[The management of Dysphagia. Part 1: diagnostics]

Patients with chronic dysphagia are often in need of artificial nutrition; though being well balanced in terms of energy and vitamins, patients are at a high risk for the loss of resistance and body weight. Dysphagia also causes a severe drawback of the overall quality of life. This paper gives an overview of the present management of dysphagia from the point of view of otolaryngologists, head-neck-surgeons, phoniatricians, and medical speech-language-voice-pathologists. The physiology of swallowing and typical symptoms of dysphagia are first explained. Then the current most important diagnostic procedures as orofacial and laryngeal function analysis, video-endoscopy, and quantitative assessments, are discussed (part 1). This also includes considerations on bolus viscosity variation, postures, swallowing maneuvers, and sensory enhancement procedures, while actual options like botulinum toxin, passy-muir speaking valve, electromyographic biofeedback, and electrostimulation are also mentioned (part 2).

Zusammenhänge zwischen „Anamnesebogen für Auditive Verarbeitungs- und Wahrnehmungsstörungen” und „Heidelberger Lautdifferenzierungstest”

BACKGROUND

A standardized anamnestic questionnaire of central auditory processing disorders ("Anamnestischer Erhebungs- und Beobachtungsbogen für auditive Verarbeitungs- und Wahrnehmungsstörungen") (FB-AVWS) was developed by German paedaudiologists. The present study examined the relations between this questionnaire and the results of selected auditory-perceptual tests to evaluate the validity of the FB-AVWS.

SUBJECTS AND METHOD

As part of a multicentric study, 113 pupils in primary schools were examined by the "Heidelberger Lautdifferenzierungstest", a test of phonemic discrimination and identification (HLAD). Additionally, the parents answered the FB-AVWS. Sensitivity, specificity and correlations with the FB-AVWS were determined referred to the HLAD.

RESULTS

We found significant, though moderate correlations, between the scale "auditory discrimination" of the FB-AVWS and the subtests "kinaesthetic/phonemic identification" and "phonemic analysis" of the HLAD. The other subscales of the FB-AVWS showed no significant correlations with the HLAD and its several subtests. The values for the sensitivity of the FB-AVWS were relatively high (93 and 100 %) as where the negatively predictive values for the HLAD as a whole and the subscale 1B (98 and 100 %), referred to HLAD. The specificity and the positive values were relatively low for the HLAD as a whole and for several of its subtests.

CONCLUSION

The FB-AVWS is a useful supplementation for the complementary clinical evaluation of central auditory disorders. It allows an assessment of the child's auditory perception and processing skills compared to the general population of primary school children. However, it is not valid as a screening or diagnostic instrument.

Dosierung von Botulinumtoxin Typ�B bei spasmodischer Dysphonie vom Adduktortyp

Today, most patients with severe adductor type spasmodic dysphonia are treated with repeated injections of botulinum toxin type A (BTA). It is known that patients who have been treated for many years and have received a high cumulative dosage may develop antibodies against BTA, making them "resistant" to further injections. For these patients, botulinum toxin type B (BTB, NeuroBloc) is considered to be a new chance to continue the treatment. When changing to BTB, one has to find an "equivalent dosage" which is estimated for cervical dystonia to be 25-33-fold of the previous Botox dosage and the 10-13-fold for the previous Dysport dosage. We report on a 62 year old female patient with antibodies against BTA. For maximum care, the first injection of BTB was performed with the sixfold of the previous Dysport dosage, which was almost the half of the needed dosage predicted from experience with cervical dystonia. The relief only lasted 3 weeks and was therefore disappointing. For the subsequent injections, we consulted Sataloff who also had one patient with antibodies treated with BTB. Based on his personnel advice, we chose the 30-fold dosage, which was effective for 3 months, resulting in improvements to voice quality (both psychoacoustic rating and acoustic measures), voice "quantity" (voice range profiles), aerodynamics (maximum phonation time, phonation quotient), and voice handicap. As with Sataloff et al. (2002), we found that the dosage of BTB probably has to be much higher than in cervical dystonia.

[The management of dysphagia -- part 2: therapy]

In the first part of the article we described diagnostic methods aiming to resolve the individual underlying pathomechanism of chronic swallowing disorders (dysphagia). From these, we deducted different therapeutic measures that can be applied either alone or in combination. Weakening of the upper esophageal sphincter with botulinum toxin is reserved for patients with structural stenosis or a relative hyperfunction of the sphincter. It can be tried to use the "Passy-Muir Valve" for tracheostomized patients that aspirate. Most cases benefit from a therapy that consists of specific exercises. "Restitution" relies on exercises to practice new movement patterns as well as improvement of muscle strength. "Compensation" is based on exercises to counteract structural and/or functional deficits. Through "adaptation" residual, therapy resistant disease can be alleviated through dietary planning of consistency, temperature, and nutrient content of food. In many cases it is necessary to combine "restitution", "compensation", and "adaptation".

Altersabh�ngigkeit sp�ter auditorischer Potenziale (NC-ERP) bei Kindern

BACKGROUND

Neutral condition event related potentials (NC-ERP) are not suitable for differentiating between children suffering from auditory processing disorders (APD) alone and APD-children with attention deficit disorder. Other factors beside severity of APD may cause "pathological" NC-ERP. Here we raise the question of whether maturational factors may be responsible for disordered NC-ERP.

METHODS

NC-ERP data from 142 APD children (range 5.4-17.2 years; mean 9.8 years) were analysed. Data were grouped according to age of children (I: <7.11 years n=34; II: 8.0-9.11 years n=46; III: 10.0-11.11 years n=39; IV: >12.0 years n=23).

RESULTS

Pathological NC-ERP were found in 82.3% (group I), 56.6% (group II), 46.2% (group III) and 8.8% (group IV). Additional analyses confirmed no correlation with ADHD.

DISCUSSION

Although there is a whole body of evidence that late auditory evoked potential may mature with age, it is not known if NC-ERP are also age dependent. Our results that NC-ERP mature with age are consistent with data for other late auditory evoked potentials. Since normative date of NC-ERP for different age groups are still lacking, NC-ERP results in children should be interpreted very cautiously.

Sp�te auditorische Potenziale (NC-ERP) bei Kindern mit Symptomen einer auditiven Verarbeitungs- und Wahrnehmungsst�rung

BACKGROUND

Auditory processing disorders (APD) result from dysfunctions of processes dedicated to audition and affect processing of information in the auditory modality. Children with APD exhibit symptoms similar to those with attention deficit disorders (ADHD). With regard to therapeutic strategies it seems mandatory to employ diagnostic procedures able to differentiate between APD and ADHD. Recently it was found that auditory evoked neutral condition event-related potentials (NC-ERP) correlate with results from psychoacoustic measures suitable to unveil dysfunctions of auditory processing, thus confirming APD. Here we investigated whether NC-ERP may be used as a tool to differentiate between APD and ADHD.

METHODS

In a retrospective analysis, NC-ERP data from 99 children with (+ADHD) and 43 without ADHD symptoms (-ADHD) were examined. All patients suffered from symptoms consistent with information processing deficits in the auditory modality. Analysis of variance was applied.

RESULTS

+ADHD children and -ADHD children did not show a significantly different distribution pattern of pathological NC-ERP.

DISCUSSION

Since the probability of pathological NC-ERP is equally distributed in children with or without ADHD, all of whom suffered from auditory processing deficits, it seems fair to conclude that NC-ERP are not suitable to differentiate between APD and ADHD. This may be due to methodological limitations. Alternatively, APD and ADHD may indeed be overlapping entities with a common yet unidentified origin.

Search for deletion 22q11.2 in interphase nuclei of buccal mucosa of patients ascertained by isolated cleft palate: a new diagnostic approach

A new approach for the detection of chromosome deletion 22q11.2 in interphase nuclei from buccal mucosa cells obtained by a non-invasive procedure is described. FISH analysis has been performed on samples from a group of 101 patients that presented consecutively for speech therapy and/or surgical correction of cleft palate. A normal result has been obtained in 98 patients; a deletion 22q11.2 was present in three patients (2.8%) with cleft palate.

[Normal nasalance for the German language. Nasometric values for clinical use in patients with cleft lip and palate]

OBJECTIVE

Rhinophonia is often present in patients with cleft lip and palate (CLP) many years after palatoplasty. It may be caused either by organic deficits, functional disorders, or both. NasalView is known as an instrument for the objective assessment of nasalance in cases of velopharyngeal insufficiency or incompetence.However,normative values for the German language are not yet available. In order to overcome this problem, this study evaluated such norms using NasalView.

METHODS

A total of 50 individuals with normal speech development were examined with NasalView. The median age was 14 years (range 11-20 years). The tone material used comprised the vowels /a:/, /e:/, /i:/, /o:/, /u:/, the sentences S(1): "Die Schokolade ist sehr lecker."("This chocolate is very tasty.") and S(2): "Nenne meine Mamma Mimmi."("Call my mummy Mimmi."), and the text passages of LT(1): "Nordwind und Sonne"("Northwind and sun"), LT(2): "Kindergeburtstag"("A child's birthday party") and LT(3): "Der grosse Gesang"("A famous song").

RESULTS

The mean nasalance for the vowels was 35.9% (+/-8.4), for S(1) (containing no nasal consonants) 24.9% (+/-5.3), and for S(2) 69.6% (+/-5.5) (with many nasal sounds). The results for the text passages were 42.1% (+/-4.2) for LT(1), 36.9% (+/-4.3) for LT(2) and 38.2% (+/-4.4) for LT(3).

CONCLUSION

The norms of nasalance for the German language presented here may be useful in measuring the long-term outcome of cleft lip and palate.

[Hearing screening with automatic evaluation of TEOAE and a new method of automatic evaluation of early auditory evoked potentials. Optimization and field trial]

BACKGROUND AND OBJECTIVE

To make a rational decision as to which screening test might be adequate as a universal newborn hearing screening, different methods have to be tested under "real-life" conditions. In addition, a good reference is required as "golden standard."

PATIENTS/METHODS

In the study presented here, an ABR with a novel algorithm for threshold-estimation was optimized and compared to TEOAE (Echoscreen) and DPOAE (GSI 60) in a three-step protocol using a standard click-evoked ABR (Evoselect) as reference of sensitivity and specificity.

RESULTS

26 ears were found to be hearing-impaired. All of them were also detected by each of the screening method (sensitivity 100%). Specificity in the final "step 2" of the study was around 87.7/92.3% for Echoscreen, 82.4/84.4% for DPOAE and 82.4/89.1 for Evoflash (left/right, respectively). Differences were not at all significant (X2-test, p > > 0.05). In summary, results were somewhat inferior to those found by other authors, probably due to more difficult conditions in the "real-life" setting.

CONCLUSIONS

A higher rate of false-alarm shows that a two-step screening is necessary. Therefore, increased resources for diagnostic procedures are required.

Suggestion for orthodontic and speech improving measures in CLP patients

The objective of the present paper is to describe a soft palate level device, the veloretractor, which is a combination of orthodontic appliance and therapeutic aid in speech therapy. Its use is demonstrated in a case report of a child with complete bilateral cleft lip and palate. Both orthodontic and phoniatric/pedaudiologic treatment needs during the course are demonstrated along with the treatment results.

[Botulinum toxin type A-induced "rebalancing" in bilateral vocal cord paralysis?]

BACKGROUND

Upper airway obstruction due to bilateral vocal cord paralysis in an 80-year-old female patient was successfully relieved by injection of botulinum toxin A (BTA) into the laryngeal adductor muscles. The patient achieved satisfactory airway ventilation. Spirograms obtained preoperatively and postoperatively documented improved peak flow rates and 1-s forced expiratory volume values. Voice quality was breathy after the injection; however, neither aspiration nor dysphagia developed. Surprisingly, the maximum phonation time increased.

PATIENTS AND METHODS

During a follow-up check 4 months later, the patient still reported less dyspnea although the vocal cords were closer together than initially after the injection. The decrease in dyspnea as reported by the patient lasted approximately 2 years.

RESULTS

The improvement in breathing following injection of BTA can be interpreted as a paralysis or weakening of the laryngeal adductors. However, it remains unclear why the maximum phonation time increased. Comparable findings, i.e., improvement in overall laryngeal function, are described in the literature as BTA-mediated laryngeal rebalancing.

[Cochlear hearing loss following Mycoplasma pneumoniae infection]

BACKGROUND

A sudden unilateral hearing loss in childhood is commonly regarded as an unusual event.

CASE-REPORT

In this paper, we report of a 10 year old girl suffering from a unilateral right-sided sudden hearing loss following an acute infection with Mycoplasma pneumoniae, which is also rarely observed. Maximum hearing loss was estimated around 30 dB (0.25-6 kHz), which resolved after infusions using plasma expanders. Both transitory and distortion product otoacoustic emissions remained absent, while latencies of acoustically evoked potentials were normal.

DISCUSSION

This suggests a damage of outer hair cell function as an explanation for the observed hearing loss. The coincidence of two rare events for children such as a spontaneous sudden unilateral hearing loss combined with an infection with Mycoplasma pneumoniae gives rise to the hypothesis of a causal relationship that is discussed according to the literature.

[Psychoacoustic scaling of acoustic voice parameters by multicenter voice ratings]

BACKGROUND

The purpose of the study was to analyze if perceptual voice quality ratings of the well-known RBH rating procedure (a 4-point scale of roughness, breathiness, and hoarseness) covary with acoustical voice parameters.

METHODS

120 voice samples from subjects with healthy and hoarse voices were rated on the RBH-index in a multicenter study with 31 raters. Multivariate regression tree analysis classified the perceptual ratings as "gold standard". Voice samples were acoustically analyzed with a feature extraction method. Feedforward-networks were trained to selected acoustical parameters having highest "relative importance" in the regression trees. Based on the best classifier, a computer program consisting of 50 simultaneous working networks was developed.

RESULTS

Mean probabilities for correct classifications were found at 0.65-0.85, implying a significance level over chance (0.25). Classifications of the program matched in 40% with a priori values in the categories roughness combined with breathiness, and in 65% in at least one domain.

CONCLUSIONS

The new method described here provides a psychoacoustically based "objective" classification of hoarse voices, which seems to enable future analysis of new parameters (like GNE), which may even improve the present results.