Consensus for voice quality assessment in clinical practice: guidelines of the European Laryngological Society and Union of the European Phoniatricians.

INTRODUCTION: To update the European guidelines for the assessment of voice quality (VQ) in clinical practice. METHODS: Nineteen laryngologists-phoniatricians of the European Laryngological Society (ELS) and the Union of the European Phoniatricians (UEP) participated to a modified Delphi process to propose statements about subjective and objective VQ assessments. Two anonymized voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 3/4. The statements with ≥ 3/4 score by 60-80% of experts were improved and resubmitted to voting until they were validated or rejected. RESULTS: Of the 90 initial statements, 51 were validated after two voting rounds. A multidimensional set of minimal VQ evaluations was proposed and included: baseline VQ anamnesis (e.g., allergy, medical and surgical history, medication, addiction, singing practice, job, and posture), videolaryngostroboscopy (mucosal wave symmetry, amplitude, morphology, and movements), patient-reported VQ assessment (30- or 10-voice handicap index), perception (Grade, Roughness, Breathiness, Asthenia, and Strain), aerodynamics (maximum phonation time), acoustics (Mean F0, Jitter, Shimmer, and noise-to-harmonic ratio), and clinical instruments associated with voice comorbidities (reflux symptom score, reflux sign assessment, eating-assessment tool-10, and dysphagia handicap index). For perception, aerodynamics and acoustics, experts provided guidelines for the methods of measurement. Some additional VQ evaluations are proposed for voice professionals or patients with some laryngeal diseases. CONCLUSION: The ELS-UEP consensus for VQ assessment provides clinical statements for the baseline and pre- to post-treatment evaluations of VQ and to improve collaborative research by adopting common and validated VQ evaluation approach.

Promoting culturally informed and sensitive practice in day-care centers-a contribution to the professionalization of day-care teachers.

Background: Based on the growing number of families and young children with a refugee background in Germany, day-care teachers face enormous challenges regarding culturally informed practice. The project "Gemeinsam stark durch den Start" (Stronger together by starting together) addresses these challenges on various levels. At the level of day-care teachers, training in culturally informed and sensitive education is combined with reflection sessions about their own attitudes and prevailing intercultural norms, thus contributing to the professionalization of day-care teachers. Aim: This paper focuses on mechanisms of action that contributed to the effectiveness of the training from two perspectives: the day-care teachers' perspective and the trainers' perspective. Methods: Staff members of 11 German day-care centers underwent graded online training sessions (team and in-depths trainings) addressing intercultural topics. All participants were presented with a questionnaire for their training evaluation before and after the training sessions. Also, participants of the in-depths trainings participated in semi-structured interviews on the training. Furthermore, qualitative interviews were conducted with all trainers (N = 4) of the workshops. Results: Day-care teachers evaluated the online training positively, especially the improvement of professionalization and the implementation of training elements. Results reveal that (work-related) reflexive sessions as well as sessions dealing with the implementation of exercise tools into daily practice were rated as fundamental parts in the training. Teachers from high-risk day-care centers estimated the trainings' effectiveness lower than those working in low-risk day-care centers. Qualitative data shows that the day-care teachers are in need of (theoretical) knowledge about all training elements and hands-on advice for dealing with specific situations. Especially day-care teachers within a high-risk environment, who already report having an elevated level of intercultural knowledge and skills, may need a higher dose training while low-risk day-care teachers may profit more from a low threshold training. Conclusion: The introduced training sessions focusing on intercultural sensitivity and competence present an important contribution to the professionalization of day-care teachers in working with children from different cultural backgrounds. Trainings should focus on reflexive elements as well as exercises in perspective taking and provide hands on materials for daily work.

Pre-clinical evaluation of APrevent® VOIS for unilateral vocal fold paralysis medialization.

Objective: To evaluate the concept and efficacy of an adjustable implant (Prototype SH30: porcine implant and APrevent® VOIS: human concept) for treatment of unilateral vocal fold paralysis (UVFP) via in vivo mini-pig studies, human computed tomographic (CT) and magnetic resonance (MR) image analysis, ex-vivo aerodynamic and acoustic analysis. Methods: Feasibility testing and prototype implantation were performed using in-vivo UVFP porcine model (n = 8), followed by a dimensional finding study using CT and MR scans of larynges (n = 75) for modification of the implant prototypes. Acoustic and aerodynamic measurements were recorded on excised canine (n = 7) larynges with simulated UVFP before and after medialization with VOIS-Implant. Results: The prototype showed in the in-vivo UVFP porcine model an improved glottic closure from grade 6 incomplete closure to complete closure (n = 5), to grade 2 incomplete closure (n = 2) and grade 3 incomplete closure (n = 1). On human CT/MR scans the identification of the correct size was successful in 97.3% using the thyroid cartilage alar "distance S" as the only parameter, which is an important step towards procedure standardization and implant design. Results were confirmed with implantation in human laryngeal cadavers (n = 44). Measurements of the acoustic and aerodynamic effects after implantation showed a significant decreased phonation threshold pressure (p = .0187), phonation threshold flow (p = .0001) and phonation threshold power (p = .0046) on excised canine larynges with simulated UVFP. Percent jitter and percent shimmer decreased (p = .2976; p = .1771) but not significant. Conclusions: Based on the preclinical results four sizes, differing in medial length, implant width and expansion direction of silicone cushions, seem to be enough to satisfy laryngeal size variations. This concept is significantly effective in medializing UVFP and improving the aerodynamic and acoustic qualities of phonation as reported in a preliminary clinical outcome study with long-term implantation. Level of Evidence: N/A.

[Laryngeal framework surgery]. / "Laryngeal framework surgery".

Laryngeal framework surgery is an umbrella term for all phonosurgical procedures by which the cartilaginous structure of the larynx and thereby the position and tension of the vocal folds are changed. The aim is to improve the voice. By far the best known and most frequently performed operation is thyroplasty type 1 according to Isshiki, also known as medialization thyroplasty, which is indicated for treatment of glottic insufficiency. Although the first medialization thyroplasty was successfully performed by Payr in Germany in 1915, more than 100 years later, it is still not widely used in Germany.

European white paper: oropharyngeal dysphagia in head and neck cancer.

PURPOSE: To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe. METHODS: Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion. RESULTS: Twenty-four sections on HNC-specific OD topics. CONCLUSION: This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Preventive interventions for children in organized team sport tackling aggression: Results from the pilot evaluation of "Fairplayer.Sport".

Current reviews revealed that there is a lack of effective programs and valuable effectiveness studies related to prevention of aggressive behavior and fostering of social competence in early adolescents participating in organized team sports (e.g., ball sports, such as soccer). Using a randomized controlled design, the present pilot study presents first results regarding the effectiveness of the preventive intervention program "Fairplayer.Sport" that was implemented with preadolescent soccer players (N = 145 preadolescents; aged 9-14 years; mean = 12.2 years) in organized team sport (13 soccer teams). Results revealed a reduction of aggressive behavior in the intervention groups compared to waiting-control groups (small effect size). This effect remained stable 3 months after program implementation. Implications for planning and implementing preventive intervention programs are discussed.

[Photoangiolytic Lasers in Laryngology]. / Photoangiolytische Laser in der Laryngologie.

With photoangiolytic lasers like KTP (Potassium-Titanyl-Phosphate, 532 nm) lasers or the new "blue" laser (445 nm), even the smallest vessels and capillaries within the vocal fold can be treated without destroying the covering epithelium. This enables effective treatment of benign and malignant sub- and intraepithelial lesions of the vocal folds such as papilloma, edema, polyps, leukoplakia, dysplasia and capillary vessels while preserving the vibratory properties of the different layers of the lamina propria. Because photoangiolytic laser light can be routed through tiny glass fibers, office-based surgery with channelled flexible endoscopes are feasible as well as phonomicrosurgical operations under general anesthesia. Furthermore, the so called "blue" laser can cut tissues and thus broadens the technical armamentarium of the phonosurgeon.

Dipping and rotating: two maneuvers to achieve maximum magnification during indirect transnasal laryngoscopy.

BACKGROUND: Since many years, office-based flexible transnasal laryngoscopy is a common routine procedure. The development of new technical equipment such as high-definition cameras and flexible tip-chip endoscopes nowadays allows for much more precise examination than a few years ago. In contrast to rigid laryngoscopy, it is possible to move the tip of the endoscope close to the vocal folds and to other structures of interest. Nevertheless, without professional handling of the equipment, one cannot benefit from the potential of the newest technology. METHOD: Two easily performed and very helpful maneuvers in flexible endoscopy are described. The "dipping maneuver" enables a maximum magnification of the mucosal surfaces of the endolarynx as well as the examination of the subglottal region and the trachea by positioning the tip of the endoscope very close to the vocal folds or even in the upper trachea during long transnasal inspiration. During the "rotation laryngoscopy", the tip of the endoscope is positioned in the posterior interarytenoid region by rotating the flexible endoscope by 180° and advancing it close to the glottis. This allows a close-up examination of the anterior commissure, the inferior aspect of the vocal folds and the inside of the Morgagni's ventricle. Before performing transnasal flexible endoscopy, we routinely apply topical anesthesia sprayed intranasally. CONCLUSION: The described techniques of flexible endoscopy are easily performed and allow a maximum magnification of the mucosal surfaces and otherwise not visible regions of the endolarynx.

Adaptation and implementation of the German social-emotional learning programme Papilio in Finland: A pilot study.

This study investigated the cross-national adaptation and implementation of Papilio, a German social-emotional learning programme, in Finnish early childhood education and care (ECEC) centres. Papilio is a developmentally focused, scientifically based intervention programme focused on preventing behavioural problems and fostering social-emotional competence in children aged 3-7. The aim of this study was to investigate and evaluate the cross-national adaptation and cross-cultural adaptation and implementation of Papilio in the Finnish ECEC context. Results from qualitative interviews with one Finnish Papilio trainer, 11 early childhood education (ECE) teachers, two ECE special education teachers and two nursery nurses are supplemented with teachers' and nursery nurses' (N = 75) questionnaire data. Qualitative thematic analysis revealed that cultural adaptations were necessary on four levels: accommodation of materials, adaptation of the contents of the materials, structure and delivery. The materials and training contents were culturally adapted, whereas the delivery of the intervention was adapted according to Finnish ECEC practices. The structural adaptation included discarding timeout, due to opposition by some educators. The educators were committed to implementing the programme as instructed and resolving the practical difficulties they encountered. Their motivation to implement Papilio increased as they observed improvements in the children's social-emotional competence during intervention.

Verification and diagnostic evaluation of the RealStar® Middle East respiratory syndrome coronavirus (N gene) reverse transcription-PCR kit 1.0.

Aim: We report the diagnostic evaluation of a confirmatory reverse transcription-PCR (RT-PCR) kit targeting the Middle East respiratory syndrome coronavirus (MERS-CoV) N gene. Material & methods: 33 patient samples from two collections sites in Riyadh, Saudi Arabia, which were pre-characterized via real-time RT-PCR targeting MERS-CoV orf1a and upE, and were tested using the MERS-CoV N gene, as a confirmatory assay. This diagnostic procedure follows a two-step diagnostics scheme, recommended by the WHO. Results: 18/33 samples tested positive, 11/33 tested negative for MERS-CoV RNA and 2/33 showed uncertain results. Conclusion: The results suggest, that the RealStar® MERS-CoV (N gene) RT-PCR kit 1.0 can be considered a suitable and reliable confirmatory assay in combination with the RealStar MERS-CoV RT-PCR kit 1.0 according to the diagnostic scheme recommended by WHO.

Pin-up Glottoplasty: Feasibility Study of a Novel Approach Medializing or Lateralizing Immobile Vocal Folds.

Principles in medializing and lateralizing vocal folds have not changed a lot within the last decades (Isshiki et al, 1974; Bruenings, 1911). We present a feasibility study for a completely new approach to perform medialization and lateralization of immobile vocal folds. The method was tested on 20 human larynges by inserting a 21G needle into the vocal fold, medializing (or, in other cases, lateralizing) the vocal cord and fixing the needle at the cricoid cartilage posteriorly. The anterior and posterior fixation points of the needle allow for a stable positioning of the needle, which we consider necessary in both cases of medialization or lateralization. The needle position was examined visually as well as three-dimensionally via cone beam computed tomography.

Arginase 2 Suppresses Renal Carcinoma Progression via Biosynthetic Cofactor Pyridoxal Phosphate Depletion and Increased Polyamine Toxicity.

Kidney cancer, one of the ten most prevalent malignancies in the world, has exhibited increased incidence over the last decade. The most common subtype is "clear cell" renal cell carcinoma (ccRCC), which features consistent metabolic abnormalities, such as highly elevated glycogen and lipid deposition. By integrating metabolomics, genomic, and transcriptomic data, we determined that enzymes in multiple metabolic pathways are universally depleted in human ccRCC tumors, which are otherwise genetically heterogeneous. Notably, the expression of key urea cycle enzymes, including arginase 2 (ARG2) and argininosuccinate synthase 1 (ASS1), is strongly repressed in ccRCC. Reduced ARG2 activity promotes ccRCC tumor growth through at least two distinct mechanisms: conserving the critical biosynthetic cofactor pyridoxal phosphate and avoiding toxic polyamine accumulation. Pharmacological approaches to restore urea cycle enzyme expression would greatly expand treatment strategies for ccRCC patients, where current therapies only benefit a subset of those afflicted with renal cancer.

New 445 nm blue laser for laryngeal surgery combines photoangiolytic and cutting properties.

BACKGROUND: Photoangiolytic lasers have broadened the surgical armamentarium for many phonosurgical interventions. However, the pulse dye laser and potassium titanyl phosphate (KTP) laser have technical drawbacks and a smaller spectrum of indications. METHODS AND RESULTS: The new 445 nm wavelength laser, the so-called 'blue laser', proves to show tissue effects comparable to the KTP laser and is also capable of treating subepithelial vessels due to its photoangiolytic properties, it can coagulate and carbonize at higher energy levels, and can be used via glass fibers in non-contact and contact mode for in-office procedures. DISCUSSION: In contrast to the KTP, the new 445 nm laser can also be used as a cutting laser, thus combining very much wanted properties of diode or CO2 lasers with photoangiolytic lasers. Further advantages of the new laser are the; (1) portability of the shoe box sized, shock-proof laser machine for in-office and operating room usage, (2) the selection of pulse rates from continuous wave (cw) to less than a millisecond, (3) stronger tissue effects compared to KTP with similar energy and pulse settings, (4) far better cutting properties than the KTP, and thus (5) more possibilities for usage in laryngology as well as in other fields or surgery. CONCLUSION: We demonstrate the feasibility of the 445 nm laser in several laboratory experiments and show clinical cases where photoangiolysis and cutting was possible. However, this is a preliminary report and further systematic studies in greater numbers are warranted.

[Intervention and Therapy for Perpetrators and Victims of Bullying: A Systematic Review]. / Intervention und Therapie für Täter und Opfer von Schulbullying: Ein systematisches Review.

Intervention and Therapy for Perpetrators and Victims of Bullying: A Systematic Review Bullying is a form of repeated and aggressive behavior with serious consequences for victims and perpetrators, who often suffer from their experiences long after the bullying episodes have ended. However, the therapeutic treatment of bullying and its consequences represents a neglected topic in bullying research. Objective of the present article is to review publications systematically describing targeted interventions for the treatment of bullying (for victims and perpetrators) and associated disorders. The selection process consisted of a comprehensive systematic search in national and international databases that identified 34 targeted interventions in 31 publications from 14 different countries. The review of ten interventions featuring a controlled design revealed that in particular treatments on both the individual and socio-ecological level (particularly parents) are effective. The remaining 24 treatments lack a controlled evaluation. Two thirds of the interventions focus on victims. In contrast to the treatment of perpetrators, the emphasis here lies on group therapy. Although treatments of bullying apply a range of therapeutic approaches and methods, cognitive behavioral therapy is represented most prominently. As a conclusion one can observe an existing lack of research in evidence-based targeted interventions for the treatment of bullying and its consequences for victims and perpetrators. To our knowledge, this is the first systematic review of therapeutic interventions for bullying in children and adolescents.

Perceived Severity of Cyberbullying: Differences and Similarities across Four Countries.

Cyberbullying is a ubiquitous topic when considering young people and internet and communication technologies (ICTs). For interventional purposes, it is essential to take into account the perspective of adolescents. This is the reason why our main focus is (1) investigating the role of different criteria in the perceived severity of cyberbullying incidents, and (2) examining the differences between countries in the perceived severity of cyberbullying. The sample consisted of 1,964 adolescents (48.2% girls) from middle and high schools of four different countries, i.e., Estonia, Italy, Germany, and Turkey. The participants' age ranged from 12 to 20 years old with a mean age of 14.49 (SD = 1.66) years. To assess perceived severity, participants rated a set of 128 scenarios, which systematically included one or more of five criteria (intentionality, repetition, imbalance of power, public vs. private, and anonymity) and represented four types of cyberbullying behaviors (Written-Verbal, Visual, Exclusion, Impersonation). The role of different criteria was analyzed using the Exploratory Structural Equation Modeling (ESEM). Results showed a similar structure across the four countries (invariant except for the latent factors' means). Further, criteria of imbalance of power and, to a lesser extent, intentionality, anonymity, and repetition always in combination, were found to be the most important criteria to define the severity of cyberbullying. Differences between countries highlighted specific features of Turkish students, who perceived all scenarios as more severe than adolescents from other countries and were more sensitive to imbalance of power. German and Italian students showed an opposite perception of anonymity combined with intentionality. For Italian participants, an anonymous attack was less threatening than for participants of other countries, whereas for German students anonymity caused more insecurity and fear. In addition, Italian adolescents were more perceptive of the criterion of intentionality. Finally, Estonian adolescents did not show strong differences in their factor scores compared to adolescents from the other countries.

Biomechanical Flow Amplification Arising From the Variable Deformation of the Subglottic Mucosa.

OBJECTIVE: This study mapped the variation in tissue elasticity of the subglottic mucosa, applied these data to provide initial models of the likely deformation of the mucosa during the myoelastic cycle, and hypothesized as to the impact on the process of phonation. STUDY DESIGN: Six donor human larynges were dissected along the sagittal plane to expose the vocal folds and subglottic mucosa. A linear skin rheometer was used to apply a controlled shear force, and the resultant displacement was measured. These data provided a measure of the stress/strain characteristics of the tissue at each anatomic point. A series of measurements were taken at 2-mm interval inferior of the vocal folds, and the change in elasticity was determined. RESULTS: It was found that the elasticity of the mucosa in the subglottic region increased linearly with distance from the vocal folds in all 12 samples. A simple deformation model indicated that under low pressure conditions the subglottic mucosa will deform to form a cone, which could result in a higher velocity, thus amplifying the low pressure effect resulting from the Venturi principle, and could assist in maintaining laminar flow. CONCLUSIONS: This study indicated that the deformation of the subglottic mucosa could play a significant role in the delivery of a low pressure airflow over the vocal folds. A large scale study will now be undertaken to secure more data to evaluate this hypothesis, and using computational fluid dynamics based on actual three-dimensional structure obtained from computed tomography scans the aerodynamics of this region will be investigated.

Unilateral hearing loss in children: a retrospective study and a review of the current literature.

Despite the introduction of universal newborn hearing screening (UNHS), unilateral hearing loss (UHL) is sometimes recognized late. This diagnostic delay has adverse repercussions, given the importance of binaural hearing for the development of normal auditory processing. It is incorrect to maintain that unilateral hearing is the minimum requirement for adequate speech development and that hearing aid provision is consequently unnecessary. In our retrospective study, hearing aid provision resulted in improved directional and selective hearing (quiet and noisy environments) and, compared with their chronically ill counterparts, the children in our study displayed superior health-related quality of life (HRQoL) scores in all areas. On the basis of the results, the authors conclude that even mild hearing losses (from an auditory threshold of 30 to 40 dB) should have the opportunity for hearing aid provision. A selective literature review was conducted in PubMed and textbooks and with reference to national and international guidelines. Early diagnosis and treatment of UHL have a positive effect on verbal-cognitive, linguistic, communicative, and socio-emotional development, as demonstrated by neurophysiological studies. Among the treatment modalities with differing effects on the quality of binaural hearing, cochlear implants are now used increasingly in children with hearing loss bordering on deafness. CONCLUSION: Published evidence and clinical experience support early diagnosis and treatment. Wherever feasible, hearing aid provision before or at the end of the first year of life is recommended for children with UHL. What is Known: • Almost 30 years ago, poor academic performance was reported in children with unilateral hearing loss (UHL). • Despite improvements in treatment options, it is traditionally held that unilateral hearing is the minimum requirement for adequate speech development and hearing aid provision is unnecessary. What is New: • Academic and behavioral deficits in children with UHL may be mediated by deficiencies in the default mode network. • Published evidence supports the recommendation for hearing aid provision before or at the end of the first year of life in children with UHL.

Quantification of change in vocal fold tissue stiffness relative to depth of artificial damage.

OBJECTIVES: To quantify changes in the biomechanical properties of human excised vocal folds with defined artificial damage. METHODS: The linear skin rheometer (LSR) was used to obtain a series of rheological measurements of shear modulus from the surface of 30 human cadaver vocal folds. The tissue samples were initially measured in a native condition and then following varying intensities of thermal damage. Histological examination of each vocal fold was used to determine the depth of artificial alteration. The measured changes in stiffness were correlated with the depth of cell damage. RESULTS: For vocal folds in a pre-damage state the shear modulus values ranged from 537 Pa to 1,651 Pa (female) and from 583 Pa to 1,193 Pa (male). With increasing depth of damage from the intermediate layer of the lamina propria (LP), tissue stiffness increased consistently (compared with native values) following application of thermal damage to the vocal folds. The measurement showed an increase of tissue stiffness when the depth of tissue damage was extending from the intermediate LP layer downwards. CONCLUSIONS: Changes in the elastic characteristics of human vocal fold tissue following damage at defined depths were demonstrated in an in vitro experiment. In future, reproducible in vivo measurements of elastic vocal fold tissue alterations may enable phonosurgeons to infer the extent of subepithelial damage from changes in surface elasticity.