PCR. Gene fragments showing difference in the expression were recovered, reamplified, cloned and sequenced, enabling homology search. Total RNA was isolated from laryngeal SCC cells and adjacent normal mucosa and subjected to Northern hybridization. RESULTS: A 159 bp gene fragment was detected, revealing 96% homology with the human myosin-binding protein-C1 (MYBPC-1) gene. Compared to the benign phenotypes the expression of MYBPC-1 was particularly increased in SCC cells, confirmed by Northern hybridization. CONCLUSION: The results presented in this work may help to extend the diagnostic panoply available for the evaluation of laryngeal tissue conspicuous for malignancy.