[Webinars for ENT specialists in Germany during the Lockdown phase of the COVID-19 pandemic 2020/2021]

INTRODUCTION

During the COVID-19 pandemic, webinars are one of the few opportunities to continue CME training to a large majority of ENT doctors. However, experiences with the quality of this digital form of education is still limited.

METHODOLOGY

In this study, six webinars for ENT specialists during the second lockdown in Germany (January to March 2021, provider Zoom) were evaluated. The quality control was performed by participants and speakers using special quality questions. School grades (1-6) were used for the evaluation. Answers were statistically evaluated.

RESULTS

On average, 1108 participants attended the six webinars. 330 ENT doctors answered the surveys. The return of the questionnaires was 30.2%, that of the speakers 100%. Eight of the nine questions asked received school grades better than 2.0 on average. The speakers needed an average of 12.8 hours to prepare the webinar. The cost per webinar was about 3.50 €.

CONCLUSIONS

Webinars have become an effective form of CME-training for ENT doctors in Germany. They can be organized quickly for a large number of participants, are less expensive and environmentally benefical. Webinars might have an important place in CME-training in the future.

[Correlation between the APHAB questionnaire and the Freiburg monosyllabic test without + with noise]

BACKGROUND

Questionnaires, e. g. the APHAB, and speech-audiometry are the most used elements in measuring the success of hearing aid fitting (HAF). This study investigates the correlations between the results of the Freiburg monosyllabic word test without and with noise (FBE, FBE-S) and the results of the APHAB before and after HAF.

METHODS

Data of the FBE, the FBE-S, and the APHAB, generated within HAF of 156 subjects were analyzed. After exclusion of a normal distribution of the data, Spearman's correlation and Cohen's effect size were determined.

RESULTS

73 (46.8 %) of the 156 subjects were females, and 83 (53.2 %) males. No significant correlation could be found between the EC-, the RV-, and the cumulative ECBNRV-subscale and the benefit of HAF in the FBE and FBE-S (EC: ease of communication, BN: background noise, RV: reverberation). Most of the remaining coefficients of correlation had a weak positive effect size. A middle positive effect size could only be demonstrated for 6 combinations, for the EC-subscale mostly.

CONCLUSION

The not strong effect sizes could assume that the results in speech-audiometry and the APHAB are not independent and complementing each other as parameters of hearing loss and benefit in HAF. The effect size could be explained by individually different possibilities for the compensation of hearing loss.

Webinar-based continuing medical education in otorhinolaryngology during the COVID-19 pandemic in Germany: a longitudinal study

OBJECTIVE

Reliance on webinars for continuing medical education (CME) has increased since the onset of the COVID-19 pandemic. Here, we aimed to evaluate the teaching methods used in these webinars.

DESIGN

Retrospective, longitudinal study.

SETTING

20 CME-approved webinars, conducted March-December 2020 in Germany, and lasting 2.25 hours each.

PARTICIPANTS

Otorhinolaryngologists pursuing CME credits.

INTERVENTIONS

Postwebinar participant assessments of the speaker, effects on practical work, desired scientific content, technical quality, interactions, attention and future training behaviour.

RESULTS

On average, 780 participants joined each webinar. The mean survey response rate was 35% (n=282). When asked how well the speaker had mastered the content, 38% responded 'very well', 44% responded 'well', 14% indicated 'satisfactory' and 4% chose 'sufficient'. The frequency of webinars was considered appropriate by 92%, too high by 4% and too low by 4% of participants. The measured attention of the participants was 90%. After the COVID-19 pandemic lockdown, 68% of participants preferred online teaching. The average costs per participant were €3.50 (about $4.25 or £3.15) per webinar.

CONCLUSIONS

Although the pandemic context likely influenced the results, we conclude that periodic ear, nose and throat webinar training during COVID-19 in 2020 was an effective alternative delivery method. We found high attention rates, high levels of participant satisfaction and low costs. Evaluations and re-evaluations will be necessary to adapt teaching concepts successfully and ensure high levels of teaching and learning efficiency.

Hearing Impairment in Old Age

BACKGROUND

Hearing impairment associated with old age (presbycusis) is becoming more common because the population is aging.

METHODS

This review is based on publications retrieved by a selective search in Medline and Google Scholar, including individual studies, meta-analyses, guidelines, Cochrane reviews, and other reviews.

RESULTS

The cardinal symptom of presbycusis is impaired communication due to bilateral hearing impairment. Patients may be unaware of the problem for a long time because of its insidious progression. Evidence suggests that untreated hearing impair- ment in old age can have extensive adverse effects on the patient's mental, physical, and social well-being. Early detection is possible with the aid of simple diagnostic tests or suitable questionnaires. In most cases, bilateral hearing aids are an effective treatment. Surgery is rarely indicated. For patients with uni- or bilateral deafness, a cochlear implant is the treatment of choice. These treatments can improve many patients' quality of life.

CONCLUSION

The small amount of evidence that is currently available suggests that presbycusis is underdiagnosed and under- treated in Germany. Early detection by physicians of all specialties, followed in each case by a specialized differential diagnostic evaluation, is a desirable goal.

Evaluating the Diagnostic Accuracy of the Head-Impulse Test: A Scoping Review

Importance

Vestibular symptoms rank among the most common complaints in medicine worldwide. Underlying disorders manifested by these symptoms are generally associated with an impairment of the vestibular-ocular reflex and can be assessed with different diagnostic procedures. In recent years, an increasing number of diagnostic test accuracy studies comparing various head-impulse test (HIT) methods with other diagnostic procedures have been published but not systematically reviewed.

Objective

To conduct a scoping review and describe key characteristics of the growing number of diagnostic studies in patients presenting with vestibular symptoms.

Evidence Review

In April 2017, published studies were identified through searches of 4 bibliographic databases: Medline, Science Citation Index Expanded, the Cochrane Library, and ScienceDirect. Studies were included if they provided diagnostic accuracy data (sensitivity and specificity) for any HIT method with reference to any other vestibular test or clinical diagnosis in patients with vestibular symptoms. Study key characteristics were extracted, and the current literature was described narratively. All analysis took place between June 2017 and July 2018.

Findings

We identified a total of 27 diagnostic studies (including 3821 participants). There were disagreements between diagnostic test accuracy data both within and between studies when different HIT methods were compared with other diagnostic procedures. The proportion of correctly identified people having the disease (sensitivity) ranged between 0% and 100% (median, 41%), whereas the proportion of correctly identified people without the disease (specificity) was higher and ranged between 56% and 100% (median, 94%).

Conclusions and Relevance

Based on the studies included in this review, sensitivity, specificity, and, more importantly, the risk of misdiagnosis and associated undertreatment or overtreatment cannot be reliably estimated by HIT methods for patients with vestibular symptoms. We recommend that further diagnostic studies consider (1) multiple possible underlying causes of vestibular symptoms and multiple test thresholds, (2) a representative sample of patients with and without the disease, and (3) reporting guidelines for diagnostic test accuracy studies.

Magnesium as an intrinsic component of human otoconia

OBJECTIVES

To investigate morphology changes of artificial otoconia (CGC) in the presence of magnesium during growth under in vitro conditions.

METHODS

Investigating human otoconia by environmental scanning electron microscope and determining their magnesium content by energy-dispersive X-ray microanalysis (EDX). Comparing structural and morphological data of human and artificial otoconia (CGC, Ca₁Mg₀) without and with magnesium substitution (Ca_1-xMg_x).

RESULTS

EDX- and X-ray data reveals that the inorganic component in human otoconia consists of calcite containing a minor amount of magnesium substitution (Ca_1-xMg_x). CGC containing magnesium (length 397.0 ± 146.4 µm, diameter 325.6 ± 100.1 µm) are slimmer and significantly smaller (p < .01) than pure CGC (length 548.6 ± 160 µm, diameter 373.0 ± 110.4 µm) and reveal a significant influence on the final morphology. The length/diameter ratio is significantly higher by incorporation of magnesium into CGC (1.84 ± 0.25 µm versus 1.48 ± 0.11 µm in pure CGC, p < .01), which brings the overall shape to a close relationship with human otoconia (1.98 ± 0.08 µm).

CONCLUSIONS

Magnesium is an intrinsic component of human otoconia by partial substitution of calcium in the calcite crystal structure (Ca_1-xMg_x) and affects the development of the shape of artificial otoconia (calcite gelatin composites, CGC).

Current diagnostic procedures for diagnosing vertigo and dizziness

Vertigo is a multisensory syndrome that otolaryngologists are confronted with every day. With regard to the complex functions of the sense of orientation, vertigo is considered today as a disorder of the sense of direction, a disturbed spatial perception of the body. Beside the frequent classical syndromes for which vertigo is the leading symptom (e.g. positional vertigo, vestibular neuritis, Menière’s disease), vertigo may occur as main or accompanying symptom of a multitude of ENT-related diseases involving the inner ear. It also concerns for example acute and chronic viral or bacterial infections of the ear with serous or bacterial labyrinthitis, disorders due to injury (e.g. barotrauma, fracture of the oto-base, contusion of the labyrinth), chronic-inflammatory bone processes as well as inner ear affections in the perioperative course. In the last years, diagnostics of vertigo have experienced a paradigm shift due to new diagnostic possibilities. In the diagnostics of emergency cases, peripheral and central disorders of vertigo (acute vestibular syndrome) may be differentiated with simple algorithms. The introduction of modern vestibular test procedures (video head impulse test, vestibular evoked myogenic potentials) in the clinical practice led to new diagnostic options that for the first time allow a complex objective assessment of all components of the vestibular organ with relatively low effort. Combined with established methods, a frequency-specific assessment of the function of vestibular reflexes is possible. New classifications allow a clinically better differentiation of vertigo syndromes. Modern radiological procedures such as for example intratympanic gadolinium application for Menière’s disease with visualization of an endolymphatic hydrops also influence current medical standards. Recent methodical developments significantly contributed to the possibilities that nowadays vertigo can be better and more quickly clarified in particular in otolaryngology.

[Current Diagnostic Procedures for Diagnosing Vertigo and Dizziness]

Modern diagnostic methods such as video head impulse test and cervical and ocular vestibular evoked myogenic potentials allow to measure canal and otolith function quantitatively and objectively. These methods contribute to a complex assessment of the functional integrity of all 5 sensory elements of the vestibular organ for the first time. Moreover, in combination with additional vestibular tests frequency specific and time depended changes of impairments of vestibular sensors and their pathways can be assessed. Over the past few years, new test methods have been established step by step in daily clinical diagnostic of vertigo and dizziness in acute vestibular syndrome and chronic complaints. Modern tests and concepts caused a paradigm shift in vestibular diagnostic. New classifications of vestibular disorders and algorithms provide a high diagnostic certainity and reliability although evidence-based investigations of diagnostic procedures are still missing.

The sense of balance in humans: Structural features of otoconia and their response to linear acceleration

We explored the functional role of individual otoconia within the otolith system of mammalians responsible for the detection of linear accelerations and head tilts in relation to the gravity vector. Details of the inner structure and the shape of intact human and artificial otoconia were studied using environmental scanning electron microscopy (ESEM), including decalcification by ethylenediaminetetraacetic acid (EDTA) to discriminate local calcium carbonate density. Considerable differences between the rhombohedral faces of human and artificial otoconia already indicate that the inner architecture of otoconia is not consistent with the point group -3m. This is clearly confirmed by decalcified otoconia specimen which are characterized by a non-centrosymmetric volume distribution of the compact 3+3 branches. This structural evidence for asymmetric mass distribution was further supported by light microscopy in combination with a high speed camera showing the movement of single otoconia specimen (artificial specimen) under gravitational influence within a viscous medium (artificial endolymph). Moreover, the response of otoconia to linear acceleration forces was investigated by particle dynamics simulations. Both, time-resolved microscopy and computer simulations of otoconia acceleration show that the dislocation of otoconia include significant rotational movement stemming from density asymmetry. Based on these findings, we suggest an otolith membrane expansion/stiffening mechanism for enhanced response to linear acceleration transmitted to the vestibular hair cells.

[Otoconia : Current aspects of research]

Otoconia are calcite-based nanocomposites containing >90 % calcite and <10 % organic material. The mean size is approximately 10 µm. The external structure of all otoconia in the utricle and saccule is similar, with a cylindrical bulbous body with a slightly hexagonal contour. The internal structure consists of a composite with varying volume thickness, dense branching structures (branches) and less dense surrounding areas (bellies). Intact otoconia can be clearly identified only by scanning electron microscopy. In the case of morphological changes (e.g. due to "degeneration") the origin of even very small particles of otoconia can be assigned using physical and chemical analytical methods. The inorganic component of otoconia (calcite) is extremely sensitive to chemical influences, which leads to morphological alterations. A "degeneration" of otoconia can be objectively accomplished in vitro by alterations in pH, electrolyte imbalance and by the influence of complex formation. These three main processes then lead to irreversible morphological alterations. Artificial (biomimetic) otoconia serve as a suitable model system for detailed investigation of growth and degenerative processes.

[Current aspects of ototoxicity. Ototoxic substances and their effects]

Ototoxicity describes reversible or irreversible disorders of inner ear functions due to the influence of chemical, biological, or physical substances. Ototoxicity should be kept in mind during differential diagnosis of hearing loss, tinnitus, dizziness, and vertigo. In clinical practice, drug-induced ototoxic effects play a major role. The otorhinolaryngologist should also be involved in interdisciplinary cooperation, e.g., during treatment with antineoplastic chemotherapeutic agents with potential ototoxic side effects. In clinical practice, multimedication and interactions between different agents can complicate precise correlation in individual cases. Recent studies also show that noncellular components, such as otoconia, are extremely sensitive to chemical attacks.

[Differential diagnosis "vertigo and dizziness"]

Vertigo and dizziness are symptoms of interdisciplinary dimension. However, the differentiation and classification of vertigo syndromes also require experience and multidisciplinary knowledge. Since the clinical syndrome is subjective, a detailed analysis of the complaints underlying is required. International disease definitions are an indispensable tool in the differential diagnosis of vertigo syndromes today. With simple diagnostic tools eye movement disorders and nystagmus can be examined and assigned to specific vestibular disorders today. Screening tests (e.g. head impulse test) are now an important instrument in the investigation of patients with vertigo syndromes in case of emergency. With objective diagnostic methods (caloric irrigation, video head impulse test, vestibular evoked myogenic potentials) the degree of functional impairment of the five vestibular receptors can be assessed quantitatively. Furthermore, in vestibulopathies, a receptor and side-specific diagnostic assessment can be performed even with regard to dynamic aspects.

Principles of calcite dissolution in human and artificial otoconia

Human otoconia provide mechanical stimuli to deflect hair cells of the vestibular sensory epithelium for purposes of detecting linear acceleration and head tilts. During lifetime, the volume and number of otoconia are gradually reduced. In a process of degeneration morphological changes occur. Structural changes in human otoconia are assumed to cause vertigo and balance disorders such as benign paroxysmal positional vertigo (BPPV). The aim of this study was to investigate the main principles of morphological changes in human otoconia in dissolution experiments by exposure to hydrochloric acid, EDTA, demineralized water and completely purified water respectively. For comparison reasons artificial (biomimetic) otoconia (calcite gelatin nanocomposits) and natural calcite were used. Morphological changes were detected in time steps by the use of environmental scanning electron microscopy (ESEM). Under in vitro conditions three main dissolution mechanisms were identified as causing characteristic morphological changes of the specimen under consideration: pH drops in the acidic range, complex formation with calcium ions and changes of ion concentrations in the vicinity of otoconia. Shifts in pH cause a more uniform reduction of otoconia size (isotropic dissolution) whereas complexation reactions and changes of the ionic concentrations within the surrounding medium bring about preferred attacks at specific areas (anisotropic dissolution) of human and artificial otoconia. Owing to successive reduction of material, all the dissolution mechanisms finally produce fragments and remnants of otoconia. It can be assumed that the organic component of otoconia is not significantly attacked under the given conditions. Artificial otoconia serve as a suitable model system mimicking chemical attacks on biogenic specimens. The underlying principles of calcite dissolution under in vitro conditions may play a role in otoconia degeneration processes such as BPPV.

Horizontal VOR function shows frequency dynamics in vestibular schwannoma

The objective of this retrospective study was to investigate the horizontal vestibulo-ocular reflex (hVOR) pathway with caloric test (low-frequency hVOR) and video head impulse test (vHIT) (high-frequency hVOR) in patients with sporadic vestibular schwannoma (69 patients, 27-86 years, mean age 58.1 years) and to compare both test methods in terms of their sensitivity and specificity to detect a retrocochlear lesion. Test results with a unilateral weakness (UWCaloric) >25 % (caloric test) or a Mean-GainvHIT <0.79/asymmetry ratio of Gain (AR-GainvHIT) >8.5 % and accompanied refixation saccades (vHIT) were considered abnormal. The overall sensitivity of the caloric test was 72 %. The evaluation of AR-GainvHIT detected more abnormal cases than did Mean-GainvHIT (44 vs. 36 %). In up to 4 %, a normal caloric test result was related to an abnormal vHIT. There was only a moderate correlation of UWCaloric and AR-GainvHIT (r = 0.54, p < 0.05) with a linear regression line intercept/slope of 32.2/0.9 (p < 0.05). Receiver operating characteristics curve analysis exhibited at a UWCaloric of 50 % a vHIT sensitivity/specificity/positive predictive value/negative predictive value of 0.45/0.9/0.94/0.42. Vestibular testing at varying frequencies provides deeper insights into hVOR function and is helpful in detecting a cerebello-pontine lesion. Whereas caloric test yields a high sensitivity for nerve dysfunction, vHIT test reveals a remaining function of hVOR in the high-frequency range.

Results in using the Freiburger monosyllabic speech test in noise without and with hearing aids

The Freiburger Speech Test (FST) has been the gold standard in speech testing by word recognition score in Germany for many years. Recently, it has been demonstrated that for an amount of 104 test-persons there is no significant deviation within the lists. The objective of this study was to determine the percentiles of the distinct measuring situations in quiet and with noise (e.g. applied in hearing aid fitting) and the average benefit using hearing aids. In this prospective study, 623 patients with SNHL and equipped with hearing aids for at least 3 months have been investigated by means of the Freiburger monosyllabic test (FBE) without and with hearing aids and in quiet or with noise (CCITT noise, 65/60 dB signal-noise ratio) in free field conditions at 65 dB to determine the ratio of intelligibility. To investigate the different diagnostic conditions a linear mixed model was applied. The dependent binary variable corresponds to the number of understood syllables. The average age of all subjects was about 72.6 years. The average rate of understanding in the FBE without hearing aids and in quiet was 38.5 %, with hearing aids and in quiet 67.7 %, without hearing aids and with noise 22.4 %, and with hearing aids and with noise 39.8 %. All results were presented with the depending confidence intervals. The extent of hearing loss and the quality of hearing aid fitting can be successfully measured using the FST in quiet and with background noise (CCITT noise). In quiet, an average hearing improving gain of 29.2 % points and with noise a gain of 17.4 % points could be estimated with a successful hearing aid fitting.

[Video head impulse test or caloric irrigation? Contemporary diagnostic tests for vestibular schwannoma]

The video head impulse test (vHIT) is a new method for investigating vestibular function that is currently poorly studied in terms of its value for clinical diagnosis in otolaryngology. Both the caloric irrigation and vHIT serve to evaluate the horizontal vestibulo-ocular reflex. In the present study, caloric irrigation and vHIT were compared in 46 patients with vestibular schwannoma. Caloric irrigation exhibits a higher sensitivity than vHIT (72% versus 41%) and both tests show only a moderate correlation. Tumor size and hearing level was significantly correlated with caloric abnormalities but not with vHIT findings. Since caloric irrigation and vHIT measure the hVOR in low and high frequency ranges, respectively, these tests have to be considered complementary and are valuable in both diagnostics and therapeutic decisions.

[Evaluation of the Freiburg monosyllabic speech test in background noise]

BACKGROUND

The Freiburg speech test has been the gold standard in speech audiometry in Germany for many years. Previously, however, this test had not been evaluated in assessing the effectiveness of a hearing aid in background noise. Furthermore, the validity of particular word lists used in the test has been questioned repeatedly in the past, due to a suspected higher variation within these lists as compared to the other word list used.

PATIENTS AND METHODS

In this prospective study, two groups of subjects [normal hearing control subjects and patients with SNHL (sensorineural hearing loss) that had been fitted with hearing aid] were examined. In a first group, 113 control subjects with normal age- and gender-related pure tone thresholds were assessed by means of the Freiburg monosyllabic test under free-field conditions at 65 dB. The second group comprised 104 patients that had been fitted with hearing aids at least 3 months previously to treat their SNHL. Members of the SNHL group were assessed by means of the Freiburg monosyllabic test both with and without hearing aids, and in the presence or absence of background noise (CCITT-noise; 65/60 dB signal-noise ratio, in accordance with the Comité Consultatif International Téléphonique et Télégraphique), under free-field conditions at 65 dB.

RESULTS

The first (control) group exhibited no gender-related differences in the Freiburg test results. In a few instances, inter-individual variability of responses was observed, although the reasons for this remain to be clarified. Within the second (patient) group, the Freiburg test results under the four different measurement conditions differed significantly from each other (p>0.05). This group exhibited a high degree of inter-individual variability between responses. In light of this, no significant differences in outcome could be assigned to the different word lists employed in the Freiburg speech test.

CONCLUSION

The Freiburg monosyllabic test is able to assess the extent of hearing loss, as well as the effectiveness of a fitted hearing aid, in the presence or absence of background-noise (CCITT-noise). The present study could not evidence statistically significant differences in outcome when using the different word lists in this test battery.

Gentamicin-induced structural damage of human and artificial (biomimetic) otoconia

CONCLUSIONS

Gentamicin causes irreversible structural damage of human and artificial otoconia by progressive dissolution of calcite. The inner architecture of otoconia is strongly affected by degradation scenarios during gentamicin exposure. Artificial otoconia can be used as a model system mimicking the chemical attacks for detailed investigations.

OBJECTIVES

To investigate the chemical interactions of gentamicin with natural calcite and human and artificial otoconia under in vivo conditions.

METHODS

Pure calcite crystals and artificial and human otoconia were exposed to gentamicin injection solutions at various concentrations. Morphological changes were observed in time steps by the use of environmental scanning electron microscopy (ESEM).

RESULTS

Dissolution of pure calcite crystals results in the formation of well oriented nanoshoots indicating an irreversible chemical reaction with gentamicin. Human and artificial otoconia reveal irreversible structural changes of their surface areas as well as of their inner structure, resulting in characteristic changes at different gentamicin concentrations. Minor changes are first observed by surface alterations and dissolution of calcite in the belly region. Major changes result in further reduction of the belly area reaching the center of symmetry. Finally, a complete dissolution of the branches takes place. Artificial otoconia provide detailed insight into surface alterations.

[Dizziness from the viewpoint of otorhinolaryngology]

Dizziness is a common symptom in daily clinical practice. Dizziness and vertigo affect the quality of life as they are associated with the risk of falls leading to limited ability of independent locomotion and thus to a reduction in social contact. The source of problems with dizziness is localized in the area of visual, somatosensory and vestibular sense inputs. The ear nose and throat (ENT) specialist is involved in an interdisciplinary context to elucidate and treat peripheral vestibular disorders. The subjective symptoms of dizziness have to be clarified by taking a careful patient history. By means of objective tests (cVEMP, oVEMP, video-head impulse test) the ENT specialist is able to selectively analyze the function of the five vestibular receptors; therefore, a topological assignment in peripheral vestibulopathy is possible. The exact diagnosis is a prerequisite for a specific therapy and many diseases can be evidence-based, safe and effectively treated.

[The video head impulse test: first clinical experiences]

BACKGROUND

Side-specific test procedures are mandatory in order to assess the function of peripheral vestibular receptors. Semicircular canals (SCC) and vestibulo-ocular reflex (VOR) can be tested by the Halmagyi and Curthoy head impulse test (HIT) and recently by means of the video head impulse test (vHIT). The vHIT procedure is a new method to measure eye and head velocity during brief and rapid head impulses. This method provides objective information of VOR and detects both overt and covert catch-up saccades.

MATERIALS AND METHODS

As clinical experiences with vHIT are limited, in this study the horizontal VOR (hVOR) was examined by means of the vHIT in 142 consecutive patients with acute or chronic vestibular syndrome.

RESULTS

A total of 20 healthy volunteers served as a control group and exhibited a normal average VOR gain of 0.97 ± 0.09 without re-fixation saccades. In patients, 47.6% showed a pathological vHIT whereas 52.4% revealed a normal test result. Covert catch-up saccades could be revealed in 13.7% by means of vHIT whereas in 86.3% overt catch-up saccades alone or in combination with covert catch-up saccades were found in the majority of catch-up saccades in peripheral vestibular disorders.

CONCLUSIONS

By means of the vHIT it is possible to obtain a side-specific and quantitative assessment of hVOR. Video-head impulse test is a reliable tool for vestibular testing even in bedside examinations of patients suffering from dizziness.

Incidence and localization of abnormal mucosa findings in patients consulting ENT outpatient clinics and data analysis of a cancer registry

For patients without symptoms and at risk, there is no established early detection program to discover carcinomas of the upper aerodigestive tract in the sense of secondary prevention. Such type of prevention seems even more desirable because the chances for a cure and the quality of life are strongly dependent on the stage of the tumor and the time of the initial diagnosis. Six hundred and eight patients without symptoms but at least one of the self-reported risk factors "smoking", "alcohol consumption" or "reflux" were examined with an endoscope or an optical microscope for pathological findings in the upper aerodigestive tract once a year. In addition, the incidence of malignancies of the upper aerodigestive tract between 2001 and 2010 was determined through the Cancer Registry of Schleswig-Holstein. Tissue samples were taken from 18 of the 608 patients. Eleven patients (1.8%) had a squamous cell carcinoma. Another patient suffered from non-Hodgkin's lymphoma and one from larynx tuberculosis. The ratio of detected malignancies in the oral cavity and the oropharynx on the one hand and the hypopharynx and larynx, which can only be examined by endoscopes, on the other hand were in our cohorts and in our survey according to the cancer registry was 5/6. The above-described methods allow examining risk patients easily and safely. According to current publications, the ratio of the found malignancies exceeds the expected ratio significantly, which presumably was caused by the examination targeting patients at risk. Due to the expanded examination area using optical instruments more than doubles the rate of discoverable malignancies compared to the limitations posed by the examination of directly visible areas of the oral cavity of the oropharynx.

[The Mini-Audio-Test (MAT). Screening inventory for hearing loss starting at the age of 50]

BACKGROUND

Progredient hearing loss is a common symptom, which is hard to detect early. This study presents an assessment to face this problem.

METHODS

1,159 subjects between the age of 50 and 75 have been investigated by a 12 question profile about their hearing in different situations. The answers have been rated by weighted points and compared with the pure-tone audiogram of the subjects.

RESULTS

6 of the 12 questions were suitable to detect a hearing loss of 25 dB in one of the 4 frequencies 0,5-1-2-4 kHz. For subjects under age of 60 a cutoff value of 3, for subjects aged 60 years or older a cutoff value of 2 points could be set for the 6 questions including "Mini-Audio-Test" (MAT).

DISCUSSION

The "Mini-Audio-Test" is able to detect a hearing loss of 25 dB at least in one of the 4 frequencies by a sensitivity of 78%, 95% confidence interval (71,8%, 83,2%), for the younger group of subjects and by 69%, 95% confidence interval (66,0%, 72,6%), for the older one. Subjects with a pathological score should be examined by an ENT-physician.

[Isolated functional loss of the lateral semicircular canal in vestibular neuritis]

Today, modern tools in vestibular testing are feasible to provide information about functional status of all five peripheral vestibular receptors. Isolated or combined loss of crista and macula receptor function can be determined in the diagnostic process. We describe a seldom case of isolated functional loss of lateral semicircular canal receptor function in a 55-year-old patient. Whereas there was no ispilateral caloric response and video head impulse test revealed a catch-up saccade, air-conducted (AC) cervical and ocular vestibular-evoked myogenic potentials (cVEMP, oVEMP), subjective visual vertical and MRI were normal.

[Diagnosis of vertigo: keep an eye on central eye movement disorders]

With specialist knowledge ophthalmologists can make a valuable contribution to the interdisciplinary work-up of patients with vertigo as the leading symptom. The neuro-ophthalmological examination of eye movements by an ophthalmologist and/or orthoptist is an important contribution because the various vertigo syndromes can only be correctly evaluated by a combined examination of the vestibular and ocular motor systems. If the ophthalmologist is the first doctor to examine a patient suspected disorders from other specialist fields can be indicated, in particular neurology and otorhinolaryngology. When taking the patient history the ophthalmologist should inquire about the type and duration of the vertigo, triggering or modifying factors and accompanying symptoms. This is followed by a systematic examination of the eye position and the different types of eye movements, the head-impulse test and a special examination to check for the presence of nystagmus.

[Falls and fall risk factors. Are they relevant in ENT outpatient medical care?]

BACKGROUND AND OBJECTIVE

The risk of falling increases with age. The problem of falls in medical care constantly rises in priority due to demographic changes in Germany. Therefore, the risk of falling should be assessed in all patients. The present study was intended to evaluate the frequency of falls in daily ENT outpatient medical care and the importance of risk factors.

PATIENTS/METHODS

A multicentre study was performed in six outpatient facilities based on a survey of falls and fall risk factors in patients living at home (n = 673) aged 60 years and older.

RESULTS

Falls are a frequent problem in the elderly. A total of 23% had one and 13.7% more than one fall within the previous year. Of these, 15% suffered injury, while only 13% used some form of fall prevention. Joint pain and problems of the hip and lower extremities (42.6%), abnormal gait (41.3%), dizziness and balance disorders (38%) as well as impaired activities of daily living (35%) are the most common risk factors for falls and multiple falls in all age groups. Impaired hearing is a fall risk factor in elderly patients.

CONCLUSIONS

Falls are a frequent problem in patients in ENT outpatient medical care. Fall prevention is advisable in the context of an interdisciplinary approach.

[Receptor function of the semicircular canals. Part 2: pathophysiology, diseases, clinical findings and treatment aspects]

Perturbation of semicircular canal function may result in a pathological angular vestibulo-ocular reflex (aVOR). The resulting impairment in gaze stabilization is perceived as "vertigo" or "dizziness" and may occur following receptor function impairment of all three semicircular canals. The head impulse test reveals hidden (covert-catchup) or visible (overt-catchup) saccades in disturbances of semicircular function. Most peripheral vestibular disorders can be treated conservatively. There are surgical treatment options for some diseases, such as intractable benign paroxysmal positional vertigo and superior semicircular canal dehiscence. Vestibular training promotes central reorganization of the VOR. Impaired semicircular receptor function, in particular bilateral vestibulopathy, may affect spatial orientation and cognitive processes. Balance prostheses could serve as a replacement for receptors in the future.

Ocular vestibular evoked myogenic potentials to air conduction (AC oVEMP): useful in clinical practice?

Cervical vestibular-evoked myogenic potential (cVEMP) and ocular VEMP (oVEMP) stimuli can be used to measure otolith function using air (AC) and bone conducted (BC) stimuli. Cervical VEMPs reflect saccular function and can be recorded using air conduction (AC), whereas oVEMPs reflect probably predominantly utricular function. Air- and bone-conducted vibration can be used, because AC oVEMP methodology seems to be fast and simple in clinical practice to measure otolith function. In this study we discuss the advantages and problems of AC oVEMP stimulation. AC oVEMP can be easily and quickly obtained within a few seconds. N10 (first negative peak) and p15 (first positive peak) latencies may be used as parameters for clinical interpretation but amplitude fluctuations are relatively large. For daily clinical use of VEMP visualization in a normogram seems feasible. Especially the AC oVEMP methodology (100 dB nHL, tone burst 500 Hz) is fast and efficient in clinical practice to measure otolith function, predominantly utricular function.

[Prevalence of abnormal mucosal findings in patients in HNO practices]

OBJECTIVE

To date, no secondary prevention program is in place for patients carrying an increased risk for developing head and neck cancer (HNSCC). In terms of successful, long-term curative therapy and increased quality of life, it would be useful to detect such diseases at an early stage.

PATIENTS AND METHODS

A total of 370 patients with at least one risk factor such as "smoking", "alcohol", or "reflux disease" and without any symptoms were examined during a 1-year period using standard HNO methods (e. g. endoscopy) for suspicious alterations of the mucosa of the upper aerodigestive tract.

RESULTS

In 13 (3.5%) of all 370 cases a biopsy was taken for further diagnosis. Squamous cell carcinoma was found in eight cases, while one further patient was suffering from non-Hodgkin lymphoma.

CONCLUSIONS

It is simple and safe to examine patients at risk of developing HNSCC by standard HNO methods. The rate of detected carcinomas is much higher than in former investigations, likely because our survey focused only on patients with specific risk factors.

[Air conducted ocular VEMP: II. First clinical investigations]

BACKGROUND

Vestibular-evoked myogenic potentials (VEMP) are widely used to assess vestibular function. Air conducted (AC) cervical VEMP (cVEMP) reflect sacculus and inferior vestibular nerve function. Ocular VEMP (oVEMP) however has been hardly examined up to now. In recent studies it has been assumed that AC oVEMP probably reflects superior vestibular nerve function. The aim of this pilot study was to evaluate clinical application of the AC oVEMP.

MATERIAL AND METHODS

AC oVEMP were recorded in patients with peripheral vestibular disorders (n=21). In addition thermal irritation and head impulse test were performed and AC cVEMP were recorded. For intense AC-sound stimulation tone bursts (500 Hz) with 100 dB nHL were used.

RESULTS

In peripheral vestibular disorders AC oVEMP and AC cVEMP could be classified into: • type 1 (inferior vestibular neuritis) with loss of AC oVEMP but normal AC cVEMP, • type 2, probable type of superior vestibular neuritis, showing present AC cVEMP but loss of AC oVEMP, • type 3, probable complete vestibular neuritis, without AC oVEMP and AC cVEMP.

CONCLUSIONS

AC oVEMP may be used as an appropriate test for clinical investigation in patients with vestibular disorders. AC oVEMP is an additional, essential test for assessing otolith function beside AC cVEMP. Further vestibular test are necessary for precise clinical interpretation.

[Air conducted ocular VEMP: I. Determination of a method and application in normal patients]

BACKGROUND

Air conducted (AC) cervical vestibular evoked myogenic potentials (AC cVEMP) and air conducted ocular VEMP (AC oVEMP) may be used for measurement of otolith function. However AC oVEMP are few examined till now. The aim of this pilot study was to apply a method for use of AC oVEMP in clinical practice.

PATIENTS AND METHODS

AC oVEMP were recorded in healthy voluntary people (n=20) using intense AC-sound stimulation (500 Hz tone bursts, 100 dB nHL). Thermal irrigation and AC cVEMP were normal as including criteria. Values were evaluated statistically.

RESULTS

AC oVEMP were recorded in all healthy patients. Mean and standard deviation for the first negative peak was 11.35±1.00 ms and for the first negative peak 16.30±1.10 ms. The mean amplitudes were 7.70±4.50 μV. The stability of n10 and p15 component was the same.

CONCLUSIONS

AC oVEMP can be easy and fast obtained. N10 and p15 latencies may used as parameter for clinical interpretation. Amplitude fluctuations are relatively large. Results can be used in further clinical investigation of AC oVEMP.

Caloric stimulation with near infrared radiation does not induce paradoxical nystagmus

Near infrared radiation can be used for warm stimulation in caloric irrigation of the equilibrium organ. Aim of this study was to determine whether near infrared radiation offers effective stimulation of the vestibular organ, whether it is well tolerated by the patients and especially whether it is a viable alternative to warm air stimulation in patients with defects of the tympanic membrane and radical mastoid cavities. Patients with perforations of the tympanic membrane (n = 15) and with radical mastoid cavities (n = 13) were tested both with near infrared radiation and warm dry air. A caloric-induced nystagmus could be seen equally effectively and rapidly in all patients. Contrary to stimulation with warm dry air, no paradoxical nystagmus was observed following caloric irrigation with a warm stimulus (near infrared radiation). Results of a questionnaire showed excellent patient acceptance of near infrared stimulation with no arousal effects or unpleasant feeling. In conclusion, near infrared radiation proved to be an alternative method of caloric irrigation to warm dry air in patients with tympanic membrane defects and radical mastoid cavities. Near infrared radiation is pleasant, quick, contact free, sterile and quiet. With this method an effective caloric warm stimulus is available. If near infrared radiation is used for caloric stimulus no evaporative heat loss occurs.

[Recording cervical and ocular vestibular evoked myogenic potentials. Part 2: influencing factors, evaluation of findings and clinical significance]

VEMP measurements are subject to various influencing factors: patient age, threshold, sound intensity and frequency. Using air (AC) and bone conduction (BC) the vestibular receptors and afferents of the otolith organs can be activated to varying degrees. Recordings of cervical (cVEMP) and ocular VEMP (oVEMP) are clinically possible. AC-cVEMP are primarily an indicator of the sacculocollic reflex pathway. Together with findings on the vestibuloocular reflex (VOR) and complimentary otolith tests, VEMP enable otolith function analysis of each side separately. In addition, the distinction between combined or isolated canal and otolith dysfunction in terms of subtyping and patterns of damage in mono- and bilateral disorders, such as vestibular neuritis or bilateral vestibulopathy, is possible. Moreover, VEMP is relevant in terms of prognostic and therapeutic considerations as well as expert assessments.