[Sauer's binaural number test in noise. Significance in expertise]. / Beidohriger Zahlentest im Störgeräusch nach Sauer. Stellenwert in der Begutachtung.

OBJECTIVE: For the determination of speech intelligibility in the expertise of hearing loss, the Freiburg speech test (number test and monosyllable test) is recommended in the Federal Republic of Germany. In the former German Democratic Republic, Sauer's binaural number test with 70 dB background noise ("beidohriger Zahlentest", BZT) was a standard element in expert opinions and was used in the calculation of bodily injury ("Körperschaden"). In the current practice, a hearing test in noise is still lacking. The present study analyzes whether and to what degree the impairment ("Grad der Schädigungsfolgen", GdS) changes when also considering Sauer's test. MATERIAL AND METHODS: In a collective of 78 patients with hearing loss (66 patients with high-frequency hearing loss and 12 patients with pancochlear hearing loss) and 22 normal hearing controls, the following audiometric measurements were conducted: pure tone audiometry, speech audiometry (Freiburg speech test), free field audiometry with and without noise, and Sauer's test. Subsequently, the hearing loss for both sides was calculated taking into consideration the values obtained with and without Sauer's test, and the respective GdS was determined. RESULTS: Patients with high-frequency hearing loss and pancochlear hearing loss had a trend for higher GdS (approximately 2 and 5%, respectively), compared to the established algorithm without the use of hearing tests in noise. However, neither the Mann-Whitney U-test nor the Bland-Altman analysis yielded relevant differences between the two methods to calculate the GdS. CONCLUSION: The routine implementation of Sauer's test in the expertise of hearing loss cannot be recommended, since no relevant change in the GdS can be expected. This is especially true for high-frequency hearing loss. In pancochlear hearing loss, use of Sauer's test can be considered if problems concerning hearing in situations with background noise are present-at least until more advanced hearing tests optimized for use in noise have been integrated into the tables for GdS calculation.

[Correlation of pure tone thresholds and hearing loss for numbers. Comparison of three calculation variations for plausibility checking in expertise]. / Korrelation von Tonschwellenaudiogramm und Hörverlust für Zahlen. Vergleich dreier Rechenvarianten zur gutachterlichen Plausibilitätsprüfung.

BACKGROUND: The present study analyzes the best combination of frequencies for the calculation of mean hearing loss in pure tone threshold audiometry for correlation with hearing loss for numbers in speech audiometry, since the literature describes different calculation variations for plausibility checking in expertise. Three calculation variations, A (250, 500 and 1000 Hz), B (500 and 1000 Hz) and C (500, 1000 and 2000 Hz), were compared. METHODS: Audiograms in 80 patients with normal hearing, 106 patients with hearing loss and 135 expertise patients were analyzed in a retrospective manner. Differences between mean pure tone audiometry thresholds and hearing loss for numbers were calculated and statistically compared separately for the right and the left ear in the three patient collectives. RESULTS: We found the calculation variation A to be the best combination of frequencies, since it yielded the smallest standard deviations while being statistically different to calculation variations B and C. The 1- and 2.58-fold standard deviation (representing 68.3% and 99.0% of all values) was ±4.6 and ±11.8 dB for calculation variation A in patients with hearing loss, respectively. CONCLUSIONS: For plausibility checking in expertise, the mean threshold from the frequencies 250, 500 and 1000 Hz should be compared to the hearing loss for numbers. The common recommendation reported by the literature to doubt plausibility when the difference of these values exceeds ±5 dB is too strict as shown by this study.

[The tasks of the ENT specialist by hearing aid fitting. Part 2: checking the fit, subjective satisfaction, ear mold and hearing aid]. / Die Aufgaben des Hals-Nasen-Ohren-Arztes bei der Hörgeräteversorgung. Teil 2: Uberprüfung von Anpassbericht, subjektiver Zufriedenheit, Ohrpassstück und Hörgerät.

The second part of this series deals with the tasks of the ENT-specialist, who must not endorse the prescription before making sure that the hearing aid recommended by the acoustician will bring sufficient hearing improvement, and that the suggested hearing aid is suitable. The report and audiograms of the acoustician must be compared to his own results, and a check of whether at least three hearing aids from different companies have been compared must be made. The primary aim of patient satisfaction can be checked by means of the "Oldenburger Inventar" (Oldenburg questionnaire), which determines the improvement of hearing ability in quiet and noise, and of auditory localization. Since the otoplastic substantially effects the amplification of the hearing aid, the ENT specialist should make sure that it does not produce feedback, that it has a second boring, and, in case of need, a Libby horn. He should also consider whether an open fitting would be more appropriate. A free-field measurement--with and without noise--shows whether the dB(opt) has been reached. The in situ measurement and the loudness rating by the Würzburger Hörfeld (Wuerzburg auditory field) are of great help in detecting fitting errors. Additional procedures, such as auditory speech training, lip reading, or technical devices, for instance FM-communication or a light alarm clock, are often employed in elderly patients.

Lipid mixing in dimyristoyl phosphatidylcholine-dimyristoyl glycerol dispersions: spin label ESR studies.

The lipid transfer and mixing properties in hydrated dispersions of dimyristoyl phosphatidylcholine (DMPC)/dimyristoyl glycerol (DMG) binary mixtures have been investigated by using electron spin resonance spectroscopy of the spin-labelled lipid components. The assay system is based on the reduction in spectral broadening from spin-spin interactions that takes place by dilution of the spin-labelled lipid on transfer to a 9-fold excess of dispersions that contain no spin label. Lipid dispersions with DMPC:DMG compositions of 70:30, 40:60 and 20:80 mol/mol, for which the fluid phases have lamellar, inverted hexagonal and isotropic structures, respectively, have been studied. Essentially no transfer of spin-labelled lipid takes place for any of the lipid mixtures in the lamellar gel phase, or in dispersions of DMPC alone at all temperatures studied. The greatest degrees of transfer are found in the fluid phase of the DMPC/DMG mixtures. In general, the extent of lipid transfer is greater for the diacylglycerol component than for the phosphatidylcholine component. The extent of transfer of phosphatidylcholine is very low in the fluid lamellar phase of the 70:30 mol/mol DMPC/DMG, as compared with that of diacylglycerol. Only in the case of the 40:60 mol/mol DMPC/DMG mixture, in the inverted hexagonal phase, are the extents of transfer comparable for both phosphatidylcholine and diacylglycerol components, indicating a bulk transfer of lipid within the dispersions. The largest extent of transfer is found for diacylglycerol in the 20:80 mol/mol DMPC/DMG mixture in the isotropic phase.

Bacterial meningitis in adults: demonstration of inner ear involvement using high-resolution MRI.

OBJECTIVE: To visualize the sites involved in audiovestibular dysfunction during bacterial meningitis in adults and to relate these findings to the extent of hearing impairment and vestibular dysfunction. BACKGROUND: Hearing impairment is among the most frequent complications of bacterial meningitis. METHODS: High-resolution MRI (HR-MRI) of the inner ear was performed in seven adult patients with hearing loss as a complication of bacterial meningitis. RESULTS: Five patients had unilateral (n = 1) or bilateral (n = 4) contrast enhancement of vestibulocochlear structures. The structures most frequently involved were the cochlear nerve (n = 9), the first cochlear turn (n = 9), the vestibulum (n = 9), and the semicircular canals (n = 7). There was a significant correlation between clinical and MRI findings: all nine ears with cochlear enhancement were deaf (hearing loss >90 dB), whereas none of the five ears with normal MRI findings had hearing losses of more than 90 dB (range, 30 to 70 dB; p = 0.0005). Vestibular dysfunction as revealed clinically and by quantitative vestibular function testing was found in six of seven patients (11 of 14 ears). Five of these patients (nine ears) also demonstrated enhancement of the vestibular organ on high-resolution MRI of the inner ear. CONCLUSIONS: High-resolution MRI can visualize the involvement of vestibulocochlear structures in bacterial meningitis in both cooperative and consciously impaired patients. These findings suggest a correlation between abnormalities on MRI and the extent of cochlear dysfunction.

Outcome and prognosis in systemic lupus erythematosus.

We have attempted to assess the factors associated with prognosis in SLE, and to document the temporal changes in outcome, related not only to improvements in survival but to the emergence of an increased prevalence or morbidity, related to disease manifestations, complications of treatment, and co-morbid conditions.

Accelerated degeneration of allografts in the first two years of life.

Between January 1988 and May 1994, 53 of 159 patients have received cryopreserved aortic and pulmonary allografts for reconstruction of the pulmonary circuit in the first 2 years of life with body weight ranging from 2.2 to 18 kg (mean, 8.2 +/- 3.4 kg). The implanted allografts ranged in internal diameter from 9 to 23 mm (mean, 16.3 +/- 3.5 mm). Of the 38 survivors who regularly had postoperative echocardiographic examinations 15 (39.5%) underwent cardiac catheterization 1 to 31 months after operation. Allograft dysfunction (gradient > or = 50 mm Hg with or without pulmonary insufficiency) was confirmed in 9 patients leading to reoperation in 5 and valvulo-angioplasty in 4. At 48 months actuarial survival was 64%. In the aortic and pulmonary allografts freedom from wall calcification at 20 months was 19% and 100%, respectively. Freedom from valve dysfunction in patients with aortic and pulmonary allografts was 53% and 88%, respectively; it was 49% in allografts with an internal diameter of 17 mm or smaller. Freedom from reoperation in all patients was 78%. In conclusion, young age, antigenicity (ABO compatibility), and type of allograft seemed to be independent risk factors for early allograft conduit degeneration and late valve dysfunction. Pulmonary allografts seemed to be more resistant to early wall calcification and valve dysfunction than aortic allografts.

Risk factors for early degeneration of allografts in pulmonary circulation.

OBJECTIVE: The aim of this study was to define risk factors for early degeneration of allografts in pulmonary circulation and to recommend some guidelines to minimize them. METHODS: Between January 1988 and March 1995, 202 patients with various types of congenital heart disease received cryopreserved allograft conduits for reconstruction of their right ventricular outflow tract. We report on 63 patients receiving allografts ranging from 9-24 mm size within the first 2 years of life. RESULTS: Survivors have been followed for 4-67 months. Survival at 5 years, including hospital mortality, was 66%. Two patients died at reoperation. Of the patients 19.6% (9/46) had early structural deterioration (SD) of their vascular allografts at a mean of 15.2 months after implantation. Seven of these have already been reoperated with allograft exchange. Freedom of reoperation was 66% at 5 years. Infants showed 48% freedom of reoperation at 5 years compared to 90% in the 1-2 years age group, while freedom of SD was 59% in infants at 48 months compared to 87% in the 1-2 years age group. Of allografts with SD in the infant group 66% had an allograft size of < 14 mm. In aortic allografts freedom of SD was 62% compared to 93% in pulmonary allografts. Freedom of allograft wall calcification was 46% at 18 months in all patients. In the statistical analysis, only infant age (P = 0.03) and aortic allograft (P = 0.02) were shown to be significant risk factors for early SD. CONCLUSION: The use of pulmonary allografts, avoidance of relatively short and small conduits of < 14 mm in diameter, might improve the durability of allografts in infants and small children.

Evaluation of TEOAE and DPOAE measurements for the assessment of auditory thresholds in sensorineural hearing loss.

Transiently evoked otoacoustic emissions (TEOAE) and distortion product otoacoustic emissions (DPOAE) can be quantified concerning their amplitude and frequency. They are known to be diminished or absent in sensorineural hearing loss. It is therefore of interest how TEOAE and DPOAE correlate with the auditory threshold and whether the auditory threshold can be predicted by these variables. In a cross sectional study of 61 patients (102 ears) with sensorineural hearing loss, auditory threshold, tympanometry, stapedius reflexes, TEOAE and DPOAE were measured. Correlation coefficients of the hearing loss (0.5-6 kHz) and the amplitude of the distortion product 2f1-f2 (0.46 4 kHz) respectively TEOAE amplitude (1-4 kHz) were computed. TEOAE showed lower correlation coefficients and less frequency specificity than DPOAE. In order to increase the correlations with the auditory threshold we fitted a multivariate linear regression model with TEOAE and DPOAE simultaneously as predictors for the auditory threshold gaining 95% prediction intervals of 19-39 dB depending on the frequency investigated. By restricting the hearing loss to a maximum of 70 dB HL the 95% prediction interval of the auditory threshold could be decreased to 18-26 dB. Further improvements can be expected if the high inter- and intraindividual variability of TEOAE and particularly DPOAE measurements can be reduced. The results allow us to use TEOAE and DPOAE in addition to click-evoked brainstem audiometry in order to provide more frequency specific information about the hearing loss in newborns, which is of the utmost importance for an ideal fitting of hearing aids.

Clinical utility of LDL-apheresis in the treatment of sudden hearing loss: a prospective, randomized study.

Although the pathogenesis of sudden hearing loss (SHL) is not as yet known, the clinical picture and the frequent association with vascular risk factors make an ischaemic event likely. This study aimed to assess the effect of an extracorporeal procedure (H.E.L.P.) in removing LDL-cholesterol, fibrinogen and lipoprotein (a) from the plasma, on the recovery of hearing SHL. This procedure using the HELP-system was compared with the usual standard treatment with prednisolone, dextranes and pentoxifyllin. We undertook a single centre, prospective, randomized study in which 18 patients were assigned to H.E.L.P.-apheresis and 9 patients were assigned to standard treatment (2:1 randomization). Audiometric and laboratory testing was performed at baseline, 24 h and 6 weeks after start of treatment. Primary endpoint was the improvement of the average pure-tone threshold between 0.125 and 8 kHz after 24 h. Twenty-four hours after H.E.L.P. treatment average pure-tone threshold recovered by 10.4 dB and by 26.4 dB after 6 weeks. The recovery of hearing of the standard treated patients was 5.8 dB and 16.8 dB after 24 h and 6 weeks respectively. LDL-cholesterol, fibrinogen and lipoprotein (a) were significantly reduced in the HELP treated patients compared with standard therapy, resulting in a significant improve in plasma viscosity, erythrocyte aggregation and resistance to oxidative stress of LDL particles. Our results suggest that the clinical outcome of SHL after a single extracorporeal LDL-apheresis is superior or at least equal to the more expensive standard treatment with prednisolone, dextranes and pentoxifyllin. Re-establishment of vascular endothelial function and improved blood rheology may be the underlying cause. These results must be confirmed in larger-scale trials.

Changes in serum osmolarity influence the function of outer hair cells.

Fast motility of outer hair cells (OHC) is thought to be based on a hydromechanic principle. In vitro, the function of OHCs can be disturbed by a change in the osmolarity of the culture medium. Whether changes in the serum osmolarity in vivo can also interfere with OHC motility has not been investigated as yet. Serum osmolarity of New Zealand White rabbits (n = 18) was elevated by a continuous infusion of glucose 40%, decreased by an infusion of aqua dest, or kept constant by an infusion of saline. OHC function was monitored using distortion products of otoacoustic emissions (DPOAE). Input output curves were established between 2 and 5 kHz (geometric mean of f2) with primaries of levels between 35 and 55 dB SPL. Cochlear perfusion was measured using a fluorescence microsphere method. Elevation of the serum osmolarity from 306 +/- 17 mosm/l to 365 +/- 23 induced a decrease of DPOAE between 3 and 12 dB SPL. Cochlear blood flow increased from 0.11 +/- 0.09 to 0.15 +/- 0.10 ml/min/g. When decreasing the serum osmolarity from 303 +/- 9 to 281 +/- 8 mosm/l, only slight changes of the DPOAE could be verified. As in the control group, cochlear perfusion was almost unchanged. In the control group, neither serum osmolarity nor DPOAE changed. Comparable to findings in vitro, increasing the serum osmolarity can lead to a disturbance of OHC function. In patients suffering from sudden hearing loss. dehydration due to physical or mental stress is often observed. This new and promising pathophysiological concept needs further clinical evaluation.

The enzymology of nasal secretion.

Normal human nasal fluid contains several enzymes of the intermediary metabolism as well as a specific protease inhibitor, which inhibits trypsinm chymotrypsin and leucocytic proteases. During the course of acute and chronic nasal and paransal sinus infections the inhibitor level varies. The inhibitor level is an indicator of poor healing. It is possible too, to differentiate viral rhinitis from bacterial or allergic or atrophic rhinitis by a signigicant increase of the activities of the enzymes GOT, LDH and CPK.

[All sudden hearing losses are not alike. Away from infusion therapy?]. / Hörsturz ist nicht gleich Hörsturz. Weg von der Infusionstherapie?

The number of patients requiring treatment for acute functional disorders of the inner ear has increased over the last decades. The diagnosis sudden loss of hearing is made when the cause of a precipitous hearing impairment cannot be determined with clinical diagnostic means. In the large majority of such cases, the pathogenesis is unclear, with vascular, viral and autoimmune processes most commonly being considered. Against this background, numerous polypragmatic therapeutic measures are employed. In general treatment of sudden loss of hearing employs a combination of several drugs with perfusion-promoting or anti-inflammatory effects. However, the efficacy of such an approach has not been established. The present article discusses a number of known ideas on the pathogenesis of this condition, together with the associated therapeutic strategies, and reports on the importance of nitrogen oxide (NO), which as recent studies appear to show, plays an important role in the physiology of the cochlea.

[The task of the HNO specialist by Hearing Aid fitting. Part 1: indications, special diagnostic tests, prescription]. / Die Aufgaben des HNO-Arztes bei der Hörgeräteversorgung. Teil 1: Indikation, gezielte Diagnostik und Verordnung.

The first part of the article deals with the indication of fitting, which mainly is given when the communication is impaired, not only in dialogue with one person, but also in conversation with several persons and in noisy surrounding. Yet, the healthy insurances cover only the expenses if the guidelines on relief-aid are considered, which are exactly listed in this article. Bevor starting the fitting of an Hearing Aid, special diagnostic tests are necessary, such as pure tone audiogram, speech audiogram including dB(opt), freefield measurement in noise, and several retrocochlear tests, as well as tinnitus determination and masking with narrow-band and broad-band noise. Most important is the correct filling in the form "Ohrenärztliche Verordnung einer Hörhilfe", including the necessity of renewal. In addition, it is necessary to accentuate the need of trying out several Hearing Aids and to let the patient know that digital Hearing Aids will not be covered by the health insurance.

[Niikawa-Kuroki syndrome. Which characteristics must the HNO doctor consider in its diagnosis]. / Niikawa-Kuroki-Syndrom. An welche Besonderheiten muss der HNO-Arzt bei der Diagnose denken?

Niikawa-Kuroki syndrome (Kabuki make-up syndrome) is a congenital disorder with characteristic facial features and possibly anomalies of the skeletal system and internal organs. There is an increasing number of reports of patients with combined hearing impairment, inner ear deformities or sensorineural hearing impairment. In addition, the patients often suffer from therapy-resistant chronic otitis media. In addition to multiple cardiac and renal deformities, our 3 year old patient has a hearing impairment due to chronic otitis media with chronic otorrhea, and requires a hearing aid. A high-definition CT scan of the petrosal bone revealed, for the first time in a patient with Niikawa-Kuroki syndrome, a large vestibular aqueduct syndrome and deformities of the vestibular system. We examine the problems involved with treating chronic otorrhea in chronic otitis media and providing patients with BTE hearing aids.

The Munich screening programme in neonates.

For development, it is necessary to stimulate the auditory pathway during the first weeks of life. This knowledge and improved techniques for the treatment of young children with hearing loss make early detection even more important, otherwise developmental disabilities inevitably occur. The method of transient-evoked otoacoustic emissions is the most useful test for neonatal screening and has the following advantages: emissions are quickly measured (i.e. within a few minutes), the measurements can be performed in the hospital nursery by trained volunteer examiners, the test produces the same results in awake, anaesthetized, sedated, and sleeping patients, and the existence of TEOAEs excludes with very high probability a peripheral hearing loss which may influence the development of speech. A prerequisite of a successful evaluation with crying and moving neonates is an apparatus with two specific rejection thresholds; one for time, the second for amplitude. Additionally, the probe has to be robust, but also small both to minimize its weight and to fit comfortably within the diameter of the neonatal ear canal.

[Check of hearing aid fitting]. / Hörgeräteüberprüfung in der Praxis.

A qualified hearing aid fitting is only possible if the ENT doctor not only prescribes the device, but also conscientiously checks the comparative adjustments made by the hearing aid acoustician. In deciding, which of the tested hearing aids achieves the best and most appropriate improvement of hearing, the physician should first thoroughly study the acoustician's fitting protocol, which contains comparative results of all devices tested. The subjective satisfaction of the patient with his hearing aid can be determined in a detailed conversation or with a special questionnaire. The examination of the otoplastic is as necessary as the improvement of speech discrimination under free field conditions, especially with additional noise. With in situ measurement, the individual transmission characteristics of the hearing aid and the otoplastic are tested in a few minutes. Conscientious control of the fitted hearing aid is only possible with loudness scaling. The scaling function shows clearly whether the fitted aid has adequate amplification, is not too loudly adjusted, and whether the field of pleasant hearing has been considered.

[The importance of hearing-aid testing by the otorhinolaryngologist]. / Die Bedeutung der Hörgeräteüberprüfung durch den Facharzt für HNO.

In a period of 16 months, 312 patients suffering from impaired hearing were supplied with hearing aids after undergoing conventional hearing tests conducted by acousticians. During the hearing follow-up tests, it was found that 111 patients (35.5%) had been optimally supplied with hearing aids and that for 98 hard-of-hearing persons (31.4%) merely fine adjustments had to be made on the hearing aids. In some cases a second bore had to be drilled into the ear mould. We had to completely refit 103 patients (33.0%) with hearing aids, since the previously fitted devices no longer complied with the type and degree of a hearing impairment based on the frequency characteristics, amplification, and dynamic range. The fitting reports had not been filled out satisfactorily in the case of 224 patients (71.8%). This was especially true of the stereophonic adjustment reports.