Speech perception 30 years after cisplatin-based chemotherapy in adults: limited clinical relevance of long-term ototoxicity?

BACKGROUND: Cisplatin-based chemotherapy (CBCT) can cause high-frequency hearing loss, but little is known about the development and clinical relevance of this hearing loss in survivors of adult-onset cancer with very long-term follow-up. This case-control study investigates hearing and speech perception both in quiet and with background noise 30-years after CBCT. PATIENTS AND METHODS: One-hundred-and-one patients (Cases) who received CBCT for testicular cancer between 1980 and 1994 were assessed with pure-tone audiometry (.125 - 8 kHz) and speech perception tests including hearing in noise test (HINT). Self-reported hearing and tinnitus was scored by participants. Results were compared with 30 age-matched controls. RESULTS: The median age of Cases and Controls was 60 (46 - 83) and 61 years (51 - 74), respectively. The median observation time for Cases was 30 years (22 - 37). Compared with Controls, Cases had 8 and 19 dB worse age-adjusted high-frequency hearing at 6 and 8 kHz, respectively (p <.05), while thresholds at lower frequencies did not differ. All but four Cases reached 100% speech perception with basic speech audiometry. There was no difference between Cases and Controls in speech perception neither in quiet nor with both speech and background noise from the front, although the within-group variance was greater among Cases. Cases scored slightly worse with speech from front and noise from either side. Self-reported hearing loss (both hearing loss in general and specifically with background noise), and tinnitus were about three times more common among Cases compared with Controls. CONCLUSIONS: Cisplatin causes high-frequency hearing loss, but speech perception tests performed both in quiet and in background noise 30 years post-treatment indicate that the clinical relevance is limited for most patients. Few patients develop severe hearing loss that requires rehabilitation but it is important to identify these patients. Self-reported hearing loss and tinnitus were more common among Cases compared with Controls.

[Qualitative research methods in clinical practice]. / Kvalitativa forskningsmetoder i klinisk medicinsk praxis.

Evidence-based medicine (EBM) corresponds to the physician's ambition to integrate his/her experience with the best current scientific knowledge, applying this integrated proficiency to clinical problems. The concept of EBM has become widely accepted and given rise to a global network usually emphasizing the randomized clinical trial (RCT) as the most important scientific method. However, clinical situations are very complex. To a greater or less extent they are all composed of diverse factors, ranging from bio-medical ones to inter-subjective relations, values and beliefs. In addition to RCT and other quantitative procedures, qualitative scientific methods could be used to explore complex clinical problems. Clinical problems always deserve to be addressed from various perspectives. Unfortunately, RCT has acquired such a dominant position as to give the impression that it is the sole preferred method within the EBM framework. Based on three examples, the present article claims that it is the questions asked by an investigation that should determine one's choice of methods, not the reverse. Consequently, we argue that it is important to remember that RCT is just one out of several potential scientific methods. The respective utility of any one method depends on the clinical issue at hand.

Eustachian tube function varies over time in children with secretory otitis media.

Impaired opening and closing functions of the Eustachian tube are considered to be pathogenic factors in secretory otitis media (SOM). As the clinical course of SOM is variable, the variability of tubal function is of interest. We aimed to explore the short- and long-term variability of tubal opening and closing functions in SOM. The study comprised 42 ears in 21 children (13 males and 8 females) with tympanostomy tubes due to SOM. The middle ear pressure was recorded during repeated passive forced openings, equalization of + 100 daPa and - 100 daPa by swallowing, Valsalva inflation and forceful sniffing. Test sessions were performed twice (separated by 30 min) on each of 2 days, with a mean interval of 3.7 months in between. In the forced opening test there was a considerable intra-individual variability over time. Expressed as SD of the mean, the variability of the forced opening and closing pressures in individual ears was on average 15% and 23%, respectively, between sessions and 20% and 30% respectively, between test days. In the equalization, Valsalva and sniff tests the rates of responses that changed from positive to negative between sessions and test days ranged from 12% to 33%. Female gender and retraction pockets were related to poorer opening function in the forced opening test. Ears with serous effusion (in contrast to mucoid) showed a similar trend and also a lower occurrence of positive equalization, Valsalva and sniff tests. It was concluded that Eustachian tube opening and closing functions are highly variable in ears with SOM. Consequently, single tubal function tests have low value when used as a prognostic tool in individual ears.

Variability of Eustachian tube function: comparison of ears with retraction disease and normal middle ears.

OBJECTIVE: To explore the short-term and longterm variability of tubal opening and closing in ears with advanced retractions and in healthy ears. STUDY DESIGN/METHODS: Twenty ears with retraction type middle ear disease (R-MED) and 20 normal ears underwent direct recording of the middle ear pressure during repeated forced openings, equalization of +100 daPa and -100 daPa by swallowing, Valsalva inflation, and forceful sniffing. Tests were performed twice (separated by 30 min) on each of 2 days separated by 3 to 4 months. RESULTS: There was considerable intraindividual variability of the forced opening pressure and the closing pressure in both groups, within as well as between sessions and test days. Although the variability was 1.5 to 2 times higher in ears with retraction than in the normal group, mean Po and Pc did not differ between the groups. Compared with normal ears, ears with retraction changed more frequently from a positive to negative test response, or vice versa, when re-tested after 30 minutes. Rates of positive response in the equalization and Valsalva tests were significantly lower in diseased ears compared with normal ears. CONCLUSIONS: Eustachian tube opening and closing functions vary more in ears with retraction disease than in normal ears, which is consistent with the variable clinical course of R-MED and implies that single tubal function tests have little prognostic value on the individual level.

Variability of Eustachian tube function in children with secretory otitis media. Evaluations at tube insertion and at follow-up.

OBJECTIVE: Despite the variable clinical course of diseases related to Eustachian tube function, the variability of tubal function has been less focused than outcomes of single tests. This study aimed to compare the passive and active tubal function and its variability in children with secretory otitis media (SOM) at tube insertion and at follow-up. METHOD: Thirty-eight ears in 19 children aged 4-10 years (mean 7.0 years) with long-standing SOM were examined 4-6 h after tube insertion, at 4 months and at 9 months. The pressure in the middle ear and the nasopharynx were recorded while performing (1) forced opening test, (2) equalization of +100 and -100 daPa, (3) Valsalva test, and (4) sniff test. The procedure was repeated after 30 min. Relationships were analyzed by uni- and multi-variate analysis of variance. RESULTS: From tube insertion to 4 months, the mean forced opening pressure increased from 282+/-128 to 355+/-153 daPa (P<0.01), and the mean closing pressure from 91+/-51 to 126+/-82 daPa (P<0.01). There was no further change at 9 months. Female gender, serous effusion (in contrast to mucoid), and more than three previous episodes of acute otitis media were related to higher opening and closing pressures. At tube insertion, 60% and 16% equalized +100 and -100 daPa, respectively, and 28% succeeded in performing Valsalva inflation. The sniff test was positive in 32%, indicating a closing failure. These rates did not change significantly over time. For individual ears, outcomes of all tests varied considerably when retested after 30 min; P(o) changed by +/-12% and P(c) by +/-26%, and 9-29% of the ears changed from a positive to negative response, or vice versa, in the equalization, Valsalva, and sniff tests. CONCLUSIONS: The unexpected finding of weaker closing forces at the day of tube insertion and increased tubal resistance at follow-up might be ascribed to changes in the muco-adhesive forces related to the disease and tube treatment. The pronounced intra-individual variability of test outcomes indicates that tubal function is dynamic and variable in ears prone to SOM, which emphasizes that results of single tubal function tests have very low prognostic value.

Qualitative research methods in otorhinolaryngology.

OBJECTIVE: Qualitative research methods explore the character and meaning of human phenomena. The methodology is unfamiliar to most clinicians, not only because of the different techniques and the type of studied issues, but also because of important differences regarding terminology and criteria for evaluating qualitative studies. This paper aims at discussing the potential contribution of qualitative methods to otorhinolaryngological research in general, and to describe a specific method with an otologic application in detail. METHOD: In order to explore different disturbing sound phenomena and coping strategies in patients with manifest tympanic membrane retractions, individual semi-structured interviews were performed. The transcripts were systematically analyzed by coding, categorizing, and interpreting the content of the text. The extracted themes, categories, and patterns were summarized. RESULTS: The method proved useful when exploring empirically known but non-measurable sound disturbances. Moreover, the findings provided further support for an alternative pathogenic theory suggesting the patient's playing an active role in the development of tympanic membrane retractions. CONCLUSIONS: Used as a complement to quantitative methods, qualitative methods offer a means for exploring the patient's experiences and role in the development, therapy, and prevention of disease. Otorhinolaryngology involves disorders of sensory functions such as hearing, equilibrium, smell and taste, as well as the vital functions of breathing and eating. The related symptoms might be experienced and coped with very differently depending on individual interpretations, fear of severe disease, etc. Furthermore, the clinician's and the patient's perspectives of symptoms and expectations regarding treatment may differ, which has implications for information, planning of therapy, and quality assessment in health care. There is no lack of study questions, but rather a lack of experience of alternative and pertinent methods.

The character and consequences of disturbing sound sensations in retraction type middle ear disease.

OBJECTIVE: Transient sound disturbances are common but neglected symptoms in retraction type middle ear disease (R-MED). The aim of this study was to explore and describe their character, their individual consequences, and their role in the development of tympanic membrane retractions. METHODS: Fifty-three subjects with manifest retractions and experiences of disturbing sound and ear sensations were interviewed. A qualitative method was used for analysis of the transcribed interviews. RESULTS: Two different patterns emerged from the interviews. 1. Too weak sound was the least common and most tolerable disturbance. It occurred in 45% and was eliminated by Valsalva's inflation. 2. Sudden and transient sensations of too loud and piercing sound, and intermittent autophony frequently caused intense and intolerable discomfort, which might in turn cause loss of control of speech and conversation. These types occurred in 74% and 60%, respectively, and were eliminated by evacuating the middle ear, for example by sniffing. Subjects who described too loud sound or intermittent autophony commonly preferred a retracted tympanic membrane position. This may explain why pressure equalization by swallowing, and inflation by Valsalva's manoeuvre often elicited discomfort. CONCLUSIONS: Transient experiences of too loud sound or intermittent autophony may indicate a shift of sound preference towards the sound experienced at negative middle ear pressure, and an unreliable tubal function in the sense that it fails to stay closed to protect the ear from sounds and pressure variations in the nasopharynx. Such experiences of altered sound may trigger evacuation of the middle ear, which eliminates the sound disturbance. It is crucial to identify, interpret, and explain the disturbances correctly in the therapy and prevention of retractions, since habitual evacuation exposes the tympanic membrane to strong negative pressure loads and a subsequent risk of developing retraction.

Evaluation of a three-stage management program for Menière's disease.

A three-stage program for management of Menière's disease, consisting of diuretics, endolymphatic sac surgery, and intratympanal installations of gentamicin was tested in a peripheral county without neurosurgical facilities during 1981-1985. All 106 patients in the program were admitted at least once to the only ENT department of the area. The authors believe that these cases represented the most serious part of a total incidence estimated to be about 6.5 times higher than what the present material represent. When evaluated at the end of the period according to the AAOO 1972 classification , only 12 patients turned out to be suffering from vertigo. However, among other factors, the possible placebo effect on a population whose Meinère-related problems were for the first time focused upon and treated must be kept in mind.