Nocturnal Olfactory Stimulation for Improvement of Sleep Quality in Patients With Posttraumatic Stress Disorder: A Randomized Exploratory Intervention Trial

Posttraumatic stress disorder (PTSD) is characterized by sleep impairment and nightmares. As pleasant odors presented during sleep affect the emotional tone of dreams without inducing arousal, we investigated whether sleep patterns in PTSD can be improved via nocturnal olfactory stimulation. Participants were 40 inpatients with PTSD (n = 35 women; age range: 20-59 years) who completed a randomized, patient-blind, placebo-controlled trial. Baseline measurement for 5 consecutive nights was followed by a 5-night experimental intervention or placebo trial. During the intervention, patients received nocturnal stimulation with a pleasant odor (odor condition) or clean air (placebo condition) via an olfactometer that delivered inspiration-triggered stimuli in a nasal tube or via an odorized nasal clip. After each night, the patients completed standardized questionnaires that assessed sleep parameters and dream content. Each night, sleep efficiency, sleep onset latency, and wakefulness after sleep onset were monitored with a motion biosensor. Baseline assessment revealed that PTSD severity was associated with poorer sleep outcomes. An interaction effect showed that nocturnal odorization affected dream intensity. Post hoc tests revealed an improvement in the group that used the nasal clip as compared to baseline, d = 0.68. No negative effects were observed after odorization with the nasal clip. Considering the limited sample size, the study indicates that nocturnal olfactory stimulation may serve as a low-cost concomitant intervention to improve sleep quality in PTSD.

Long-Term Outcomes of Vibroplasty Coupler Implantations to Treat Mixed/Conductive Hearing Loss

Objective: To evaluate the long-term safety and performance of four different vibroplasty couplers (round window, oval window, CliP and Bell coupler) in combination with an active middle ear implant. Methods: This was a multicentre, prospective, long-term study including 5 German hospitals. Thirty adult subjects suffering from conductive or mixed hearing loss were initially enrolled for the study, 24 of these were included in the final analysis with up to 36 months of postsurgical follow-up data. Bone conduction and air conduction were measured pre- and postoperatively to evalu ate safety. Postoperative aided sound field thresholds and Freiburger monosyllable word recognition scores were compared to unaided pre-implantation results to confirm performance. Additional speech tests compared postoperative unaided with aided results. To determine patient satisfaction, an established quality-of-life questionnaire developed for conventional hearing aid usage was administered to all subjects. Results: Mean postoperative bone conduction thresholds remained stable throughout the whole study period. Mean functional gain for all couplers investigated was 38.5 ± 11.4 dB HL (12 months) and 38.8 ± 12.5 dB HL (36 months). Mean word recognition scores at 65 dB SPL increased from 2.9% in the unaided by 64.2% to 67.1% in the aided situation. The mean postoperative speech reception in quiet (or 50% understanding of words in sentences) shows a speech intelligibility improvement at 36 months of 17.8 ± 12.4 dB SPL over the unaided condition. The signal-to-noise ratio (SNR) improved by 5.9 ± 7.2 dB SNR over the unaided condition. High subjective device satisfaction was reflected by the International Inventory for Hearing Aids scored very positively. Conclusion: A significant improvement was seen with all couplers, and audiological performance did not significantly differ between 12 and 36 months after surgery.

A new theory interprets the development of a retraction pocket as a natural self-healing process

PURPOSE

The thesis that cholesteatoma evolves from a retraction pocket is widely accepted today. Yet, its prime etiology, the question of what triggers the invagination of healthy skin, still remains unclear despite centuries of investigations into the origin of cholesteatoma. A new idea interprets the horizontal migration of skin into the middle ear cavities as a self-healing process, curing an underlying inflammation in the tympanic cavity, through the overgrowth and contact with immunologically active tissue.

METHODS

A retrospective analysis of the interrelation of retraction pockets and underlying granulation tissue was conducted in 209 second-look cholesteatoma surgeries over the last decade.

RESULTS

A stable tympanic membrane over aerated, healthy middle ear mucosa was found in 71.3% of cases. In 11%, small retractions with air in other parts of the middle ear cleft (epitympanic, sinus or anterior mesotympanum) were described. In 6.2%, granulations under a retraction were found. Only 3.8% of the reports revealed air behind a retraction or did not provide enough information on the mucosa situation behind the drum membrane.

CONCLUSIONS

A new hypothesis interprets the origin of a retraction pocket-the precursor of a cholesteatoma-as a natural attempt by the body to cure an underlying inflammation in a cavity. Analogous phenomena exist, e.g. the migration of the omentum towards a local inflammation in the abdomen. This idea, which is supported by the findings in our 209 second-look surgeries, is the first explanation of the origin of retraction pockets that is compatible with the various characteristics of original or recurrent cholesteatoma. A prophylaxis against a recurrent cholesteatoma might be attained by securing free drainage of the mucosa into the tubal orifice with the use of thin silicone foils in an attempt to prevent any granulation in the middle ear cleft, similar to the principles of modern rhinosinusoidal surgery with its emphasis on unblocked mucosa clearance. This allows gas production in the healed middle ear mucosa to recover, reducing the risk of a recurrent retraction.

Influence of ambient air pressure changes on vestibular symptoms after stapes surgery

OBJECTIVE

To examine if vestibular irritation after stapes surgery may be provoked by pressure changes across the tympanic membrane, which consecutively results in displacements of the ossicular chain and the piston prosthesis suspended to it.

METHODS

In this prospective study 15 patients (13 female, 2 male) received unilateral stapes surgery (4 left, 11 right ear) with stapedotomy (n=14) or stapedectomy (n=1) at an academic tertiary referral center. Surgery was performed under local anesthesia via a transmeatal approach with a piston prosthesis 0.4×4.5mm. The fixation of the stapes, the exclusion of a malleus head fixation, and the gliding capacity of the malleus-incus joint were examined intraoperatively. A pure tone audiogram at four frequencies, a tympanometry with simultaneous video-oculography (VOG), caloric testing, and posturography with and without simultaneous tympanometry were performed six days before surgery, six weeks and three months after surgery, respectively.

RESULTS

The mean air bone gap improved significantly from 25 (±8) dB preoperatively to 10 (±6) dB after surgery. In the tympanometry with simultaneous VOG only two patients showed nystagmus beats into the operated ears during only one of the two follow-up appointments. All other patients did not show any vestibular symptoms or nystagmus during any of the follow-up appointments. In the combined testing of posturography and tympanometry no patient showed any pathological findings.

CONCLUSION

In patients who underwent stapes surgery with a piston prosthesis no vestibular symptoms can be provoked by pressure changes in the external auditory canal.

Position paper on olfactory dysfunction

Background

Olfactory dysfunction is an increasingly recognised condition, associated with reduced quality of life and major health outcomes such as neurodegeneration and death. However, translational research in this field is limited by heterogeneity in methodological approach, including definitions of impairment, improvement and appropriate assessment techniques. Accordingly, effective treatments for smell loss are limited. In an effort to encourage high quality and comparable work in this field, among others, we propose the following ideas and recommendations. Whilst the full set of recommendations are outlined in the main document, points include the following: • Patients with suspected olfactory loss should undergo a full examination of the head and neck, including rigid nasal endoscopy with small diameter endoscopes. • Subjective olfactory assessment should not be undertaken in isolation, given its poor reliability. • Psychophysical assessment tools used in clinical and research settings should include reliable and validated tests of odour threshold, and/or one of odour identification or discrimination. • Comprehensive chemosensory assessment should include gustatory screening. • Smell training can be helpful in patients with olfactory loss of several aetiologies.

Conclusions

We hope the current manuscript will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency and generalisability of work in this field.

MDM2 and CDK4 amplifications are rare events in salivary duct carcinomas

Salivary duct carcinoma (SDC) is an aggressive adenocarcinoma of the salivary glands associated with poor clinical outcome. SDCs are known to carry TP53 mutations in about 50%, however, only little is known about alternative pathogenic mechanisms within the p53 regulatory network. Particularly, data on alterations of the oncogenes MDM2 and CDK4 located in the chromosomal region 12q13-15 are limited in SDC, while genomic rearrangements of the adjacent HMGA2 gene locus are well documented in subsets of SDCs. We here analyzed the mutational status of the TP53 gene, genomic amplification of MDM2, CDK4 and HMGA2 rearrangement/amplification as well as protein expression of TP53 (p53), MDM2 and CDK4 in 51 de novo and ex pleomorphic adenoma SDCs.

25 of 51 cases were found to carry TP53 mutations, associated with extreme positive immunohistochemical p53 staining levels in 13 cases. Three out of 51 tumors had an MDM2 amplification, one of them coinciding with a CDK4 amplification and two with a HMGA2 rearrangement/amplification. Two of the MDM2 amplifications occurred in the setting of a TP53 mutation. Two out of 51 cases showed a CDK4 amplification, one synchronously being MDM2 amplified and the other one displaying concurrent low copy number increases of both, MDM2 and HMGA2.

In summary, we here show that subgroups of SDCs display genomic amplifications of MDM2 and/or CDK4, partly in association with TP53 mutations and rearrangement/amplification of HMGA2. Further research is necessary to clarify the role of chromosomal region 12q13-15 alterations in SDC tumorigenesis and their potential prognostic and therapeutic relevance.

Cochlear implantation using the underwater technique: long-term results

INTRODUCTION

The opening of the round window and the insertion of the electrode array into the scala tympani during cochlear implant surgery can lead to a pressure shock of the delicate inner ear structures. By filling the tympanic cavity with Ringer Solution during these surgical steps (underwater technique), the hydrostatic pressure of the fluid acts as a smooth pressure stabilizer, avoiding a pressure shock of the inner ear structures. The aim of this retrospective study was to present long-term results of this new method of cochlear implantation in underwater technique.

METHODS

Altogether, 47 implantations in 43 patients with residual hearing at the frequencies 250, 500 and 1000 Hz in the unaided preoperative pure tone audiometry were included. A cochlear implantation via round window with a conventional full-length electrode was performed in underwater technique. Changes of residual hearing 7 weeks and 24 months after surgery were analyzed.

RESULTS

Overall postimplant hearing preservation 7 weeks after implantation was achieved in 22 ears (47%). Subsequent follow-up was performed on average 24 months after surgery (range 12 months-4.2 years) in all patients. At this late postoperative evaluation, preservation of hearing was recorded in 18 ears (38%). Neither the follow-up time nor the type of electrode had a significant impact on the postoperative hearing loss.

CONCLUSION

The underwater technique is an atraumatic cochlear implantation technique with hearing preservation rates comparable to results in literature and a very small hearing preservation decline rate over time even when using full-length CI electrodes.

Influence of repetitive diving in freshwater on pressure equalization and Eustachian tube function in recreational scuba divers

INTRODUCTION

We investigated the effect of repetitive pressure exposure during freshwater dives on Eustachian tube function and the middle ear, assessed by the Eustachian tube function test (ETFT).

METHODS

This prospective observational cohort study included 23 divers over three consecutive days of diving in freshwater lakes in Nordhausen, Germany. Participants underwent otoscopy and ETFT before the first dive, between each dive and after the last dive. ETFT included regular tympanometry (R-tymp), tympanometry after Valsalva (V-tymp) and after swallowing (S-tymp). The peak pressure difference between the R-tymp and the V-tymp (R-V_dP) defined effectiveness of pressure equalization after Valsalva manoeuvres. We evaluated the change in compliance and peak pressure and correlated the results to the otoscopic findings and diving experience.

RESULTS

Twenty-three divers performed 144 dives. Middle ear barotrauma was assessed using the Edmonds modification of the TEED scoring system. In the ETFT, the R-tymp peak pressure displayed a negative shift from day one to three (P = 0.001) and differed significantly between the experience groups (P = 0.01). R-V_dP did not change significantly on any of the three days of diving (all P > 0.05). Participants without MEBt showed significantly lower R-tymp values than did those with barotrauma (P = 0.019).

CONCLUSION

Repetitive pressure exposure during three consecutive days of freshwater diving led to a negative shift of the peak pressure in the middle ear. Less experienced divers showed significantly higher middle ear peak pressure and higher pressure differences after equalization manoeuvres. Higher middle ear peak pressure was also associated with a higher prevalence of barotrauma.

Surgical anatomy of the round window-Implications for cochlear implantation

BACKGROUND

The round window is an important portal for the application of active hearing aids and cochlear implants. The anatomical and topographical knowledge about the round window region is a prerequisite for successful insertion for a cochlear implant electrode.

OBJECTIVE OF REVIEW

To sum up current knowledge about the round window anatomy and to give advice to the cochlear implant surgeon for optimal placement of an electrode.

TYPE OF REVIEW

Systematic Medline search.

SEARCH STRATEGY

Search term "round window[Title]" with no date restriction. Only publications in the English Language were included. All abstracts were screened for relevance, that is a focus on surgical anatomy of the round window. The search results were supplemented with hand searching of selected reviews and reference lists from included studies.

EVALUATION METHOD

Subjective assessment.

RESULTS

There is substantial variability in size and shape of the round window. The round window is regarded as the most reliable surgical landmark to safely locate the scala tympani. Factors affecting the optimal trajectory line for atraumatic electrode insertion are anatomy of the round window, the anatomy of the intracochlear hook region and the variable orientation and size of the cochlea's basal turn.

CONCLUSIONS

The very close relation to the sensitive inner ear structures necessitates a thorough anatomic knowledge and careful insertion technique, especially when implanting patients with residual hearing. In order to avoid electrode migration between the scalae and to achieve protect the modiolus and the basilar membrane, it is recommended to aim for an electrode insertion vector from postero-superior to antero-inferior.

Influence of repetitive diving in saltwater on pressure equalization and Eustachian tube function in recreational scuba divers

INTRODUCTION

We investigated in a prospective, observational trial the feasibility of using the Eustachian tube function test (ETFT) to measure the effect of repetitive pressure exposure during open seawater dives on Eustachian tube function.

METHODS

The study included 28 adult divers during six consecutive days of diving in the Red Sea. Participants underwent otoscopy and ETFT before the first dive, between each dive and after the last dive. ETFT included regular tympanometry (R-tymp), tympanometry after Valsalva (V-tymp) and after swallowing (S-tymp). The R-tymp was obtained as 'baseline' peak pressure. After a Valsalva, the peak pressure should shift (positively), revealing a positive shift of the tympanic membrane. This pressure shift is defined here as R-VdP. The changes in compliance and peak pressure were recorded and correlated with otoscopic findings and diving experience. Middle ear barotrauma was scored using the Edmonds modified TEED scale.

RESULTS

The 28 participants performed 437 dives. Positive shift of pressure in the middle ear was evident with significant changes from day one to day three (P < 0.0001). Divers with barotrauma showed significantly lower values of R-tymp peak pressure and significantly higher negative R-VdP, compared to divers with normal otoscopic findings (P < 0.05). Diving experience significantly correlated with R-tymp peak pressure and prevalence of middle ear barotrauma.

CONCLUSION

Significant changes in middle ear pressure and pressure equalization from repeated pressure exposure in saltwater were seen using ETFT. Repetitive, multi-day diving led to significantly decreased compliance and increased R-tymp peak pressure (overpressure) in the middle ear. Most profound changes were observed in less and intermediate experienced divers.

Influence of backside loading on the floating mass transducer: An in vitro experimental study

HYPOTHESIS

The vibration of the floating mass transducer (FMT) of a single active middle-ear implant (AMEI) is distinctly influenced by the properties of the material coupled to its back side.

BACKGROUND

In round window vibroplasty, the FMT needs to be padded against the surrounding bone opposite from the round window membrane. This represents one factor influencing its performance as a round window driver. Therefore, we examined the effects of different materials linked to the back side of an FMT on its vibration range.

METHODS

The back side of an FMT was glued to a silicone cylinder 1.0 mm in diameter and 1.0 mm - 1.5 mm in length and of 40A, 50A or 70A Shore hardness; to cartilage of equivalent size; or to a round window soft coupler (RWSC), all firmly fixed on a steel plate. The vibrations were determined by a laser Doppler vibrometer (LDV) measuring the velocity of the centre point on the front side of the FMT.

RESULTS

The materials on the back side of the FMT significantly influenced the vibration range of the FMT. The RWSC and silicone of 40A Shore hardness allowed for the highest detected velocities, while cartilage led to a distinct reduction similarly to 70A silicone.

CONCLUSION

The coupling on the back side of an FMT distinctly affects its vibration range. In this regard, the RWSC and silicone of 40A Shore hardness yield the least impairment of vibration. Thus, the RWSC may be a feasible option in round window vibroplasty when additionally connected to the FMT opposite from the round window membrane.

Long-term Results of the Cartilage Shoe Technique to Anchor a Titanium Total Ossicular Replacement Prosthesis on the Stapes Footplate After Type III Tympanoplasty

Importance

Multiple techniques for a more secure and stable anchoring of the foot of a total ossicular replacement prosthesis (TORP) on the footplate have been proposed. To address this issue, a technique was developed that fits a cartilage shoe into the oval niche to guide the base of the prosthesis into a preformed central perforation.

Objective

To evaluate the long-term results of the cartilage shoe technique used to anchor a titanium TORP on the stapes footplate in patients after type III tympanoplasty.

Design, Setting, and Participants

Medical record review of total ossiculoplasties at a single center. The study included all patients who had undergone a tympanoplasty using a TORP between January 1, 2004, and December 31, 2008, at the Department of Otorhinolaryngology-Head and Neck Surgery, University of Cologne, Cologne, Germany.

Main Outcomes and Measures

Hearing thresholds were determined by a 4-frequency (500-4000 Hz) pure-tone average air-bone gap (PTA-ABG). Intraoperative findings from revision surgery and second-look operations are reported.

Results

Forty-two ears were eligible for follow-up examination, averaging 6.8 years (range, 4.8-9.1 years) after surgery, that comprised otoscopy and audiometry. The mean age of 22 women and 20 men was 42.8 years (age range, 6-78 years). The overall PTA-ABG decreased from a mean (SD) of 33.0 (8.4) decibels (dB) before surgery to a mean (SD) of 22.0 (10.1) dB after surgery (P ≤ .001, η = 0.402). Before surgery, 64% (27 of 42) of the patients had a PTA-ABG exceeding 30 dB, which was 30 dB or less in 76% (32 of 42) of the patients after surgery. After canal wall down (n = 18) and tympanoplasties with intact canal wall (n = 24), the PTA-ABG was reduced from a mean (SD) of 33.0 (8.9) dB to 24.6 (11.2) dB (P = .01, η = 0.271) and from a mean (SD) of 32.0 (7.3) dB to 19.6 (9.2) dB (P ≤ .001, η = 0.511), respectively. For transmeatal revision ossiculoplasty (n = 33), the PTA-ABG improved from a mean (SD) of 32.0 (8.6) dB to 21.0 (10.2) dB (P ≤ .001, η = 0.389), similar to primary ossiculoplasty (n = 9), with a mean (SD) of 33.0 (5.5) dB PTA-ABG before surgery and a mean (SD) of 21.0 (9.8) dB PTA-ABG after surgery (P = .005, η = 0.478). Intraoperative findings from revision surgery (n = 11) during the study period and second-look procedures (n = 7) showed that the cartilage shoe prevented a lift off the footplate in all but 2 patients, even in the presence of recurrent cholesteatoma.

Conclusions and Relevance

The use of the cartilage shoe that anchors a titanium TORP on the stapes footplate can be advocated for good and reliable long-term results after total ossiculoplasty.

Position paper on olfactory dysfunction

BACKGROUND

Olfactory dysfunction is an increasingly recognised condition, associated with reduced quality of life and major health outcomes such as neurodegeneration and death. However, translational research in this field is limited by heterogeneity in methodological approach, including definitions of impairment, improvement and appropriate assessment techniques. Accordingly, effective treatments for smell loss are limited. In an effort to encourage high quality and comparable work in this field, among others, we propose the following ideas and recommendations. Whilst the full set of recommendations are outlined in the main document, points include the following: - Patients with suspected olfactory loss should undergo a full examination of the head and neck, including rigid nasal endoscopy with small diameter endoscopes. - Subjective olfactory assessment should not be undertaken in isolation, given its poor reliability. - Psychophysical assessment tools used in clinical and research settings should include reliable and validated tests of odour threshold, and/or one of odour identification or discrimination. - Comprehensive chemosensory assessment should include gustatory screening. - Smell training can be helpful in patients with olfactory loss of several aetiologies.

CONCLUSIONS

We hope the current manuscript will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency and generalisability of work in this field.

Repetitive freshwater diving: risk factors and prevalence of barotrauma

OBJECTIVE

The aim was to investigate the influence of repetitive scuba diving in fresh water on the middle ear mucosa. The prevalence of middle ear barotrauma (MEB) and risk factors for MEB were evaluated.

STUDY DESIGN

Prospective cohort study, Level of evidence 1b.

METHODS

During three days, 23 divers made 144 repetitive dives in a freshwater lake. Participants underwent otoscopic examinations and were questioned about ENT-related complaints in the morning before the first dive, in between the dives and after the last dive. Otoscopic findings were documented and classified according to the TEED scale (0 = normal eardrum to 4 = perforation), for the right and the left ear separately.

RESULTS

In total, 416 examinations were performed. ENT-related complaints during diving, mostly failed pressure equalization (74%), were reported after 10% of all dives. Most common pathology was MEB (TEED 1-3, 26%). Valsalva maneuver was possible during all exams. Significant increase of MEB (TEED⟩0) occurred with an increasing cumulative number of dives per day (P ⟨ .0001). Diving depth significantly influenced the MEB distribution (P = .035). MEB with higher TEED levels (2 and 3) was present only in the less experienced and intermediate divers. With increasing TEED level, more participants reported ENT-related problems (P ⟨ .0001). However, 74.4% of divers with MEB were still asymptomatic.

CONCLUSION

During three days of diving, the MEB prevalence increased with a cumulative number of dives per day. The major risk factors were diving depth and diving experience. Higher TEED level correlated with an increasing number of subjective ENT-related disorders during diving.

Multicenter Clinical Trial of Vibroplasty Couplers to Treat Mixed/Conductive Hearing Loss: First Results

Objective: To evaluate the safety and effectiveness of round window (RW), oval window (OW), CliP and Bell couplers for use with an active middle ear implant. Methods: This is a multicenter, long-term, prospective trial with consecutive enrollment, involving 6 university hospitals in Germany. Bone conduction, air conduction, implant-aided warble-tone thresholds and Freiburger monosyllable word recognition scores were compared with unaided preimplantation results in 28 moderate-to-profound hearing-impaired patients after 12 months of follow-up. All patients had previously undergone failed reconstruction surgeries (up to 5 or more). In a subset of patients, additional speech tests at 12 months postoperatively were used to compare the aided with the unaided condition after implantation with the processor switched off. An established quality-of-life questionnaire for hearing aids was used to determine patient satisfaction. Results: Postoperative bone conduction remained stable. Mean functional gain for all couplers was 37 dB HL (RW = 42 dB, OW = 35 dB, Bell = 38 dB, CliP = 27 dB). The mean postoperative Freiburger monosyllable score was 71% at 65 dB SPL. The postimplantation mean SRT50 (speech reception in quiet for 50% understanding of words in sentences) improved on average by 23 dB over unaided testing and signal-to-noise ratios also improved in all patients. The International Outcome Inventory for Hearing Aids (IOI-HA)quality-of-life questionnaire was scored very positively by all patients. Conclusion: A significant improvement was seen with all couplers, and patients were satisfied with the device at 12 months postoperatively. These results demonstrate that an active implant is an advantage in achieving good hearing benefit in patients with prior failed reconstruction surgery.

Is there a difference between active opening of the Eustachian tube in a hypobaric surrounding compared to a hyperbaric surrounding?

INTRODUCTION

The Eustachian tube (ET) is the key to pressure equalization between the middle ear and ambient pressure. To date, little is known about differences of the opening mechanisms under hyper- or hypobaric conditions. Aim of this study was to compare standard ET opening parameters during standardized hypo- and hyperbaric exposures.

METHODS

Thirty healthy participants were exposed to a standardized profile of decompression and compression (SPDC) in a hypo-/hyperbaric pressure chamber. Impedance, expressed as tympanic membrane compliance, was recorded at intervals during the excursions from 1 atmosphere absolute (atm abs) to 0.8 and 1.2 atm abs respectively. Parameters for tubal opening were obtained during SPDC: ET opening pressure (ETOP), ET opening duration (ETOD) and ET opening frequency (ETOF), hypobaric (Phase 1) and hyperbaric (Phase 2) data were compared.

RESULTS

Mean value for Valsalva maneuver ETOP was 40.10 ± 19.02 mbar in Phase 2 vs. 42.82 ± 21.75 mbar in Phase 1. For ETOD it was 2.80 ± 2.09 seconds in Phase 2 vs. 2.51 ± 1.90 seconds in Phase 1. For swallowing, mean value for ETOP was 33.47 ± 14.50 mbar in Phase 2 vs. 28.44 ± 14.04 in Phase 1. ETOD was 0.82 ± 0.60 seconds in Phase 2 vs. 0.76 ± 0.55 seconds in Phase 1. There was no statistical significance for ETOP, ETOD and ETOF between the two phases.

CONCLUSION

No statistical significant difference was evident for active pressure equalization (Valsalva and swallowing) between a hyperbaric setting (dive) and a hypobaric setting (flight) in healthy subjects.

Surgical anatomy and pathology of the middle ear

Middle ear surgery is strongly influenced by anatomical and functional characteristics of the middle ear. The complex anatomy means a challenge for the otosurgeon who moves between preservation or improvement of highly important functions (hearing, balance, facial motion) and eradication of diseases. Of these, perforations of the tympanic membrane, chronic otitis media, tympanosclerosis and cholesteatoma are encountered most often in clinical practice. Modern techniques for reconstruction of the ossicular chain aim for best possible hearing improvement using delicate alloplastic titanium prostheses, but a number of prosthesis-unrelated factors work against this intent. Surgery is always individualized to the case and there is no one-fits-all strategy. Above all, both middle ear diseases and surgery can be associated with a number of complications; the most important ones being hearing deterioration or deafness, dizziness, facial palsy and life-threatening intracranial complications. To minimize risks, a solid knowledge of and respect for neurootologic structures is essential for an otosurgeon who must train him- or herself intensively on temporal bones before performing surgery on a patient.

Vibroplasty for mixed and conductive hearing loss

OBJECTIVE

To summarize new application methods of an active middle ear implant (Vibrant Soundbridge) in patients with conductive or mixed hearing loss.

DATA SOURCES

Publications listed in the Medline/PubMed database.

STUDY SELECTION

All publications published in English language; search term Vibrant Soundbridge AND floating mass transducer in all fields.

DATA EXTRACTION

Structured analysis of all publications.

DATA SYNTHESIS

Extraction of significant findings and conclusions and audiometric data.

CONCLUSION

Modern application methods of an active middle ear implant (VSB) open new therapeutic options for patients with various outer and middle ear diseases resulting in conductive or mixed hearing loss. Titanium couplers can help to couple the active middle ear implant in a standardized way to remnants of the ossicular chain or to the round window. Thus, the active middle ear implant has been established as an alternative treatment option for patients with mixed and conductive hearing. However, the heterogeneity of the studies published so far complicates the analysis of the audiometric results, and thus, the functional hearing gain after VSB implantation varies a lot.

Do the blinds smell better?

If people lose a sense organ, there is thought to be an increase in the remaining sensory functions. Previous studies showed ambiguous results on this topic. In a prospective matched pair case-control study on 46 blind and 46 normal-sighted subjects, the olfactory performance was examined using the Sniffin' Sticks Test [threshold-discrimination-identification (TDI) test], determining the olfactory threshold, the identification and the discrimination performance. There was no significant difference between the groups. Neither the overall olfactory performance (TDI score) nor any of its subtests did correlate with the vision or with the duration of blindness. The study could not detect any superior smell abilities of blind subjects as compared to sighted subjects.

Endoscopic laser-assisted diverticulotomy without versus with wound closure in the treatment of Zenker's diverticulum

The aim of the present study was to compare the modifications of endoscopic laser-assisted diverticulotomy regarding closure of mucosal wound at the cricopharyngeal bridge. The results of 62 cases after endoscopic laser-assisted diverticulotomy without and with wound closure were retrospectively compared. After laser-assisted transection of the cricopharyngeal bridge, the mucosa wound was left open (OW) in 35 cases (56%), whereas a closure of the mucosa wound (CW) with sutures and fibrin glue was performed in 27 patients (44%). Duration of hospitalization, residual diverticular sac rate and occurrence of complications did not differ significantly between the two groups. Mean surgical time was significantly less in the OW cases. According to these results, it can be assumed that readapting and sealing the wound after transecting the cricopharyngeal bridge does not significantly reduce the complication rate. It does, however, extend the length of surgery and increases the cost of the procedure.

[Generation Y in ENT: leading a young generation of doctors]

BACKGROUND

The shortage of qualified doctors and nurses has led to a competition between hospitals. Analyzing the circumstances of the competition, nurses and doctors of so-called generation Y are important. These employees are mainly female and have different requirements compared to previous generations. Therefore, knowledge of these requirements will become a critical success factor for hospitals in the future.

METHOD

We interviewed medical students in Kiel and Hannover from 2005 to 2011 about the clinical department chosen, the criteria for choosing a specific clinic, and the importance of MD and PhD programs. In addition, we conducted an internet and Medline search for scientific studies on labor shortage, generation Y, and demographics. The data were sorted by main categories and relevance for hospitals. Statistical analyses were performed using descriptive measures.

RESULTS

We received 1,097 answers which represents approx. 75% of all students. Sixty-seven percent of the students were female, 33% male. Preferences for departments revealed internal medicine, pediatrics, and anesthesiology as the top three. ENT followed at rank 10. The main criteria for choosing a clinic were working climate, structure and broadness of education, family friendliness, and respect. MD programs were rated 2.6, while PhD programs were rated 3.6. Staff members of Generation Y "live while working" and disagree with hierarchies. Internet and computers are part of their daily routine.

CONCLUSION

Employees of Generation Y challenge leadership in hospitals by increasing demands. However, Generation Y can increase professionalization and competitiveness for hospitals significantly.

Olfactory dysfunction: common in later life and early warning of neurodegenerative disease

BACKGROUND

Disturbances of smell and taste are common. About 5% of the general population have anosmia (absence of the sense of smell). Olfactory dysfunction can markedly impair the quality of life.

METHODS

Review of pertinent literature retrieved by a selective search.

RESULTS

In recent years, simple and reliable tests of the sense of smell have been introduced in otorhinolaryngology. Olfactory testing has become a new focus of attention in neurology as well, mainly because many patients with neurodegenerative diseases-including the majority of those with Parkinson's or Alzheimer's disease-have olfactory loss early on in the course of their disorder. Olfactory dysfunction is thus regarded as an early sign of neurodegenerative disease that may allow a tentative diagnosis to be made years before the motor or cognitive disturbances become evident. As for the treatment of olfactory loss, anti-inflammatory drugs and surgery can help in some cases, and olfactory training can lead to significant improvement of post-viral olfactory deficits.

CONCLUSION

Olfactory dysfunction is common and becomes more common with advancing age. It is increasingly receiving attention as an important sign for the early diagnosis and the differential diagnosis of neurodegenerative disorders.

[The shortage of qualified staff in Germany: a survey on head physicians' expectations of young doctors]

BACKGROUND

The shortage of medical specialists in Germany has led to increased competition between hospitals, particularly in the recruitment of young skilled doctors. The quality of training appears to be the critical factor in a clinic's recruiting process. At the same time, the suitability of candidates is decreasing. There is currently no data on the suitability of candidates for otorhinolaryngology, nor are there any forecasts about the labor shortage in this speciality.

METHODS

We compiled a questionnaire according to accepted guidelines, which was then sent to 160 ENT departments by email. We asked about the size and location of the department and the number of applicants that were suitable or unsuitable. Finally, we asked about the current availability of staff as well as the requirements set by the head physician.

RESULTS

The response rate was 34% (54 questionnaires). Departments received an average of 20 applications per year, of which 36% were unsuitable. Departments received more applications in the new German states than in the old; however, no difference in the quality of candidates was seen. University hospitals receive almost three times more applications than other hospitals. The size of the department correlates with the number of applications and quality of the candidates. Almost 60% of chief physicians expected the lack of qualified staff to worsen in the future. However, 40% of chief physicians of large departments (> 50 beds) expected the situation to improve or remain unchanged. Chief physicians' main expectations of candidates included commitment, independent learning and team spirit.

CONCLUSIONS

A broad and structured residency program for new employees is the most important factor in the recruitment of new physicians. Large departments and university hospitals have advantages here. The expectations of head physicians differ from those of young staff in terms of commitment and autonomous learning.

Smell and taste disorders

Smell and taste disorders can markedly affect the quality of life. In recent years we have become much better in the assessment of the ability to smell and taste. In addition, information is now available to say something about the prognosis of individual patients. With regard to therapy there also seems to be low but steady progress. Of special importance for the treatment is the ability of the olfactory epithelium to regenerate.

The sandwich cartilage shoe technique for ossicular reconstruction in a case of an unsecure stapes footplate

This article describes a new surgical method for total ossicular reconstruction in a case of a broken stapes footplate. We developed the technique of the "cartilage shoe sandwich," which consists of two surgical steps. First, the closure of the oval window is achieved by a cartilage shoe without a central perforation. During this surgical intervention, the prearrangement of a secure placement of a total ossicular replacement prosthesis is provided by a second cartilage with a central hole that is plugged with silicone. In a staged procedure, the silicone plug is removed and the ossicular reconstruction can be performed. The audiological results of the first patients show a stable inner ear function with an air-conduction gain of 9 dB. The technique described herein has proven to be safe and reliable in total ossicular reconstruction in the event of an unsecure stapes footplate.

Passive and active middle ear implants

Besides eradication of chronic middle ear disease, the reconstruction of the sound conduction apparatus is a major goal of modern ear microsurgery. The material of choice in cases of partial ossicular replacement prosthesis is the autogenous ossicle. In the event of more extensive destruction of the ossicular chain diverse alloplastic materials, e.g. metals, ceramics, plastics or composits are used for total reconstruction. Their specialised role in conducting sound energy within a half-open implant bed sets high demands on the biocompatibility as well as the acoustic-mechanic properties of the prosthesis. Recently, sophisticated titanium middle ear implants allowing individual adaptation to anatomical variations are widely used for this procedure. However, despite modern developments, hearing restoration with passive implants often faces its limitations due to tubal-middle-ear dysfunction. Here, implantable hearing aids, successfully used in cases of sensorineural hearing loss, offer a promising alternative. This article reviews the actual state of affairs of passive and active middle ear implants.

Experiments on the coupling of an active middle ear implant to the stapes footplate

BACKGROUND

Although the function of active middle ear implants in cases of intact ossicular chains and ventilated middle ears is well known, information about sound transfer function to the inner ear in cases of chronic middle ear effusion and defective middle ear structures is needed. A temporal bone model was developed to measure (1) the coupling of the active middle ear implant Vibrant Soundbridge in cases of nonventilated radical cavities, and (2) the effect of effusion and cartilage shielding.

METHODS

Three fresh human temporal bone specimens were studied. After preparation of a radical cavity, the floating mass transducer was coupled to the stapes footplate. The transducer was stimulated with 50 mV multisinus signals and inner ear fluid vibration was measured using a microphone in the round window niche. Several coupling conditions were simulated with mass and stiffness variations and cartilage shielding.

RESULTS

Coupling modality and prestress have the most influence on the sound transfer function to the inner ear. Cartilage shielding may ensure better coupling of the FMT to the footplate. The effect of middle ear effusion is negligible.

CONCLUSION

The Vibrant Soundbridge provides good sound transfer to the inner ear not only in cases of coupling onto an intact ossicular chain in a ventilated middle ear but also in cases of coupling to the stapes footplate in non-ventilated radical cavities.

Clinical results with an active middle ear implant in the oval window

BACKGROUND

Some patients with chronic middle ear disease and multiple failed revisions, who also need a hearing aid, may benefit from an active middle ear implant. An advantage of an active middle ear implant is that the ear canal is unoccluded.

METHODS

Following extensive experimental development in temporal bones and investigations of various locations and attachments of a Vibrant Soundbridge transducer, a new titanium clip holder for the vibrant floating mass transducer was developed. This assembly is a total ossicular replacement prosthesis (TORP) that is placed on the stapes footplate. Six patients were implanted with this device.

RESULTS

Acoustic results demonstrate significantly improved gain, especially in the high frequencies, which is typically unobtainable by conventional hearing aids.

CONCLUSION

The simple procedure of placing an active TORP assembly on the stapes footplate, similar to the implantation of a passive TORP prosthesis during tympanoplasty, offers promising treatment for cases of incurable middle ear disease.

Postural control before and after cochlear implantation: standard cochleostomy versus round window approach

CONCLUSION

The approach to the cochlea did not influence postural control after cochlear implantation (CI) surgery. Most patients already have impaired vestibular function before surgery. These balance deficits did not change after CI surgery in the majority of patients but static balance might be improved by CI surgery.

OBJECTIVES

To determine whether the technique used to insert the CI electrode has an influence on vestibular function.

METHODS

Static and dynamic postural control and caloric vestibular function were measured prospectively before and after CI surgery in 36 CI patients with standard cochleostomy (SC) insertion and 16 patients with insertion across the round window (RW). The test battery consisted of the modified clinical test of sensory interaction on balance (mCTSIB), the Rhythmic Weight Shift (RWS), the Walk Across (WA), and the Tandem Walk (TW) test.

RESULTS

Caloric testing was normal in the majority of CI candidates and remained normal after surgery. mCTSIB results were not significantly different before and after CI surgery between the SC and RW groups. Within both subgroups, the mCTSIB composite value improved within 6 weeks after surgery compared with the values obtained before surgery. Dynamic standing balance showed no postoperative change in RWS.

Effects of short inter-stimulus intervals on olfactory and trigeminal event-related potentials

CONCLUSION

Chemosensory event-related potentials (CSERPs) were identified in all measurements using the 20 s and the 10 s inter-stimulus interval (ISI) protocol, reducing the recording time to 75% or 57% compared with the standard protocol. A possible explanation for the rising CSERP amplitudes by shortening the ISI in CO(2) stimulation is due to a phenomenon known as trigeminal sensitization during repeated stimulation.

OBJECTIVES

CSERPs are influenced by the ISI. The aim of this study was to evaluate the changes in CSERPs by decreasing the ISI from 30 s to 20 s or 10 s, respectively.

SUBJECTS AND METHODS

Ten normosmic healthy subjects participated this study. Phenyl ethyl alcohol (PEA), hydrogen sulphide (H(2)S) and carbon dioxide (CO(2)) were used in CSERP measurements with different ISI protocols (30 s (standard), 20 s and 10 s). Amplitudes and latencies of ISI protocols were submitted to ANOVA for repeated measurements and t tests for paired samples.

RESULTS

The amplitudes of CSERPs with PEA and H(2)S stimuli were decreasing with shortening the ISI significantly. In contrast, the highest amplitudes of trigeminal CSERPs were recorded with the 10 s ISI protocol with CO(2). The ANOVA revealed a significantly different effect of shortening the ISI on CSERPs on the right and the left side.

Clinical significance of stapedioplasty biomechanics: swimming, diving, flying after stapes surgery

A piston prosthesis in stapedioplasty significantly modifies the function of the normal ossicular chain. Due to the fact that the ear works as a pressure receptor, a piston prosthesis will be displaced at ambient air pressure changes in a different way than the normal stapes. Our ear is constantly exposed to these pressure changes in daily live, for example during swallowing, with tubal opening, with wind gusts at the external ear, during flying, or diving. Temporal bone experiments showed that elevated static pressures, like in tympanometry, can displace a piston up to 0.5mm in the vestibule. These large movements, which are caused by the missing attachment of the piston to the annual ligament, may explain why a short piston can be lifted out of the footplate perforation (e.g. after sneezing) or a piston with excessive length might come into contact with the membranous labyrinth, causing vertigo with an inward movement. Flying or diving can be performed by the patients after stapedioplasty, provided that a test with tympanometry is tolerated without evoking vertigo.

Comparison of Optical Rhinometry and Active Anterior Rhinomanometry Using Nasal Provocation Testing

OBJECTIVE

To investigate whether there is a correlation between active anterior rhinomanometry (RMM) and optical rhinometry (ORM) data in the detection of changes in nasal congestion.

DESIGN

In 70 subjects both ORM and RMM were performed. Changes in nasal congestion were induced by nasal provocation with histamine, allergens, solvent, and xylometazoline hydrochloride, 0.1%. Using visual analog scales, subjects rated the degree of nasal congestion and how comfortable each of the 2 measures was. In total, 136 measurements were evaluated.

SUBJECTS

Seventy subjects were included in the study. All had a normal otorhinolaryngologic status with no acute or chronic infections.

INTERVENTIONS

Nasal provocation tests with allergens, histamine, control solution, or xylometazoline were performed.

MAIN OUTCOME MEASURES

Congestion or decongestion of the nasal mucosa was measured via nasal resistance (RMM), changes in light absorption of the nasal tissue (ORM), and visual analog scale.

RESULTS

When comparing the relative change in light extinction in ORM with nasal airflow in RMM, we found correlation coefficients up to r = -0.69. Results from RMM were correlated with the subjects' ratings of nasal congestion (r = -0.63). In comparison, the correlation coefficient between these ratings and ORM was r = 0.84. In addition, ORM was rated to be more comfortable than RMM.

CONCLUSIONS

The subjects' ratings of nasal congestion correlated to a higher degree with the results from ORM than with those from RMM. In addition, ORM was rated as more comfortable than RMM. Overall, ORM appeared to be a valid technique for the assessment of changes in nasal congestion.

[Impact of TORP diameter on fracture of the footplate]

BACKGROUND

A columella-prosthesis is the typical reconstruction procedure of the ossicular chain in cases with a destroyed stapedial arch. Lightweight titanium prostheses are commonly used for this type of surgery. The smaller the prosthesis foot the lower the risk of dislocation and friction of the prosthesis with the bony rim of the oval niche. However, using a smaller prosthesis foot, fracture of the footplate and penetration of the prosthesis into the inner ear are conceivable.

METHODS

Using fresh temporal bone preparations, lacking the stapedial arch, in conjunction with a load cell, the force needed to fracture the footplate was measured. Different prostheses with different foot diameters (0.2 - 0.8 mm) were used in these experiments. Furthermore, a human stapes was evaluated morphologically by scanning electron microscopy.

RESULTS

The forces leading to fracture of the footplate were measured to be between 250 mN and 980 mN. Statistical analysis showed no significant difference between 0.2 mm and 0.8 mm prosthesis foots. Moreover, different forces were attributed to varying thickness of the stapes footplate. In scanning electron microscopy the rough and uneven bony surface of the footplate could be demonstrated.

CONCLUSION

Due to the uneven footplate, only punctual contact of the prosthesis foot can be achieved. Hence, the risk of footplate fracture is not considerably higher by using smaller diameters. However, the use of smaller feet in upcoming generations of TORPs seems to be appropriate.

[Vallecular cyst as a rare cause of progressive inspiratory stridor]

BACKGROUND

Vallecular cysts are frequently observed, benign masses of the upper aerodigestiv tract. Usually they appear as harmless and asymptomatic and go unnoticed by the patient. In rare cases, obstructions of the upper airway due to monstrous vallecular cysts may become life threatening.

CASE

We report on a 69-year-old otherwise healthy woman with a rapidly progressive history of dyspnea caused by a pedicled vallecular cyst. Increasing stridor prompted emergency surgical resection.

CONCLUSION

Vallecular cysts that increase in size can cause dyspnea due to obstruction of the aditus of the larynx. This case demonstrates the need for surgical treatment at an early stage of pedicled vallecular cysts.

Mechanical obstruction of the olfactory cleft reveals differences between orthonasal and retronasal olfactory functions

Following up on recent observations in patients with nasal polyposis (NP), the present study aimed to investigate whether a mechanical obstruction of the anterior olfactory cleft (OC) would produce differential effects on orthonasal and retronasal olfactory functions. To this end, we studied 33 healthy subjects in a randomized trial. Sponges with high content of saline were either placed in the OC or on the respiratory epithelium, such that this was blinded to both subject and observer. The results indicated that orthonasal (P = 0.04) but not retronasal (P = 0.15) olfactory identification ability was lower when the OC was blocked. This confirms the idea that differences between orthonasal and retronasal olfactory functions, as observed in NP patients, are, at least to some degree, due to mechanical obstruction of the anterior portion of the OC. The present data also suggest that mechanical obstruction is a means to induce reversible hyposmia void of side effects which can be performed in a blinded fashion. This might become a valuable model of hyposmia for future investigations.