The status of Eustachian tube balloon dilations in Nordic countries.

There is no unanimous consensus for indications of eustachian tube balloon dilation (ETBD). Nordic countries have relatively similar hospital organizations and treatment guidelines. Therefore, it was logical to organize a consensus meeting of ETBD. The symposium: Nordic Experiences on Eustachian Tube Balloon Dilation, in Copenhagen, 30-31 March, 2017. The panellists from Denmark, Finland, Norway and Sweden and the attendees of the meeting agreed a consensus on the following issues: Candidates, Definition of Eustachian Tube Dysfunction, Diagnostic Work up, Differential Diagnosis, Contraindications, ETBD Procedure, Complications, Follow-up, and Outcomes. The article also presents the status for ETBD in each of these countries. Thereafter the consensus statement has been discussed in the national societies and meetings for ear surgeons in each of these countries. It can be assumed that surgeons in the hospitals of these Nordic countries generally follow the recommendations from the consensus meeting.

[Workup and treatment of Eustachian tube dysfunction in adults].

Symptoms of Eustachian tube dysfunction are frequent and multiple. Therefore, clear definitions and diagnostic criteria are important in order to achieve appropriate patient flow. So far, there has been a lack of consensus on this subject, but the proposed definitions and diagnostic criteria in this review may aid to achieve this. Tubomanometry is a diagnostic tool to evaluate Eustachian tube function, and balloon dilation of the Eustachian tube can be a helpful treatment in patients with Eustachian tube dysfunction.

Postoperative infections following cochlear implant surgery.

INTRODUCTION: The aim of this study was to report the frequency and management of postoperative wound infections and to investigate bacteriology and biofilm formation following 653 consecutive cochlear implantations in adults. METHODS: A retrospective file review of 653 consecutive adult cochlear implantations between 1994 and 2015 at the Department of Otorhinolaryngology at Odense University Hospital. A reporting consensus was used to classify infections. RESULTS: The major and minor infection rates were 2% and 8%, respectively. The explantation rate due to infection was 1%. The most common pathogen found was Staphylococcus aureus and biofilm formation was found in 73% of the explantations. CONCLUSION: Postoperative infection occurred in 10% of the implantations. However, few of these were severe. Staphylococcus aureus was the most common pathogen and the presence of biofilm seemed to be associated with a higher risk of explantation.

Autosomal dominant stapes fixation, syndactyly, and symphalangism in a family with NOG mutation: Long term follow-up on surgical treatment.

OBJECTIVE: Evaluation of clinical findings and audiological outcome after surgery in a Danish family with autosomal dominant facio-audio-symphalangism syndrome with stapes fixation, syndactyly and symphalangism. METHODS: Retrospective report on eight affected family members in a Danish family. Clinical investigation included X-ray, audiology and in one case video-recorded surgery. Main outcome measure was audiologic results after stapedectomy. Sanger DNA sequencing of NOG was performed on peripheral blood. RESULTS: Audiologic analysis showed that seven of eight affected family members had bilateral conductive hearing loss. Three patients were treated with stapedectomy, on one or both ears, due to fixation of stapes. All the affected members had syndactyly and symphalangism. A not previously reported mutation in the NOG gene (c.688_699del, p.Cys230_Cys232delins11) was found to segregate with the stapes fixation, syndactyly, and symphalangism. p.Cys230_Cysdelins11 was classified as likely pathogenic according to guidelines from the American College of Medical Genetics and Genomics. CONCLUSION: The clinical presentation of the reported mutation corresponds with previous case reports of families with NOG mutation. In this family, surgery with stapedectomy had lasting effect without renewed fixation of the stapes in a follow up period of 18 months-38 years.

Thyroid fine-needle aspiration and The Bethesda Classification System.

INTRODUCTION: Fine-needle aspiration (FNA) is a cornerstone in diagnosing thyroid nodules. For decades, Danish FNA has been categorised into the groups: "FNA not performed", "Inadequate", "Cystic", "Inconclusive", "Benign", "Suspicious", "Malignant" and "Information missing". Internationally, The Bethesda Classification System (TBCS) is increasingly accepted, especially owing to a detailed specification of FNA suspicious for malignancy. The Danish "Suspicious" group is very broad and includes atypia, follicular neoplasia and FNA suspicious of other malignancies. The purpose of this study was to apply TBCS to the Danish "Suspicious" FNA group and to estimate the frequency of malignancy in the individual Bethesda groups (BG). METHODS: This descriptive study is based on a prospective cohort from the THYKIR database. It includes 479 patients with a "Suspicious" FNA and surgical treatment in The Region of Southern Denmark from 2001 to 2013. Based on pathology records, FNA was classified according to the TBCS. Malignancy was determined by the histological diagnosis from the THYKIR database. RESULTS: The Danish "Suspicious" group was allocated to the BG I, II, III, IV, V and VI with a malignancy risk of 36.4%, 13.3%, 17.2%, 16.1%, 55.3% and 88.2%, respectively. CONCLUSIONS: The Danish "Suspicious" group contains a broad spectrum of BG with varying malignancy risk. The results indicate a need for standardisation of the Danish FNA classification. A national introduction of the TBCS might secure an international and comparable standard. FUNDING: none. TRIAL REGISTRATION: not relevant.

[Meningitis and septic sinus thrombosis in connection with otitis media].

This is a case report of a 30-year-old female, who presented to the emergency department with headache, nausea and neck pain after five days of otitis media. After lumbar puncture, CT and MRI the patient was treated for meningitis with initial improvement in the clinical state. After four days she developed contralateral neurological symptoms, and after five days she had a seizure. MR-venography showed thrombosis of the lateral dural sinus with venous cerebral infarction. The treatment of intravenously administered antibiotics, mastoidectomy and anticoagulation is discussed and compared with other cases in the literature.

Vestibular Outcome After Cochlear Implantation Is Not Related to Surgical Technique: A Double Blinded, Randomized Clinical Trial of Round Window Approach Versus Cochleostomy.

OBJECTIVE: To establish whether the round window approach (RWA) leads to less vestibular dysfunction and dizziness than the standard cochleostomy approach (SCA) during cochlear implant (CI) surgery, as assessed using the video head impulse test (vHIT).Additionally, objective findings were compared with the subjective dizziness perceived by the patient. STUDY DESIGN: Double blinded, clinical randomized trial. SETTING: University Hospital. PATIENTS: Fifty-two ears from 46 patients were included. Inclusion criterion was a gain value more than 0.50. INTERVENTION: Patients were randomized to the RWA or the SCA. Evaluation with the vHIT was performed before surgery, 1 day after surgery, and 1 month after surgery. Subjective dizziness was measured using a visual analogue scale (VAS) and the dizziness handicap inventory (DHI). MAIN OUTCOME MEASURES: Gain values and the incidence of catch-up saccades. RESULTS: Three out of 23 patients in the SCA group experienced catch-up saccades compared with no patients in the RWA group, indicating the occurrence of objective vestibular dysfunction after CI surgery; the difference was not statistically significant. The VAS increased in both groups the day after surgery. The difference between the groups was not statistically significant. No statistically significant changes in the gain value or the DHI score could were observed between the two groups. CONCLUSION: No statistically significant difference between the cochleostomy approach and the round window approach using the vHIT and subjective dizziness perceived by the patient was found.

Refixation Saccades with Normal Gain Values: A Diagnostic Problem in the Video Head Impulse Test: A Case Report.

Refixation saccades with normal gain value occur more frequently with increasing age. The phenomenon has also been observed in different vestibular disorders. In this case, we present a young male with normal gain value and refixation saccades tested with the video head impulse test (vHIT) the day after his cochlear implantation. One month after surgery, refixation saccades were no longer present. This suggests that refixation saccades can occur as a result of temporary pathology such as surgery. Refixation saccades with normal gain values might reflect a partial deficit in the vestibulo-ocular reflex. However, this partial deficit is in conflict with the current way of interpreting vHIT results in which the vestibular function is classified as either normal or pathological based only on the gain value. Refixation saccades, which are evident signs of vestibulopathy, are not considered in the evaluation. A new way of interpreting the vHIT based on the saccades must be considered.

Risk of malignancy in fine-needle aspiration biopsy in patients with thyroid nodules.

INTRODUCTION: Fine-needle aspiration biopsy (FNAB) is the cornerstone of thyroid nodule evaluation. In most cases, FNAB can discriminate between benign and malignant disease. In other cases, it is only indicative of malignancy and the results are considered "suspicious". In Denmark, thyroid FNAB results are categorised into six groups: "inadequate", "cystic", "inconclusive", "benign", "suspicious" and "malignant". The risk of malignancy in the Danish "suspicious" group is of interest for patients as well as doctors participating in the diagnosis and treatment. The Danish Thyroid Surgery Database (THYKIR) registers preoperative thyroid FNAB and final histology. The aim of this study was to assess the malignancy risk among patients with a suspicious thyroid FNAB according to the Danish criteria and to identify possible predictors of malignant histology. METHODS: A prospective cohort counting 483 patients with a "suspicious" thyroid FNAB who had been treated surgically in The Region of Southern Denmark in the 2001-2013 period was retrieved from the THYKIR database. RESULTS: The risk of malignancy in the Danish thyroid FNAB "suspicious" group is 22%. Serum thyroid-stimulating hormone outside the normal range and vocal cord palsy may be patient-related predictors of malignancy. CONCLUSION: Awaiting the introduction of reliable tools for preoperative evaluation, the current practice with histo-logical clarification of the "suspicious" thyroid FNAB seems justified. FUNDING: none. TRIAL REGISTRATION: not relevant.

[Temporary loss of vestibular function after cochlear implant surgery].

Loss of vestibular function is a common side effect to cochlear implant (CI) surgery. We present a patient who experienced balance problems and showed a reduced vestibulo-ocular reflex (VOR) gain (0.47 ± 0.10) combined with saccades in the horizontal semicircular canals demonstrated by the video head impulse test the day after CI surgery. One month after the operation VOR gain was normal (0.95 ± 0.05) and neither balance problems nor saccades occurred. Our findings indicate that vestibular dysfunction after CI surgery can be reversible, and VOR gain can return to normal.

Reliability and comparison of gain values with occurrence of saccades in the EyeSeeCam video head impulse test (vHIT).

The vHIT (video head impulse test) investigates the vestibular function in two ways: a VOR (vestibulo-ocular reflex) gain value and a head impulse diagram. From the diagram covert and overt saccades can be detected. Evaluation of the vestibular function based on vHIT depends on both parameters. There is a lack of knowledge regarding the reliability of the two parameters. The objective was to investigate the reliability of vHIT by comparing gain values between examiners on the same subjects, and to see how differences affected the occurrence of saccades. SUBJECTS: 25 subjects who had undergone cochlear implant (CI) surgery. Subjects were tested using the vHIT by two of four different examiners. Two judges interpreted the occurrence of saccades in the diagram. MAIN OUTCOME MEASURES: VOR gain values and the occurrence of saccades in the diagram. Differences in gain values between examiners varied from 0.2 to 0.58 with an average of 0.14 (95 % CI 0.12-0.16) on the right ear and 0.17 (95 % CI 0.15-0.19) on the left ear. Occurrences of saccades in the same patient were reproduced in 93 % of the cases by all examiners. Kappa's coefficient on the occurrence of saccades was 0.83. Interclass correlation coefficient (ICC) of the gain values between examiners ranged from 0.62 to 0.70. Differences in gain values amongst examiners did not seem to affect the occurrence of saccades in the same patient. The occurrence of saccades, therefore, seems to be more reliable than the gain value in the evaluation of the vestibular function. Interpretation of vHIT results should, therefore, first depend on the occurrence of saccades and second on the gain value.

Bone-anchored hearing aids are effective and associated with a high degree of satisfaction.

INTRODUCTION: The objective of this study was to evaluate patients' satisfaction with bone-anchored hearing aids (BAHA). METHODS: This study was retrospective and based on a postal questionnaire. The study sample consisted of patients undergoing surgery at Odense University Hospital in the 1992-2013-period. The questionnaire was a combination of Satisfaction with Amplification in Daily Life questions from the Hearing Aid Research Lab at the University of Memphis and questions used in a previous Danish study. We also used data from each patient's medical records. All information was collected in a database. RESULTS: The response rate was 80% and the user percentage 88. The majority of the patients used their BAHA seven days a week and most of the day. 88% reported that it was in their best interest that they had received a BAHA. 80% of the respondents were able to communicate better using their BAHA in one-on-one conversations. CONCLUSION: BAHA is helpful in one-on-one conversations in quiet surroundings. Sound quality in group situations seems to be the main problem associated with BAHA. However, this study showed that BAHA is an effective hearing aid that is associated with a high degree of satisfaction. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

[Balloon dilation of Eustachian tube is a new treatment of chronic otitis media].

Balloon dilation of Eustachian tube is a novel method for managing chronic ventilatory dysfunction in patients with chronic otitis media, as an alternative to classic grommet insertion. Although few retrospective studies have been conducted the method seems to be rapid, simple and safe with promising short-term results. This paper presents the method and summarizes the results of available studies. Optimization of patient selection is needed and we discuss the development of better objective measurement methods as well as the need for randomized prospective studies, which are currently being conducted.

Promising results after balloon dilatation of the Eustachian tube for obstructive dysfunction.

INTRODUCTION: As the first ear, nose and throat department in Denmark, we introduced balloon dilatation of the Eustachian tube as a treatment of obstructive dysfunction in the summer of 2012. We present our preliminary experiences with this new treatment in adults. MATERIAL AND METHODS: Preoperatively, several different tests were performed including otomicroscopy, audiometry, tympanometry and Toynbee's test. The patients were classified as Class 1 (if they could make a pressure equalisation of the middle ear by a normal Valsalva's test), Class 2 (if they needed an extended Valsalva's test), Class 3 (if only a test with the Otovent could make air flow to the middle ear), and Class 4 (if no passage of the Eustachian tube could be achieved). Furthermore, the patients filled out questionnaires using a visual analogue scale (VAS). RESULTS: A total of 50 treatments were performed in 34 patients (16 patients had bilateral problems). Four patients (six Eustachian tubes) had intermittent problems, while 30 patients had chronic dysfunction. A significant effect of the treatment was documented when measuring both audiometry, tympanometry, Toynbee's test, classification of Eustachian tube dysfunction and VAS questionnaires. Some patients (e.g. patients with atelectatic ear drums) were not helped by the treatment. Among the first 40 treatments, 10% were observed to have acute otitis media post-operatively. DISCUSSION: The majority of the patients experienced a positive effect of the treatment. Our results are comparable to those of other similar studies. We regard this new treatment as very promising, but look forward to more research. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

[An abscess in the tongue]. / Tungeabsces.

Abscesses of the tongue are rare and potentially life-threatening because of risk of airway obstruction. It is most often preceded by trauma. In this paper we present an otherwise healthy patient with an abscess in the tongue eleven days after a trauma involving the presence of an insect believed to be a spider in the mouth. The symptoms were oedema, redness and pain of the tongue. A computed tomography was used as a diagnostic tool. The abscess was successfully treated with incision and antibiotics. Abscess should be considered as a differential diagnosis in patients presenting with a swollen tongue.

Efficiency of laser treatment in patients with hereditary hemorrhagic telangiectasia.

Earlier studies have shown the effect of laser treatment on epistaxis in patients with hereditary hemorrhagic telangiectasia (HHT). At the present time, only very few prospective trials have been performed, and many studies are based on patients' subjective assessment of the severity of epistaxis. This prospective study measures the objective effect of laser treatment in HHT patients with mild to moderate epistaxis. We introduce an objective measure to assess the severity of epistaxis: the bleeding time (BT). Before and after treatment, the quality of life, as measured by the patient, was assessed and compared to normative data. In 30 patients, we measured the BT before laser treatment 1.5 and 6.5 months after treatment. The Short form 36 (SF-36), a validated health questionnaire, was completed before and 6.5 months after treatment. Compared to preoperative value, BT was significantly reduced 1.5 and 6.5 months after laser treatment (p < 0.05) in both cases. No significant difference in quality of life, before and after treatment, was found. The quality of life of the HHT patients was reduced in five out of eight dimensions when compared with the Danish background population. Laser treatment reduces epistaxis in HHT patients with mild to moderate epistaxis for at least 6 months; this group of patients have reduced quality of life compared to the background population.

[Otosyphilis]. / Otosyfilis.

We present a case in which a patient infected with human immunodeficiency virus (HIV) developed a sensorineural hearing loss and tinnitus due to inner-ear syphilis affection. The patient had normal otomicroscopy, tympanometry, ear, nose & throat examination, caloric test and intracranial magnetic resonance imagining. Relevant serological blood samples and lumbal puncture indicated syphilis in its secondary stage or the early latent phase. Audiometry demonstrated a considerable improvement and tinnitus decreased after ten days of treatment with antibiotics and prednisone.

[Results after stapedotomy in otosclerosis]. / Resultater efter primaer stapedotomi ved otosklerose.

INTRODUCTION: The purpose of this study was to assess the results after primary otosclerosis surgery at Odense University Hospital. MATERIAL AND METHODS: The study was based on information collected from a database and from patient records. A total of 154 primary stapedotomies (138 patients) were performed using small-fenester-technique in the period 1996-2005. Five experienced ear surgeons performed the operations. The surgeons were still in the learning phase with regard to otosclerosis surgery. RESULTS: A significant improvement was found regarding the air-conduction pure tone average (PTA) (52.8 dB to 31.4 dB), the bone conduction PTA (25.2 dB to 23,1 dB), air-bone gap (27.6 dB to 8.3 dB), and the speech reception threshold (44.8 dB to 22.5 dB). One operation (0.6%) resulted in severe sensory-neural hearing loss, while other types of complications were seen after 7,2% of the operations. After thirteen operations (8.4%), reoperation was subsequently needed. CONCLUSION: Patients undergoing primary otosclerosis surgery gained a significant hearing improvement. The results of this survey matched those of larger international and Danish studies. Experienced ear surgeons can perform stapedotomy with good results without having initial experience in otosclerosis surgery.

[Cochlear implantation in deaf adults: effect on quality of life]. / Cochleaimplantat til døve voksne: konsekvenser for livskvaliteten.

INTRODUCTION: Our aim was to assess the effect of cochlear implant (CI) surgery on the mental quality of life in totally deaf adults using a generic type of questionnaire. MATERIALS AND METHODS: The survey comprised 40 adult CI users who answered a standard and a retrospective version of the Short Form 36 questionnaire (SF-36). In the questionnaires, specific questions focused on four dimensions of the mental quality of life: vitality, social functioning, and emotional and mental health. RESULTS: Due to qualitative and quantitative deficiencies, the emotional scale was omitted. A statistically significant improvement in the quality of life (p<05) was demonstrated in the three remaining subscales between pre-implant and post-implant scores. The greatest improvement was observed in the social functioning subscale. Pre-implant mean scores on all three subscales of the SF-36 were markedly below the mean scores of the equivalent subscales of the Danish population, whereas the post-implant mean scores in two out of three cases were above the mean scores of the Danish population. DISCUSSION: CI was shown to have a statistically significant positive impact on the quality of life of adult deaf patients. This is in accordance with other published studies.