[Laser Doppler vibrometric measurements on human temporal bones]. / Laser-Doppler-vibrometrische Messungen an humanen Felsenbeinen.

Laser Doppler vibrometric (LDV) measurements on human temporal bones represent the standard method for predicting the performance of active middle ear implants (AMEI) and are used as preclinical tests in the development, approval process, and indication expansion of AMEI. The quality of the coupling of the floating mass transducer to the mobile structures of the middle ear is decisive for the performance of the implant and patients' hearing perception. The cochlea can be stimulated via the oval window (forward stimulation) or the round window (reverse stimulation). For forward stimulation, the ASTM standard F2504-05 defines a method to ensure physiologically normal properties of the temporal bones used in the experiments. For reverse stimulation, which depends even more critically on the quality of the temporal bone, a comparable standard method is lacking. Appropriate preparation and storage of the human petrous bone as well as suitable LDV test setups with respect to calibration and reproducibility of measuring positions and angles provide results that allow a comparison of different types of coupling and also correlate well with clinical data.

[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.

Screening for irradiation vasculopathy by intima-media thickness sonography in head and neck cancer patients.

PURPOSE: Post-irradiation vasculopathy is a severe form of atherosclerosis and affects the prognosis of head and neck cancer survivors. Sonographic intima-media thickness (IMT) precedes stenosis, plaque formation, and cerebrovascular events. Therefore, IMT may be a valuable screening marker for post-irradiation toxicity. However, the critical irradiation dose and the onset of IMT increase remain unclear. METHODS: The cross-sectional study analysed the carotid artery IMT in 96 irradiated patients and 41 controls regarding irradiation dose, post-irradiation-interval, and cardiovascular risk factors. Distinct irradiation doses to the tumour side and the contralateral hemineck enabled detection of dose depended effects within one patient and control of risk factors. RESULTS: Radiotherapy caused a dose-dependent increase in IMT. The toxicity did not have saturation effects for > 60 Gy. The IMT increase occurred in short-term following radiotherapy and the risk for a pathological value (> 0.9 mm) rose significantly. The correlation between IMT and radiotherapy was comparable to established cardiovascular risk factors. CONCLUSION: Radiotherapists should consider the additional toxicity of high doses for non-metastatic head and neck cancer. If neck metastases require radiotherapy with boost, IMT measurement is suitable for early detection of carotid artery damage.

[Evaluation of standardized questionnaires for diagnosis and differentiation of obstructive and patulous Eustachian tube dysfunction]. / Untersuchung standardisierter Anamnesefragebögen zur Diagnostik und Differenzierung von obstruktiven und klaffenden Tubenfunktionsstörungen.

BACKGROUND: Patulous Eustachian tube (ET) dysfunction can impair quality of life (QOL) due to autophony, pressure sensation, and an altered impression of sound. In cases of nonspecific complaints the diagnosis of patulous ET can be difficult, and its distinction from chronic obstructive ET dysfunction is particularly challenging. Since there is currently a lack of standardized diagnostic and therapeutic options, a structured diagnostic workup is essential for accurate diagnosis of this condition. The Eustachian Tube Dysfunction Patient Questionnaire (ETDQ-7) was established by McCoul et al. in 2012 for investigating chronic obstructive ET dysfunction. The Patulous Eustachian Tube Handicap Inventory-10 (PHI-10) was published by Kobayashi et al. in 2017 as an instrument to evaluate patulous ET. PATIENTS AND METHODS: The PHI-10 questionnaire was translated into German and validated in a total of 83 patients (41 healthy subjects, 13 patients with tinnitus, 11 patients with patulous ET, and 18 patients with chronic obstructive ET dysfunction). In addition, the PHI-10 (German) was compared to ETDQ­7. RESULTS: The results of the English version of the PHI-10 questionnaire could be confirmed using the German version. The German version of the PHI-10 and the results of the PHI-10 and ETDQ­7 for each group of patients are presented. The ETDQ­7 leads to false-positive results in patients with patulous ET and the PHI-10 generates false-positive results in patients with chronic obstructive ET dysfunction. Both questionnaires result in false-positive results in patients with tinnitus. CONCLUSION: The PHI-10 and ETDQ­7 (German) can be recommended as an additional tool for preoperative assessment of ET dysfunction. However, they insufficiently discriminate between patulous and obstructive ET dysfunction and are not suitable for patients with tinnitus. The strength of the two questionnaires lies in their suitability for use in monitoring therapeutic success during follow-up.

[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.

Implantation of a new active bone conduction hearing device with optimized geometry.

Here, we describe the surgical technique for implanting a new, active, transcutaneous bone conduction hearing aid. The implant technology is based on a system that has been in use reliably since 2012. The geometry of the new implant has been adapted based on experience with previously introduced implants. The surgery was feasible, standardized, and safe. Due to the optimized geometric design that improved the bone fit, it is not necessary to use specialized, detailed preoperative planning, except in challenging anatomical conditions; e.g., in young children, malformations, poor pneumatization, or after a canal wall down mastoidectomy.

[Implantation of a new active bone conduction hearing device with optimized geometry. German version]. / Implantation eines neuen, aktiven, knochenverankerten elektronischen Hörimplantats mit verkleinerter Geometrie.

Here, we describe the surgical technique for implanting a new, active, transcutaneous bone conduction hearing aid. The implant technology is based on a system that has been in use reliably since 2012. The geometry of the new implant has been adapted based on experience with previously introduced implants. The surgery was feasible, standardized, and safe. Due to the optimized geometric design that improved the bone fit, it is not necessary to use specialized, detailed preoperative planning, except in challenging anatomical conditions; e.g., in young children, malformations, poor pneumatization, or after a canal wall down mastoidectomy.

[Georgia, a country of diverse aid from Germany in the ENT field]. / Georgien, ein Land vielfältiger Hilfen aus Deutschland auf dem HNO-Gebiet.

Following a long-term tradition, several teams of German ENT specialists are currently working in different Georgian clinics on a charitable basis. The current paper describes the structures of the medical and health insurance systems in this southern Caucasian country. The course of medical education for physicians in Georgia is portrayed and differences to the German situation which explain why young Georgian colleagues have difficulties when moving to Germany are highlighted. The paper describes the typical stay of a German ENT specialist in Georgia and also points out how these physicians are in turn supported in their charitable work by medical devices and equipment sent from Germany. Finally, the input that German colleagues can contribute to improving the situation in the Georgian health care system is discussed from the perspective of German ENT specialists and future goals of the cooperation between German and Georgian physicians are summarized.

[Intraoral voice recording-towards a new smartphone-based method for vocal rehabilitation. German version]. / Die intraorale Sprachaufnahme ­ die Perspektive einer neuen Smartphone-basierten Methode zur stimmlichen Rehabilitation.

After laryngectomy, a new voice is needed. We present the first steps in the development of a smartphone-based method. A microphone is placed in the mouth to record the pseudo-whispering voice of laryngectomized patients. This recording is analyzed by voice recognition software followed by voice synthesis. Eventually, this will be performed on a smartphone. We placed a microphone at 10 different places inside and outside the mouth (two in front of the mouth (at 2 and 20 cm), five on the palate and three on the lower jaw) and made voice recordings in eight healthy men. These recordings were analyzed by voice recognition software. The text generated by the software was compared with the original text. Over all positions, the correct detection of words recorded in the mouth was 19.3% vs. 75.2% (p = 0.01) outside the mouth. In the mouth, recording taken on the maxilla (22.8%) was much better than on the mandible (13.5%) (p = 0.01). The optimum position for a microphone on the maxilla was at the highest point of the palate with 31.9% correct word identification there (p = 0.028). Further investigations have to be undertaken with forthcoming development of smartphone processing power and with development of a smartphone-based voice recognition application.

Intraoral voice recording-towards a new smartphone-based method for vocal rehabilitation.

After laryngectomy, a new voice is needed. We present the first steps in the development of a smartphone-based method. A microphone is placed in the mouth to record the pseudo-whispering voice of laryngectomized patients. This recording is analyzed by voice recognition software followed by voice synthesis. Eventually, this will be performed on a smartphone. We placed a microphone at 10 different places inside and outside the mouth (two in front of the mouth (at 2 and 20 cm), five on the palate and three on the lower jaw) and made voice recordings in eight healthy men. These recordings were analyzed by voice recognition software. The text generated by the software was compared with the original text. Over all positions, the correct detection of words recorded in the mouth was 19.3% vs. 75.2% (p = 0.01) outside the mouth. In the mouth, recording taken on the maxilla (22.8%) was much better than on the mandible (13.5%) (p = 0.01). The optimum position for a microphone on the maxilla was at the highest point of the palate with 31.9% correct word identification there (p = 0.028). Further investigations have to be undertaken with forthcoming development of smartphone processing power and with development of a smartphone-based voice recognition application.

Optical coherence tomography and confocal laser scanning microscopy as non-invasive tools in the diagnosis of sinonasal inverted papilloma: a pilot study.

Optical coherence tomography (OCT) and confocal laser scanning microscopy (CLSM) are light-based imaging techniques that allow for a visualization of microscopic tissue properties in vivo. Our study was to examine whether they allow for differentiation of inverted papilloma (IP) from nasal polyps (NP). Five cases of IP and NP, respectively, were investigated intraoperatively with OCT and CLSM. Biopsies were taken of the investigated area and were analyzed ex vivo with OCT and CLSM and then underwent HE-staining for standard light microscopy. On OCT images, IP showed the characteristic inverted character of the epithelium, that was thicker with a high degree of variability of thickness compared to the thin and homogenous epithelium of NP. In addition, the characteristic stromal edema of NP could be visualized. On CLSM images, the typical epithelial invaginations of IP appeared as crypts, while in NP the highly organized cylindric epithelium could be visualized. In vivo, OCT acquired images of sufficient quality to visualize these characteristics, while CLSM did not. Our study demonstrates that OCT and CLSM can distinguish IP from NP. Further technical development is required to apply the techniques clinically to guide intranasal biopsies or even to make them dispensable.

[Otorhinolaryngology in the field of demography, growing outpatient care and regionalization]. / Die HNO-Heilkunde im Spannungsfeld von Ambulantisierung und Regionalisierung.

BACKGROUND: Otorhinolaryngology (ENT) departments are strongly affected by current changes in the reimbursement schemes for inpatients. The study was designed to investigate these effects on the ENT Department in Rostock and selected comparison clinics, as well as to outline solutions. METHODS: We analyzed diagnosis-related group (DRG) reports of the ENT Clinic at Rostock University Medical Center from 2013 to 2015, according to the size of the outpatient potential. Comparisons were made with other surgical departments such as maxillofacial surgery and ophthalmology in terms of average length of stay and the resulting deductibles. We also compared billing as day surgery and complete outpatient surgery for the main small surgical procedures such as tonsillectomy and septum surgery. Finally, we compared the discounts with 22 ENT departments in other maximum care hospitals. RESULTS: The average case mix index of an ENT department in Germany is 0.75, case load average of 2,500 patients and common length of stay 4.1 days. In a typical academic ENT department as in Rostock, health plans usually discount around 500 T€ (thousand euro), which is considerably higher than comparable departments, e.g., oral and maxillofacial surgery or ophthalmology departments. However, discounts on a DRG for inpatient surgery is still approximately 1,000 € more revenue than surgery in an outpatient setting. The benchmark analysis shows that health plans in rural areas are more likely to accept inpatient surgery with discounts for small procedures than strict billing according to outpatient reimbursement schemes. CONCLUSION: These effects can result in an insufficient cost effectiveness of ENT departments in Germany. As a consequence, substantial restructuring of the in- and outpatient treatment seems necessary, also for academic ENT departments, e.g., in the form of day surgery or ambulatory surgical centers, outpatient clinics with special contracts and specialized inpatient surgery. However, this results in greater demands on the training of young physicians and management of patient flows within the department.

[Treatment of nasolacrimal duct obstruction from the otorhinolaryngologist's perspective]. / Die Behandlung von Tränenwegsstenosen aus HNO­ärztlicher Sicht.

BACKGROUND: Epiphora is the classic symptom of nasolacrimal duct obstruction, particularly among elderly people. Dacryocystorhinostomy (DCR) via external (Toti) and endonasal (West) approaches are well-established surgical treatments. OBJECTIVE: The aim of the present article is to describe the etiology and diagnostics of nasolacrimal duct obstruction. Furthermore, treatment modalities are discussed according to the current literature, with particular consideration of the otorhinolaryngologist's perspective. MATERIALS AND METHODS: A search of the current literature focused on the past 5 years was performed in PubMed. RESULTS: Several retrospective and prospective randomized studies describe the external and endonasal DCR approaches as safe surgical procedures, with high success rates of around 90 %. The endoscope is standardly used for visualization during the endonasal approach. Powered instruments such as diamond drills enable generation of a large rhinostomy, even in very hard bone. The application of silicone stents does not confer a significant additional advantage in terms of postoperative success rates. CONCLUSION: DCR is a safe surgical procedure with high success rates. It can be strongly recommended for patients suffering from intra- or post-saccular nasolacrimal duct obstruction. Furthermore, the external and endonasal approaches (according to Toti and West, respectively) are comparable techniques. The use of silicone stents is indicated only in special cases.

Visualisation of passive middle ear implants by cone beam and multi-detector computed tomography: a comparative in vitro study.

OBJECTIVES: Modern passive middle ear titanium prostheses are filigree structures, resulting in poorer depiction on CT compared to prostheses used in the past. We compared the visibility of newer prostheses on cone beam CT (CBCT) to multi-detector CT (MDCT) with standard and lower dose in vitro, and analysed image noise and metal artefacts. METHODS: Six different titanium middle ear prostheses (three partial and one total ossicular replacement prostheses, two stapes prostheses) were implanted twice in formalin-fixed head specimens-first correctly and then with displacement. Imaging was performed using standard CBCT and MDCT as well as MDCT with lower dose (36 single imaging investigations). Images were analysed with knowledge of the used types of middle ear prostheses, but blinded with respect to the positioning in the specific case. RESULTS: On all images the type of prostheses and their positions could be clearly recognized. Their identifiability including their details was rated as statistically significantly higher for all CBCT investigations than for MDCT. MDCT with lower dose showed the worst results. No statistical differences were found in image noise and metal artefacts. CONCLUSIONS: If available, CBCT should be preferred over MDCT in diagnostic evaluation of passive middle ear prostheses. KEY POINTS: • Middle ear prostheses became more filigree, leading to poorer visibility on CT. • High spatial resolution and paraxial reconstructions are necessary requirements for imaging evaluation. • CBCT and MDCT can identify type and positioning of titanium prostheses. • Metal artefacts play a minor part in filigree titanium prostheses. • Regarding visualisation of prostheses details, cone beam CT aids the evaluation.

[Direct Drive Simulation - Sound-Simulation of the Vibrant Soundbridge®]. / Direct Drive Simulation - Klangsimulation des Vibrant Soundbridge®-Hörens.

BACKGROUND: The Direct-Drive-Simulation (DDS) tends to simulate the sound quality of hearing with the active middle ear implant Vibrant Soundbridge(®) (VSB). Up to now a scientific evaluation of the validity is missing. Furthermore, the test procedure has not been described yet. Aim of this study was to evaluate the test validity and to describe the test realization in detail. MATERIAL AND METHODS: 10 patients evaluated their sound impression on scales from 1 to 10 concerning sound quality during DDS, postoperative free field testing at least 3 month after the first fitting of the VSB and in the everyday life situation. 3 patients were implanted bilaterally. Together, 36 data sets could be analyzed. RESULTS: Coupling of the Floating Mass Transducer (FMT), which was placed inside of a silicone probe during DDS was successful in all cases. In 11 out of 13 cases the coupling quality was judged as "good" an only in 2 cases as "medium". None of the patients needed local anesthesia. Comparing the evaluation of the sound impression during DDS preoperatively, and with the implanted VSB in free field testing and in everyday life no significant differences were found. CONCLUSION: The DDS offers the possibility of a realistic preoperative sound simulation of the "VSB-hearing" in case of sensorineural hearing loss. Thus, the test is supposed to facilitate the patient's decision towards possible treatment options. The specialist gets additional information regarding the indication especially when audiologic indication criteria are critical. The DDS should be a basic part of the preoperative diagnostic prior to VSB-implantation.

Vibrant soundbridge in aural atresia: does severity matter?

Congenital aural atresia (CAA) poses significant challenges to surgical remediation. Both bone anchored hearing aids (BAHA) and the Vibrant Soundbridge (VSB) have been considered as alternatives or adjuncts to conventional atresiaplasty. A consensus statement on VSB implantation in children and adolescents recommended against implantation when the Jahrsdoerfer score was less than 8. More recent publications suggest that patients with Jahrsdoerfer scores between three and seven may benefit from VSB implantation. The purpose of this study was to further investigate the outcomes of VSB implantation in CAA. The study was a multi-center, retrospective review. A retrospective review of data (patient's demographic, clinical, implant and audiological information) from four collaborating centers that have performed VSB implantation in CAA was performed. Outcomes based on severity of the atresia using the Jahrsdoerfer and Yellon-Branstetter scoring systems were also evaluated. Data from 28 patients from the four centers revealed no iatrogenic facial nerve injuries or change in bone thresholds. Post-operative speech threshold and speech recognition was, respectively, 39 dB and 94%. Jahrsdoerfer and Yellon scores ranged from 4 to 9 and 4 to 12, respectively. The scores did not correlate to or predict outcomes. Three individual elements of the scores did correlate to initial, but not long-term outcomes. Atresiaplasty and BAHA in the management of CAA are not complete solutions. VSB may offer an alternative in these surgically complex patients for achieving amplification, though better metrics for patient selection need to be developed. LEVEL OF EVIDENCE : IV.