Union of the European Phoniatricians' position statement on the exit strategy of phoniatric and laryngological services: staying safe and getting back to normal after the peak of coronavirus disease 2019 (issued on 25th May 2020).

BACKGROUND: The following position statement from the Union of the European Phoniatricians, updated on 25th May 2020 (superseding the previous statement issued on 21st April 2020), contains a series of recommendations for phoniatricians and ENT surgeons who provide and/or run voice, swallowing, speech and language, or paediatric audiology services. OBJECTIVES: This material specifically aims to inform clinical practices in countries where clinics and operating theatres are reopening for elective work. It endeavours to present a current European view in relation to common procedures, many of which fall under the aegis of aerosol generating procedures. CONCLUSION: As evidence continues to build, some of the recommended practices will undoubtedly evolve, but it is hoped that the updated position statement will offer clinicians precepts on safe clinical practice.

Effect of diesel exhaust generated by a city bus engine on stress responses and innate immunity in primary bronchial epithelial cell cultures.

Harmful effects of diesel emissions can be investigated via exposures of human epithelial cells, but most of previous studies have largely focused on the use of diesel particles or emission sources that are poorly representative of engines used in current traffic. We studied the cellular response of primary bronchial epithelial cells (PBECs) at the air-liquid interface (ALI) to the exposure to whole diesel exhaust (DE) generated by a Euro V bus engine, followed by treatment with UV-inactivated non-typeable Haemophilus influenzae (NTHi) bacteria to mimic microbial exposure. The effect of prolonged exposures was investigated, as well as the difference in the responses of cells from COPD and control donors and the effect of emissions generated during a cold start. HMOX1 and NQO1 expression was transiently induced after DE exposure. DE inhibited the NTHi-induced expression of human beta-defensin-2 (DEFB4A) and of the chaperone HSPA5/BiP. In contrast, expression of the stress-induced PPP1R15A/GADD34 and the chemokine CXCL8 was increased in cells exposed to DE and NTHi. HMOX1 induction was significant in both COPD and controls, while inhibition of DEFB4A expression by DE was significant only in COPD cells. No significant differences were observed when comparing cellular responses to cold engine start and prewarmed engine emissions.

Ambient and laboratory observations of organic ammonium salts in PM1.

Ambient measurements of PM1 aerosol chemical composition at Cabauw, the Netherlands, implicate higher ammonium concentrations than explained by the formation of inorganic ammonium salts. This additional particulate ammonium is called excess ammonium (eNH4). Height profiles over the Cabauw Experimental Site for Atmospheric Research (CESAR) tower, of combined ground based and airborne aerosol mass spectrometric (AMS) measurements on a Zeppelin airship show higher concentrations of eNH4 at higher altitudes compared to the ground. Through flights across the Netherlands, the Zeppelin based measurements furthermore substantiate eNH4 as a regional phenomenon in the planetary boundary layer. The excess ammonium correlates with mass spectral signatures of (di-)carboxylic acids, making a heterogeneous acid-base reaction the likely process of NH3 uptake. We show that this excess ammonium was neutralized by the organic fraction forming particulate organic ammonium salts. We discuss the significance of such organic ammonium salts for atmospheric aerosols and suggest that NH3 emission control will have benefits for particulate matter control beyond the reduction of inorganic ammonium salts.

Ischaemic necrosis of the tongue as a rare complication of cardiogenic shock.

Ischaemic necrosis of the tongue is an unusual clinical finding. In most cases it is associated with vasculitis, particularly giant cell arteritis (GCA). Other causes include profound cardiogenic shock. We report a case of tongue necrosis in an 81-year-old Caucasian woman. The patient was admitted to the intensive care unit (ICU) for cardiogenic shock. Swelling of the tongue was reported before intubation and evolved into tongue ischaemia and necrosis of the tip of the tongue. After surgical debridement the patient recovered. To our knowledge, this is the second report of a patient surviving tongue necrosis resulting from cardiogenic shock.

Tridimensional assessment of adductor spasmodic dysphonia pre- and post-treatment with Botulinum toxin.

Spasmodic dysphonia voices form, in the same way as substitution voices, a particular category of dysphonia that seems not suited for a standardized basic multidimensional assessment protocol, like the one proposed by the European Laryngological Society. Thirty-three exhaustive analyses were performed on voices of 19 patients diagnosed with adductor spasmodic dysphonia (SD), before and after treatment with Botulinum toxin. The speech material consisted of 40 short sentences phonetically selected for constant voicing. Seven perceptual parameters (traditional and dedicated) were blindly rated by a panel of experienced clinicians. Nine acoustic measures (mainly based on voicing evidence and periodicity) were achieved by a special analysis program suited for strongly irregular signals and validated with synthesized deviant voices. Patients also filled in a VHI-questionnaire. Significant improvement is shown by all three approaches. The traditional GRB perceptual parameters appear to be adequate for these patients. Conversely, the special acoustic analysis program is successful in objectivating the improved regularity of vocal fold vibration: the basic jitter remains the most valuable parameter, when reliably quantified. The VHI is well suited for the voice-related quality of life. Nevertheless, when considering pre-therapy and post-therapy changes, the current study illustrates a complete lack of correlation between the perceptual, acoustic, and self-assessment dimensions. Assessment of SD-voices needs to be tridimensional.

Voicing quantification is more relevant than period perturbation in substitution voices: an advanced acoustical study.

Quality of substitution voicing-i.e., phonation with a voice that is not generated by the vibration of two vocal folds-cannot be adequately evaluated with routinely used software for acoustic voice analysis that is aimed at 'common' dysphonias and nearly periodic voice signals. The AMPEX analysis program (Van Immerseel and Martens) has been shown previously to be able to detect periodicity in irregular signals with background noise, and to be suited for running speech. The validity of this analysis program is first tested using realistic synthesized voice signals with known levels of cycle-to-cycle perturbations and additive noise. Second, exhaustive acoustic analysis is performed of the voices of 116 patients surgically treated for advanced laryngeal cancer and recorded in seven European academic centers. All of them read out a short phonetically balanced passage. Patients were divided into six groups according to the oscillating structures they used to phonate. Results show that features related to quantification of voicing enable a distinction between the different groups, while the features reporting F(0)-instability fail to do so. Acoustic evaluation of voice quality in substitution voices thus best relies upon voicing quantification.

The "Deglutition Handicap Index" a self-adminitrated dysphagia-specific quality of life questionnaire: sensibility to change.

OBJECTIVE: The aim of this study is to assess the efficacy of UES's dysfunction treatments with the DHI (Deglutition Handicap Index). MATERIAL AND METHOD: 24 patients suffering of UES's dysfunction were included prospectively between 2008 and 2009 in 2 centers (France and Netherlands). Patients completed DHI before and after treatment. For statistics, Wilcoxon two-sample tests were used. RESULTS: The mean score was 57 +/- 17 in the preoperative and 26 +/- 19 in the post operative time. The statistical difference was significant p < 0.0001. The difference is also significant for the 3 subscales (symptoms, functional, emotional). CONCLUSION: The DHI has been validated in terms of content, concurrent, construct validity and temporal reliability. It can be used for assessing efficacy of treatments used for dysphagia.

Perceptual evaluation of substitution voices: development and evaluation of the (I)INFVo rating scale.

Substitution voicing cannot be evaluated accurately by the GRBAS perceptual rating scale, and there is a need for a valuable alternative. Therefore, we developed and tried out a perceptual rating scale, consisting of five new parameters: impression, intelligibility, noise, fluency and voicing, each to be scored between 0 (very bad score) to 10 (very good score for a substitution voice). In analogy to the GRBAS scale, they are then converted to deviance scores ranging from 0 (similar to good substitution voicing) to 3 (very deviant from good substitution voicing). Inter-individual agreement measured in a set of 24 semi-professional jury members seemed to be moderate for all parameters. Mean figures of 0.52, 0.51, 0.46, 0.53 and 0.46 are obtained for the parameters impression, intelligibility, noise, fluency and voicing, respectively. Because a high correlation exists between the first two parameters (0.917) and relying on the correlation figures between the two "I"s and the other parameters (correlation values for "impression" vary from 0.79-0.86; values for "intelligibility" range from 0.74-0.83), we suggest to discard the parameter impression, which turns the actual IINFVo scale into INFVo. The proposed (I)INFVo perceptual rating scale seems promising for the assessment of substitution voicing. Eventual improvements and practical proposals are discussed.

[Perceptive evaluation of substitution voices: the I(I) NFVo rating scale]. / Evaluation perceptive des voix de substitution: l'echelle I(I)NFVo.

OBJECTIVES: Evaluation of a perceptual specific rating scale for specific severe non laryngeral dysphonia. MATERIAL AND METHOD: 113 speech samples from substitution voices were scored perceptually according to the IINFVo scale: overall quality impression (I), impression of Intelligibility (I), additive and unnecessary noise (N), speech fluency (F) and presence of voiced segments (Vo). Each parameter was scored on a visual analogue scale from 0 (minimally deviant) to 10 (maximally deviant substitution voicing). These samples were presented to semi-professional jury-members (second grade speech therapy students) and professional jury-members (phoniatricians and speech therapists, specialised in the oncological field). RESULTS: Interindividual agreement between semi-professionals was moderate (0.57-0.68). Interindividual agreement between professionals was higher (0.82-0.86). These figures are similar or even better compared to the classical perceptual evaluation scale for laryngeal speech (GRBAS). CONCLUSION: Our study suggests that the I(I)NFVo rating scale is suitable for perceptual evaluation of substitution voicing and consistency results are comparable with the classical perceptual rating scale (GRBAS).

Implementation of the European Laryngological Society (ELS) basic protocol for assessing voice treatment effect.

OBJECTIVES: 93 patients with various kinds of organic benign voice pathology (vocal fold nodules, polyp, Reinke's oedema, unilateral paralysis, sulcus/scar) and/or with muscle tension dysphonia, were evaluated before and after their voice treatment (phonosurgery with voice therapy, antireflux medication, or voice therapy alone) in order to check the clinical relevance of a basic multidimensional protocol for assessing functional results of voice treatments, as developed by the Committee on Phoniatrics of the ELS. MATERIAL AND METHOD: The protocol has been used in different university voice clinics. It comprises 5 dimensions: Perception: Grade, Breathiness and Roughness from the GRBAS-scale, rated by two experienced judges: a phoniatrician/laryngologist and a speech therapist. Acoustics: Jitter % and Shimmer % computed on a /a:/, at comfortable loudness and pitch. Also Fo-range and softest possible intensity. Videostroboscopy: Glottal closure, regularity, mucosal wave and symmetry, rated separately. Phonation quotient: computed by dividing the vital capacity (ml) by the maximum phonation time (s) (best value of 2x3 trials). Self rating by the patient: voice quality in itself and general social/occupational handicap due to the voice problem rated separately. RESULTS: Results show that, at group level, the overall effects for each parameter indicate a significant improvement after treatment. However, the correlations between the pre/post changes for the different parameters are weak (low redundancy). CONCLUSION: The assessment of voice pathology needs to be multidimensional, as these multidimensional informations about voice changes lead to a better understanding of the actual way in which a treatment works.

Acoustic analysis of snoring: review of literature.

Acoustic analysis of snoring could make patient assessment more accurate, treatment planning more efficient and could provide objective documentation reliable for comparison. However, spectral characteristics are irregular and difficult to analyse. The authors give an overview of the available literature and the various applied methods. These methods differ in purpose and are subject to restrictions. Until now, acoustic analysis of snoring remains controversial. For linking the results of the acoustic analysis with anatomical levels or degree of obstruction, further study is needed to develop a reliable parameter.

Standard ENT clinical evaluation of the sleep-disordered breathing patient; a consensus report.

Sleep disordered breathing (SDB) patients usually undergo an ENT clinical examination before any therapeutic decision. This clinical examination would be predictive about the occurrence of Obstructive Sleep Apnea Syndrome, cost effective, reproducible and would determine the sites of obstruction in the upper airways. To achieve this, ENT specialists from Belgium, representatives of academic hospitals in the country, have tried to establish an updated work-up in the clinical evaluation of the SDB patients. History, risk factors evaluation, excessive daytime sleepiness, static and dynamic evaluation of the upper airways (velopharynx aspect, tonsils grading, Mallampati score, Müller's maneuver, fiberoptic evaluation) have been standardized in a consensus report easily accessible to the vast majority of ENT specialists. This consensus must be understood as a clinical work-up to perform before the monitoring of breathing during sleep.

Surgical treatment of the sleep-disordered breathing patient; a consensus report.

Sleep disordered breathing patients may undergo surgical treatment after history, clinical examination and polysomnographic study if they demonstrate upper airway obstruction. This article focus on the surgical treatment designed for these patients. Sino-nasal surgery, rhinopharyngeal procedure, velopharyngeal procedures (Uvulopalato-pharyngoplasty, Laser assisted uvulopalatoplasty, Radiofrequency tissue volume reduction) as well as base of the tongue procedures were discussed among a panel of Belgian ENT specialists offering their experience in this field. Algorithm on corrective surgery as well as guidelines for postoperative management are proposed in the management of sleep disordered breathing patients.

Recurrent focal epithelial hyperplasia due to HPV13 in an HIV-positive patient.

There are few reports on focal epithelial hyperplasia (FEH) in association with human immunodeficiency virus (HIV) infection; thus the relationship between them has not been completely clarified yet. We present a case of recurrent FEH in an HIV-positive man (the first described in Belgium), which, according to the PCR-DNA testing, was due to human papilloma virus type 13 (HPV13). To our knowledge, based on the accessible literature, this type of HPV has not been detected in any other documented study of FEH in HIV-positive patients before. Our patient experienced three recurrences of FEH in 1 year. It is therefore suggested that immunodeficiency due to HIV infection is responsible for the HPV-related FEH and the subsequent recurrences. In order to support the consideration of FEH as an oral manifestation of an HIV-related opportunistic infection, every new 'HPV-type' oral lesion in HIV-positive patients must be completely documented.

Colonization of a voice prosthesis by Cryptococcus neoformans.

Tracheoesophageal voice prostheses in laryngectomized patients commonly deteriorate due to the presence of yeasts, particularly Candida species. We describe the first case of colonization of such a device by Cryptococcus neoformans in a patient with a history of glottic carcinoma. The isolate showed an identical genomic pattern with C. neoformans from pigeon excreta in the patient's environment.

99Tc(m) labelled HL91 versus computed tomography and biopsy for the visualization of tumour recurrence of squamous head and neck carcinoma.

This phase I pilot study reports on (1) the safety and feasibility of 99Tc(m)-HL91, an amine oxime core radioligand that has shown oxygen dependent binding, and imaging; and (2) its usefulness for the visualization of local tumour recurrence of a biopsy proven squamous cell carcinoma of the head and neck (SCCHN) as compared to spiral computed tomogaphy (CT) and biopsy. Nine men (mean age 33 years, range 34-74 years) were prospectively included. For safety measurements, vital signs were recorded and serum chemical analysis carried out, with a complete blood cell count and urine analysis, and an ECG was performed prior to injection of 99Tc(m)-HL91 and repeated during the investigation. Single photon emission computed tomography (SPECT) scans of the head and neck, and of a standard, were performed at 2 h and 4 h post-injection of 740 MBq 99Tc(m)-HL91. Tumour-to-normal tissue background (T/N) ratios and percentage uptake were measured for all 99Tc(m)-HL91 scans. Spiral CT scans were obtained using a Somaton 4+ Siemens scanner within 1 week from the 99Tc(m)-HL91 scans. Based on CT and the 99Tc(m)-HL91 scan findings guided biopsies were performed. No adverse or subjective side effects were noticed. Vital signs, ECG findings, clinical laboratory, blood and urine assays remained stable in all patients. Spiral CT suggested local recurrence in 5/9 patients accompanied by nodal involvement in three, all of which proved positive on biopsy. 99Tc(m)-HL91 scintigraphy was false positive in one patient and true positive (TP) in 3/5 local recurrences and two out of three sites of lymph node involvement depicted by spiral CT. The mean T/N ratios at 2 h and 4 h in TPs were 1.28 (range 1.1-1.66) and 1.40 (range 1.0-1.6), respectively. The corresponding absolute percentages of 99Tc(m)-HL91 lesional uptake at 2 h and 4 h were mu = 0.05% (SD = 0.03%) and mu = 0.048% (SD = 0.035%). The findings suggest 99Tc(m)-HL91 is a safe radioligand and that metabolic binding in a large fraction but not all of local SCCHN recurrences may be expected. The inference that tumour 99Tc(m)-HL91 avidity could be a non-invasive measure of tumour hypoxia deserves however independent confirmation with needle oximetry.

Mycobacterium interjectum as causative agent of cervical lymphadenitis.

A mycobacterial strain isolated from a lymph node of a 3-year-old female with cervical lymphadenitis was identified as Mycobacterium interjectum by means of sequencing of the 16S rRNA gene. Analysis of this case and previously published cases demonstrates the importance of M. interjectum as a causative agent of cervical lymphadenitis in young children.

Surgical therapy in transsexual patients: a multi-disciplinary approach.

A transsexual patient has the constant and persistent conviction that he or she belongs to the opposite sex, thus creating a deeply seated gender identity conflict. With psychotherapy being unsuccessful, it has been proven that in carefully selected patients, gender reassignment or adjusting the body to the mind (both with hormones and surgery) is the best way to normalize their lives. Optimal treatment of these patients requires the multidisciplinary approach of a gender team with the input of several specialties. Such a team consists of a nucleus of physicians who sees the patient more frequently: the psychiatrist, the endocrinologist, the plastic surgeon, the gynecologist and the urologist and a more peripheral group that sees the patients more incidentally: the psychologist, the otorhinolaryngologist, the dermatologist, the speech therapist, the lawyer, the nurse and the social worker. Between 1987 and 1999, a total of 71 male-to-female (MTF) and 54 female-to-male transsexuals have undergone gender confirming surgery in our hospital. This article gives a review and an update on the different surgical procedures as well as on the outcome in our patient population. The results in this series of patients clearly demonstrate that a close cooperation of the different surgical specialties, within our multidisciplinary gender team, is the key to success in treating transsexual patients.

Ectopic cervical thymus: case report and review of the literature.

The authors present a case of ectopic cervical thymus in a 4-month-old child. Ectopic cervical thymus is an uncommon etiology of a neck mass in a child. It is often misdiagnosed preoperatively as a possible malignancy. It is usually located along the embryologic course of thymus migration from the angle of the mandible to the superior mediastinum. Its treatment is surgical since malignant transformation and respiratory infection have been described. No case of immune deficit after total thymectomy has been described in the literature.

Phonosurgery in gender dysphoria.

A particular type of phonosurgery is voice change surgery in cases of gender dysphoria. This paper presents a review of the surgical techniques available for raising or lowering speaking fundamental frequency. A cricothyroid approximation to raise the vocal pitch is the most common procedure. This procedure results in an increase of about one octave immediately postoperatively and about half an octave after stabilization of the voice.