[Structure and establishment of the German Cochlear Implant Registry]

Hearing rehabilitation of patients with severe hearing loss or deafness using cochlear implants (CI) is a very successful but also complex and lifelong process that requires high quality standards for structure, process, and results. Medical registries represent an ideal tool for conducting quality control relevant to care while at the same time collecting scientific data. Therefore, at the initiative of the Executive Committee of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), a Germany-wide CI registry (the German Cochlear Implant Register, DCIR) was to be established. The following goals were to be achieved: 1) legal and contractual basis for the register; 2) definition of the register contents; 3) development of evaluation standards (hospital-specific and national annual reports); 4) development of a logo; 5) practical operation of the registry. After defining a catalog of services that defines the content, structure, and operation of the DCIR, a registry operator with audiological expertise was sought. After considering various offers, the registry was technically implemented in cooperation with the provider INNOFORCE (Ruggell, Liechtenstein) as registry operator. This also included the realization of an interface for data transfer from previously existing databases and development of a data protection concept for productive operation of the DCIR under the scientific leadership of the DGHNO-KHC Executive Committee. Since January 2022, it has been possible for participating hospitals to enter pseudonymized data into the DCIR. To date, 75 hospitals in Germany have contractually agreed to participate in the registry. During the first 15 months, data from over 2500 implants in over 2000 patients were registered in the DCIR. The work presented here describes the structuring, development, and successful establishment of the DCIR. Introduction of the DCIR represents an important milestone of future scientifically based quality control in CI care. The registry presented here can therefore be considered as an example for other areas of medical care and thus also sets an international standard.

Structure and establishment of the German Cochlear Implant Registry (DCIR)

Hearing rehabilitation of patients with severe hearing loss or deafness using cochlear implants (CI) is a very successful but also complex and lifelong process that requires high quality standards for structure, process, and results. Medical registries represent an ideal tool for conducting quality control relevant to care while at the same time collecting scientific data. Therefore, at the initiative of the Executive Committee of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), a Germany-wide CI registry (the German Cochlear Implant Register, DCIR) was to be established. The following goals were to be achieved: 1) legal and contractual basis for the register; 2) definition of the register contents; 3) development of evaluation standards (hospital-specific and national annual reports); 4) development of a logo; 5) practical operation of the registry. After defining a catalog of services that defines the content, structure, and operation of the DCIR, a registry operator with audiological expertise was sought. After considering various offers, the registry was technically implemented in cooperation with the provider INNOFORCE (Ruggell, Liechtenstein) as registry operator. This also included the realization of an interface for data transfer from previously existing databases and development of a data protection concept for productive operation of the DCIR under the scientific leadership of the DGHNO-KHC Executive Committee. Since January 2022, it has been possible for participating hospitals to enter pseudonymized data into the DCIR. To date, 75 hospitals in Germany have contractually agreed to participate in the registry. During the first 15 months, data from over 2500 implants in over 2000 patients were registered in the DCIR. The work presented here describes the structuring, development, and successful establishment of the DCIR. Introduction of the DCIR represents an important milestone of future scientifically based quality control in CI care. The registry presented here can therefore be considered as an example for other areas of medical care and thus also sets an international standard.

Conception and implementation of a certification system for quality control of cochlear implant treatment in Germany

A standardized and structured process is indispensable for optimal hearing rehabilitation with cochlear implants (CI). The Executive Committee of the German Society of Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC), initiated the conception of a certification program and a Whitepaper based on the Association of the Scientific Medical Societies in Germany (AWMF) clinical practice guideline (CPG) describing the current medical standards of CI care in Germany. The goal was to independently confirm implementation of this CPG and make this information publicly available. With the support of an independent certification organization, successful implementation of the CI-CPG by a hospital would then be verified and confirmed by awarding the "Cochlear implant-provision institution" (Cochlea-Implantat-versorgende Einrichtung, CIVE) quality certificate. A structure for implementation of a certification system was developed based on the CI-CPG. The following steps were required: 1) conception of a quality control system for certification of hospitals working in accordance with the CI-CPG; 2) development of required structures for an independent review of quality-relevant structure, process, and result parameters; 3) development of a standard procedure for independent certification of hospitals; 4) development of a certificate and a logo to demonstrate successful certification; 5) practical implementation of the certification. Following design of the certification program and the required organizational structure, the certification system was successfully launched in 2021. Applications for the quality certificate could be formally submitted from September 2021. A total of 51 off-site evaluations were performed by December 2022. In the first 16 months from introduction, 47 hospitals were successfully certified as CIVE. In this period, 20 experts were trained as auditors, who have since then carried out 18 on-site audits in hospitals. In summary, the conceptual design, structure, and practical implementation of a certification program for quality control in CI care was successfully implemented in Germany.

[Recommendations of the German Society of Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC) for the granting of resident training program authorizations]

The 2018 template for otorhinolaryngology specialist training of the German Medical Association is increasingly implemented by the federal associations. In this regard, the German Society recommended an otorhinolaryngology resident training plan for Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC) together with the Professional Association of German Otorhinolaryngologists as a suggested guideline for the federal medical associations. In this context, the state medical associations currently work on criteria on the basis of which otorhinolaryngologists and their training institutions can be granted authority for such a certified otorhinolaryngology resident training program.The DGHNO-KHC last made recommendations for the granting of authorizations for specialist training in otorhinolaryngology in 1999. Many contents have changed as a result of the 2018 model specialist training regulations. Therefore, a scientifically formulated proposal for the granting of continuing education authorizations is herewith provided as recommendation to the federal state medical associations.

[Conception and implementation of a certification system for quality control of cochlear implant treatment in Germany. German version]

A standardized and structured process is indispensable for optimal hearing rehabilitation with cochlear implants (CI). The Executive Committee of the German Society of Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC), initiated the conception of a certification system and a Whitepaper based on the Association of the Scientific Medical Societies in Germany (AWMF) clinical practice guideline (CPG) describing the current medical standards of CI care in Germany. The goal was to independently confirm implementation of this CPG and make this information publicly available. With the support of an independent certification organization, successful implementation of the CI-CPG by a hospital would then be verified and confirmed by awarding the "Cochlear implant-provision institution" (Cochlea-Implantat-versorgende Einrichtung, CIVE) quality certificate. A structure for implementation of a certification system was developed based on the CI-CPG. The following steps were required: 1) conception of a quality control system for certification of hospitals working in accordance with the CI-CPG; 2) development of required structures for an independent review of quality-relevant structure, process, and result parameters; 3) development of a standard procedure for independent certification of hospitals; 4) development of a certificate and a logo to demonstrate successful certification; 5) practical implementation of the certification. Following design of the certification system and the required organizational structure, the certification system was successfully launched in 2021. Applications for the quality certificate could be formally submitted from September 2021. A total of 51 off-site evaluations were performed by December 2022. In the first 16 months from introduction, 47 hospitals were successfully certified as CIVE. In this period, 20 experts were trained as auditors, who have since then carried out 18 on-site audits in hospitals. In summary, the conceptual design, structure, and practical implementation of a certification system for quality control in CI care was successfully implemented in Germany.

Positionspapier: ICD-Codierung der chronischen Rhinosinusitis mit Nasenpolypen (CRSwNP) im ICD-10-GM als Grundlage für eine Therapie mit Biologika – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA), der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC) und des Deutschen CRS-Registers

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der Schleimhäute von Nase und Nasennebenhöhlen. In Deutschland sind 3 verschiedene monoklonale Antikörper für die Indikation „Zusatztherapie zu intranasalen Glukokortikosteroiden für die Behandlung Erwachsener mit schwerer chronischer Rhinosinusitis mit Nasenpolypen“ zugelassen. Um die Verordnung in der zugelassenen Indikation (In-Label) zu dokumentieren, ist neben einer Dokumentation zahlreicher medizinischer Parameter die korrekte Auswahl der ICD-10-GM-Codierung entscheidend. Hierfür existieren in Deutschland bislang keine konsentierten Empfehlungen.

Methoden Basierend auf der internationalen Literatur und bisherigen Erfahrungen werden von einem Expertengremium von AeDA, DGHNO-KHC und Deutschem CRS-Register Codierungsmöglichkeiten von CRS und CRSwNP analysiert und auf dieser Basis eine konsentierte Empfehlung für die ICD-10-GM-Codierung in Deutschland ausgesprochen.

Ergebnis Die Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme ICD-10-GM (International Classification of Diseases, 10. Revision, German Modification) ist die amtliche Klassifikation zur Verschlüsselung von Diagnosen in der ambulanten und stationären Versorgung in Deutschland. Der ICD-10-GM unterscheidet nicht adäquat zwischen heute anerkannten klinischen und immunologischen Differenzierungen der CRSsNP und der CRSwNP. Dennoch wird insbesondere bei indiziertem Einsatz von Biologika in der Therapie der schweren CRSwNP eine möglichst exakte Verschlüsselung mit den Codes J33.8 (im Einzelfall J33.1 oder J33.9) empfohlen.

Schlussfolgerungen Das Verständnis über die immunologischen Grundlagen der CRSwNP eröffnet neue Behandlungsansätze mit monoklonalen Antikörpern für Patienten mit schwerer, unkontrollierter Erkrankung. Hier geben wir Empfehlungen für eine adäquate ICD-10-GM-Codierung in Deutschland.

Empfehlungen zur Überprüfung der Wirksamkeit und Verlaufsdokumentation von Mepolizumab bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the mucous membranes of the nose and sinuses. Eosinophilic inflammation is described as a common endotype. The anti-IL5 antibody mepolizumab was approved in November 2021 as an add-on therapy to intranasal glucocorticosteroids for the treatment of adults with severe chronic rhinosinusitis with nasal polyps when systemic glucocorticosteroids or surgery do not provide adequate disease control. While national and international recommendations exist for the use of mepolizumab in CRSwNP, it has not yet been adequately specified how this therapy is to be monitored, what follow-up documentation is necessary, and when it should be terminated if necessary.

METHODS

A literature search was performed to analyze previous data on the treatment of CRSwNP with mepolizumab and to determine the available evidence by searching Medline, Pubmed, the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including 10/2022 were considered.

RESULTS

Based on the international literature and previous experience by an expert panel, recommendations for follow-up, adherence to therapy intervals and possible therapy breaks, as well as termination of therapy when using mepolizumab for the indication CRSwNP in the German health care system are given on the basis of a documentation sheet.

CONCLUSIONS

Understanding the immunological basis of CRSwNP opens up new non-surgical therapeutic approaches with biologics for patients with severe, uncontrolled courses. Here, we provide recommendations for follow-up, adherence to therapy intervals, possible therapy pauses, or discontinuation of therapy when mepolizumab is used as add-on therapy with intranasal glucocorticosteroids to treat adult patients with severe CRSwNP that cannot be adequately controlled with systemic glucocorticosteroids and/or surgical intervention.

Empfehlungen zur Überprüfung der Wirksamkeit und Verlaufsdokumentation von Dupilumab bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

BACKGROUND

 Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the nasal and paranasal mucosa. A Type-2 inflammation is described as the most common endotype. Since October 2019 the anti-IL-4/-IL-13 antibody dupilumab has been approved in Germany as an add-on therapy to intranasal corticosteroids for the treatment of adults with severe chronic rhinosinusitis with nasal polyps, when systemic corticosteroids alone or surgery do not provide adequate disease control. While recommendations for the use of dupilumab in CRSwNP exist at both national and international levels, until now it has not been adequately established, how therapy should be monitored and when it should be discontinued in the German Health Care System.

METHODS

 A literature search was performed analyzing previous data on the treatment of CRSwNP with dupilumab and to determine the available evidence by searching Medline, Pubmed, the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to 05/2022 were included.

RESULTS

 Based on international literature and previous experience, recommendations are given by an expert panel for follow-up and possible therapy breaks, therapy intervals or termination of therapy when using dupilumab for the indication CRSwNP in the German health care system based on a documentation form.

CONCLUSIONS

 Understanding the immunological basis of CRSwNP opens new non-surgical therapy approaches with biologics for patients with severe courses. The authors give recommendations for follow-up, possible therapy breaks, therapy intervals and a termination for dupilumab treatment as add-on therapy with intranasal corticosteroids for the treatment of adult patients with severe CRSwNP that cannot be adequately controlled with systemic corticosteroids and/or surgical intervention.

Positionspapier: Empfehlungen zur Anwendung von Mepolizumab bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC)

BACKGROUND

 Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the paranasal sinus mucosa with eosinophilic inflammation as the most common endotype. The anti-IL5 antibody mepolizumab was approved for the treatment of severe CRSwNP in the EU in November 2021.

METHODS

 A literature search was performed to analyze the immunology of CRSwNP and determine the available evidence by searching Medline, Pubmed, and the German national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including 12/2021 that investigated the effect of mepolizumab in CRSwNP were considered.

RESULTS

 Based on the international literature and previous experience, recommendations for the use of mepolizumab in CRSwNP in the German health care system are given by an expert panel on the basis of a documentation form.

CONCLUSIONS

 Understanding about the immunological basis of CRSwNP opens new non-surgical therapeutic approaches with biologics for patients with severe courses. Mepolizumab is approved since November 2021 for add-on therapy with intranasal corticosteroids for the treatment of adult patients with severe CRSwNP who cannot be adequately controlled with systemic corticosteroids and/or surgical intervention.

Positionspapier: Empfehlungen zur Anwendung von Omalizumab bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der paranasalen Schleimhäute, der als Endotyp meistens eine TH2-Inflammation zugrunde liegt. IgE-Antikörper spielen dabei eine wichtige Rolle. Der anti-IgE-Antikörper Omalizumab wurde im August 2020 für die Therapie der schweren CRSwNP zugelassen.

Methoden In einer Literatursuche wurde die Immunologie der CRSwNP analysiert und die Evidenz zur Wirkung von Omalizumab bei dieser Erkrankung ermittelt durch Recherchen in Medline, Pubmed sowie den nationalen und internationalen Studien- und Leitlinien-Registern und der Cochrane Library.

Ergebnisse Basierend auf diesen Angaben aus der internationalen Literatur werden von einem Expertengremium Empfehlungen für die Anwendung von Omalizumab bei CRSwNP im deutschen Gesundheitssystem gegeben.

Schlussfolgerung Omalizumab ist zugelassen für Patienten ab 18 Jahren mit schwerer chronischer Rhinosinusitis mit Nasenpolypen als Zusatztherapie zu intranasalen Kortikosteroiden (INCS), wenn durch eine Therapie mit INCS keine ausreichende Krankheitskontrolle erzielt werden kann.

Positionspapier: Hinweise zur Patienteninformation und -aufklärung vor Anwendung von Biologika bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) – Teil 2: Omalizumab – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung, oftmals auf der Grundlage einer Typ-2-Inflammation. Für die Behandlung von Patienten mit einer schweren Ausprägung ohne ausreichendes Ansprechen auf die Standardtherapie mit topischen nasalen Steroiden und/oder Zustand nach endonasaler Operation sind als Biologika aktuell Dupilumab und Omalizumab für die Therapie zugelassen. Nachdem wir in einer früheren Publikation für Dupilumab bereits entsprechende Hinweise gegeben haben, ist das Ziel der vorliegenden Arbeit die Standardisierung von Patienteninformation und -aufklärung vor einer Therapie mit Omalizumab.

Methoden Auf Grundlage des aktuellen Wissensstandes zur Immunologie der CRSwNP und zu den erwünschten und möglichen unerwünschten Wirkungen von Omalizumab werden Empfehlungen für die Patienteninformation entwickelt.

Ergebnisse Basierend auf der internationalen Literatur, der aktuellen Fachinformation und Erfahrungen aus der praktischen Anwendung und den derzeitigen Pharmakovigilanz-Daten hat ein Expertengremium Empfehlungen für die Patienteninformation und -aufklärung zur Anwendung von Omalizumab bei CRSwNP entwickelt und auf dieser Grundlage einen Patienteninformations- und Aufklärungsbogen erstellt.

Schlussfolgerung Die Information und Einwilligung des Patienten wird vor der Verordnung bzw. Verabreichung von allen Biologika, damit auch Omalizumab, empfohlen. Das vorliegende Positionspapier enthält wichtige Informationen zur praktischen Umsetzung und einen Vorschlag für eine Patienteninformation.

[Effects of the SARS-CoV‑2 pandemic on the otolaryngology university hospitals in the field of research, student teaching and specialist training]

Hintergrund

Ab Frühjahr 2020 kam es zur weltweiten Verbreitung von SARS-CoV‑2 mit der heute als erste Welle der Pandemie bezeichneten Phase ab März 2020. Diese resultierte an vielen Kliniken in Umstrukturierungen und Ressourcenverschiebungen. Ziel unserer Arbeit war die Erfassung der Auswirkungen der Pandemie auf die universitäre Hals-Nasen-Ohren(HNO)-Heilkunde für die Forschung, Lehre und Weiterbildung.

Material und Methoden

Die Direktorinnen und Direktoren der 39 Universitäts-HNO-Kliniken in Deutschland wurden mithilfe einer strukturierten Online-Befragung zu den Auswirkungen der Pandemie im Zeitraum von März bis April 2020 auf die Forschung, Lehre und die Weiterbildung befragt.

Ergebnisse

Alle 39 Direktorinnen und Direktoren beteiligten sich an der Umfrage. Hiervon gaben 74,4 % (29/39) an, dass es zu einer Verschlechterung ihrer Forschungstätigkeit infolge der Pandemie gekommen sei. Von 61,5 % (24/39) wurde berichtet, dass pandemiebezogene Forschungsaspekte aufgegriffen wurden. Von allen Kliniken wurde eine Einschränkung der Präsenzlehre berichtet und 97,5 % (38/39) führten neue digitale Lehrformate ein. Im Beobachtungszeitraum sahen 74,4 % der Klinikdirektoren die Weiterbildung der Assistenten nicht gefährdet.

Schlussfolgerung

Die Ergebnisse geben einen Einblick in die heterogenen Auswirkungen der Pandemie. Die kurzfristige Bearbeitung pandemiebezogener Forschungsthemen und die Einführung innovativer digitaler Konzepte für die studentische Lehre belegt eindrücklich das große innovative Potenzial und die schnelle Reaktionsfähigkeit der HNO-Universitätskliniken, um auch während der Pandemie ihre Aufgaben in der Forschung, Lehre und Weiterbildung bestmöglich zu erfüllen.

[New ways in hearing rehabilitation after cochlear implantation]

INTRODUCTION

After cochlear implantation, auditory and speech training is usually necessary. Up until now, this has been performed on an out- or inpatient basis in direct contact with a therapist. Due to technical advances but also particularly because of an increasing use of digital media and a desire for mobility and independence, the demand for digital training programs is increasing in the field of hearing rehabilitation.

MATERIALS AND METHODS

In a first step, the most important elements of auditory training were determined on the basis of commonly used auditory and speech processing models, and the core features of a computer-based teletherapeutic hearing platform were defined. This process considered motivational elements and adaptive mechanisms as regularly used in educational and speech and language therapy. In a second step, an initial prototype of the "train2hear" teletherapeutic hearing platform was developed by an interdisciplinary research team.

RESULTS

The core of the train2hear platform is an initial analysis according to the International Classification of Functioning, Disability, and Health (ICF), on the basis of which an individual training plan is designed. Various adaptive mechanisms enable the level of difficulty to be continually adapted to the individual user's learning progress. A videoconference tool enables contact between the patient and the therapist.

CONCLUSION

The train2hear platform represents a first prototype of a computer-based auditory rehabilitation program in German. Further evaluation and development in a clinical study are needed to determine the feasibility and efficacy of the platform.

[Regional distribution of the cochlear implant (CI) centers in Germany]

The treatment of patients with severe hearing loss or deafness with a cochlear implant (CI) represents a standard in Germany today. However, there is hardly any data on the current number of clinical CI centers (CI clinics) and their geographical distribution. The patient self-help organization, German Cochlear Implant Society (DCIG), and the German Society for Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC) have therefore initiated a survey to determine the regional distribution, the range of services, the consideration of existing quality standards and cooperation with patient self-help organizations of the individual clinical CI centers.For this purpose, a total number of 170 ENT departments or their directors (37 professors and 133 chief physicians), respectively, were contacted by e-mail and provided with a questionnaire. The survey took place from October 2019 to February 2020.Of the 170 departments contacted, 71 (41.8 %) took part in the survey. Of these, 70 departments (98.6 %) confirmed to perform CI surgeries. Thus, 41.8 % of all clinics contacted reported to perform CI surgeries (70 of 170 clinics), while this information was not available from 99 clinics. All 70 clinical CI centers (100 %) reported to conduct CI surgeries on adults, 60 centers (85.7 %) also on children (< 18 years). 36 departments (51.4 %) reported that the total number of CI surgeries at their facility in 2018 was more than 50. In 64 departments (91.4 %), the recommendations of the DGHNO-KHC on CI care (according to the White Paper CI care 2018) were followed. A collaboration between the department and patient self-help organization was confirmed by 67 institutions (95.7 %). The geographical distribution of the clinical CI centers showed a heterogeneous distribution pattern between the individual federal states and also within the respective federal state.The work presented here is a first assessment of the situation with regard to the regional distribution of clinical CI centers in Germany. A clustering of CI centers was noticeable in metropolitan areas, sometimes with several facilities in one city. The predominant attention to quality-related aspects, such as the consideration of the DGHNO-KHC white paper and the cooperation with patient self-help, is gratifying. The limitations of the study result from limited participation in the survey (41.8 % of the contacted clinics).

Positionspapier: Hinweise zur Patienteninformation und -aufklärung vor Anwendung von Biologika bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC) – Teil 1: Dupilumab

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der nasalen und paranasalen Schleimhaut, der oftmals eine Typ-2-Inflammation zugrunde liegt. Durch die Entwicklung von Biologika, die in diese Entzündungsmechanismen eingreifen können, steht eine neuartige Therapiemöglichkeit zur Verfügung.

Methoden Auf Grundlage des aktuellen Wissensstandes zur Immunologie der CRSwNP und der Wirkung von Biologika sowie deren mögliche unerwünschte Wirkungen werden Empfehlungen für die Patienteninformation entwickelt.

Ergebnisse Basierend auf der internationalen Literatur und bisherigen Erfahrungen hat ein Expertengremium Empfehlungen für die Patienteninformation und -aufklärung zur Anwendung von Biologika bei CRSwNP entwickelt und auf dieser Grundlage einen Aufklärungsbogen erstellt.

Schlussfolgerung Die Information und Einwilligung des Patienten ist vor der Verordnung bzw. Verabreichung von Biologika erforderlich. Das vorliegende Positionspapier enthält wichtige Informationen hierzu und einen Vorschlag für eine Patienteninformation.

[Effects of the SARS-CoV-2 pandemic on the otorhinolaryngology university hospitals in the field of medical care]

INTRODUCTION

Since December 2019, the SARS-CoV-2 virus has been rapidly spreading worldwide. In Germany, an exponential increase in the number of infections was registered at the beginning of March 2020 and led to a call of the Ministry of Health to create more capacity for intensive medical treatment in hospitals. The aim of the present study was to determine the effects of the SARS-CoV-2 pandemic on Oto-Rhino-Laryngology (ORL) university hospitals regarding patient care.

MATERIALS AND METHODS

An online survey was sent out to all chairmen of the 39 ORL university hospitals in Germany. The answers to the questions referred to the defined period from March 15^th to April 15^th 2020 and were carried out using the online survey tool "SurveyMonkey". 87 questions focused on general information, health care, and structural effects in the respective institution.

RESULTS

All chairmen of the 39 university hospitals in Germany participated in the survey. The collected data prove the considerable impact on organizational, structural and medical aspects of patient care. For example, the surveyed clinics reported a decrease in outpatient cases by 73.8 % to 26.2 ± 14.2 % and in surgical treatments by 65.9 % to 34.1 ± 13.9 %. In contrast, emergency treatment remained unchanged or even increased in 80 % of the facilities and surgical treatment of emergency patients remained unchanged or even increased in more than 90 %. Emergency outpatient and surgical treatment of patients was provided throughout the pandemic in all facilities. In total, about 35 000 outpatients and about 12 000 surgical cases were postponed. As a result of the acute structural changes, the potential danger of falling below current treatment standards was seen in individual areas of patient care.

DISCUSSION

The assessment of the impact of the SARS-CoV-2 pandemic is heterogeneous. The majority of the chairmen are critically aware of the risk of falling below current medical treatment standards or guidelines. In the phase of an exponential increase in the number of infections, significant changes in treatment processes had to be accepted for understandable reasons. However, with the currently significantly reduced number of infections, falling below treatment standards and guidelines should not be allowed to remain constant and tolerated.

SUMMARY

This study shows a differentiated picture with regard to the effects of the SARS-CoV-2 pandemic on outpatient, inpatient and operative patient care at the ORL university hospitals in Germany and illustrates the importance of these institutions for ensuring patient care during this critical phase.

Positionspapier: Anwendung von Biologika bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis (CRS) betrifft weltweit ca. 5–12 % der Allgemeinbevölkerung und wird traditionell eingeteilt in einen Phänotyp ohne (CRSsNP) und einen mit Ausbildung von Nasenpolypen (CRSwNP). Wurden Nasenpolypen bis vor kurzem eher als mechanisches Hindernis mit der Notwendigkeit einer operativen Beseitigung betrachtet, wird die CRSwNP heute als eine multifaktorielle entzündliche Erkrankung der nasalen und paranasalen Schleimhäute angesehen, der als Endotyp häufig eine T2-Inflammation zugrunde liegt. Biologika, die mit diesen Entzündungsmechanismen interferieren, stellen interessante neue Therapiemöglichkeiten dar.

Methoden Das aktuelle Wissen zur Immunologie der CRSwNP und Wirkung von Biologika wurde mittels einer Literaturanalyse durch Recherchen in Medline, PubMed sowie den nationalen und internationalen Studien- und Leitlinienregistern und der Cochrane Library zusammengestellt.

Ergebnisse Basierend auf der internationalen Literatur und bisherigen Erfahrungen werden von einem Expertengremium Empfehlungen für die Anwendung von Biologika bei CRSwNP im deutschen Gesundheitssystem auf der Grundlage eines Dokumentationsbogens gegeben.

Schlussfolgerung Das Verständnis über die immunologischen Grundlagen der CRSwNP eröffnet neue nichtoperative Therapieansätze mit Biologika für Patienten mit schweren Verlaufsformen.

Positionspapier: Empfehlungen zur Behandlung der chronischen Rhinosinusitis während der COVID-19-Pandemie im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNO-KHC) – Diese Empfehlungen basieren auf dem EAACI Positionspapier „Treatment of chronic RhinoSinusitis with nasal polyps (CRSwNP) in the COVID-19 pandemics – An EAACI Position Paper”, Allergy, 2020 und wurden auf die Situation im deutschen Gesundheitswesen angepasst

Hintergrund  Von der chronischen Rhinosinusitis (CRS) sind weltweit etwa 5–12 % der Allgemeinbevölkerung betroffen. Die CRS gilt als chronische Atemwegserkrankung, die nach den Empfehlungen der WHO ein Risikofaktor für COVID-19-Patienten sein kann. Die entzündlichen Veränderungen der Nasenschleimhäute bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) sind in den meisten Fällen vom Entzündungsendotyp 2 (T2).

Methoden  Der aktuelle Wissensstand sowohl zu COVID-19 als auch zu den Behandlungsmöglichkeiten von CRSwNP wurde durch eine Literaturrecherche in Medline, Pubmed, internationalen Leitlinien, der Cochrane Library und im Internet analysiert.

Ergebnisse  Auf Grundlage der internationalen Literatur, der aktuellen Empfehlungen der WHO und anderer internationaler Organisationen sowie der bisherigen Erfahrungen gab ein Expertengremium von EAACI und ARIA Empfehlungen für die Behandlung von CRSwNP während der COVID-19-Pandemien.

Schlussfolgerung  Intranasale Kortikosteroide stellen die Standardbehandlung für CRS bei Patienten mit einer SARS-CoV-2-Infektion dar. Chirurgische Behandlungen sollten auf ein Minimum reduziert werden und nur bei Patienten mit lokalen Komplikationen und solchen, für die keine anderen Behandlungsmöglichkeiten bestehen, durchgeführt werden. Systemische Kortikosteroide sollten bei COVID-19-Patienten vermieden werden. Die Behandlung mit Biologika kann bei nicht infizierten Patienten unter sorgfältiger Überwachung fortgesetzt werden und sollte während einer SARS-CoV-2-Infektion vorübergehend unterbrochen werden.

[Hearing and cognition: neurocognitive test batteries in otorhinolaryngology]

BACKGROUND

Hearing and cognition are closely related to each other. Particularly in suboptimal listening situations, cognitive abilities become important to enable speech comprehension. Besides, studies have indicated that hearing impairment is associated with a more rapid mental decline compared to persons with normal hearing. However, hearing loss also has an impact on neurocognitive testing, which is generally based on auditive stimuli. With increasing age, the risk of sensory but also of cognitive impairments increases. So far this comorbidity receives little consideration in otorhinolaryngology.

MATERIALS AND METHODS

The paper presents an overview and evaluation of widely used German neurocognitive test batteries for older patients, with regard to the different test modalities and their focus.

RESULTS

A multitude of different neurocognitive screening tests and detailed test batteries are available, particularly in the field of dementia. So far, sensory deficits have not been considered in neurocognitive testing, neither concerning application nor interpretation. Normative data adapted to the hearing impaired are still missing.

CONCLUSION

With regard to demographic changes and the well-known bias between hearing and cognition, screening of neurocognitive functions should be implemented in basic otorhinolaryngologic diagnostics. More comprehensive test batteries might be useful for research purposes or speech therapy.

[Helping people to help themselves : 10 years of successful graduate medical training in otorhinolaryngology in Rwanda (Africa)]

After the horrifying genocide in Rwanda in 1994, medical care of the small country almost broke down completely. During the following years, different medical fields had to be redeveloped. However, until 2009, there was no training program for otorhinolaryngology offered in Rwanda. Together with the University of Rwanda, we established a Master of Medicine Program that started in 2010. With the support of German otorhinolaryngologists, 10 ENT specialists have completed their training to date and 15 colleagues are currently still undergoing education in the program.

Medication use in patients with chronic rhinosinusitis in Germany - a large retrospective patient-based study

BACKGROUND

The aim of the present study was to provide an insight into medical treatment practices among patients with chronic rhinosinusitis (CRS) in Germany. An investigation of ICD codes and ATC classes of CRS patients in general and otolaryngology offices in Germany should reveal the prevalent treatment behaviors of German physicians.

METHODS

The present study used data from the Disease Analyzer database (IQVIA). The study sample included patients from 940 general (GP) and 106 otolaryngology (ENT) practices who were coded as having chronic sinusitis (ICD-10: J32) or nasal polyps (ICD-10: J33) in 2015 (index date). The primary outcome measures were the number of patients with these diagnoses per practice as well as the proportion of patients with prescriptions for topical corticosteroids, systemic corticosteroids, antibiotics, antihistamines, and local decongestants within 365 days after the first diagnosis.

RESULTS

This retrospective study included 26,768 patients with coding for chronic sinusitis (ICD-10: J32) and 516 patients for nasal polyps (ICD-10: J33) in 940 GP practices and 19,826 patients with coding for chronic sinusitis (ICD-10: J32) and 1,773 patients for nasal polyps (ICD-10: J33) in 106 ENT practices. In patients coded as having chronic sinusitis (ICD-10: J32), topical corticosteroids were prescribed at a low rate (GP: 12.3%, ENT: 34.3%). In patients coded as having nasal polyps (ICD-10: J33), topical corticosteroid usage was higher in GP practices (27.3%) and in ENT practices (71.2%).

CONCLUSIONS

Topical corticosteroid usage in CRS patients in GP practices in Germany is as low as in other Western countries. Increased usage of topical corticosteroids in CRS patients with polyposis should be encouraged in GP and ENT practices.

[Bone Conduction and Active Middle Ear Implants]

The majority of patients with moderate to severe hearing loss can be supplied with conventional hearing aids depending on severity and cause for hearing loss in a satisfying way. However, some patients either do not benefit enough from conventional hearing aids or cannot wear them due to inflammatory reactions and chronic infections of the external auditory canal or due to anatomical reasons. For these patients there are fully- and semi-implantable middle ear and bone conduction implants available. These devices either directly stimulate the skull (bone conduction devices), middle ear structures (active middle ear implants) or the cochlea itself (direct acoustic stimulation). Patients who failed surgical hearing rehabilitation or do not benefit from conventional hearing aids may achieve a significant better speech understanding and tremendous improvement in quality of life by implantable hearing devices with careful attention to the audiological and anatomical indication criteria.

The expression pattern and inhibitory influence of Tenascin-C on the growth of spiral ganglion neurons suggest a regulatory role as boundary formation molecule in the postnatal mouse inner ear

Sensorineural hearing loss, as a consequence of acoustic trauma, aging, genetic defects or ototoxic drugs, is highly associated with irreversible damage of cochlear hair cells (HCs) and secondary degeneration of spiral ganglion (SG) cells. Cochlear implants (CIs), which bypass the lost HC function by direct electrical stimulation of the remaining auditory neurons, offer an effective therapy option. Several studies imply that components of the extracellular matrix (ECM) have a great impact on the adhesion and growth of spiral ganglion neurons (SGNs) during development. Based on these findings, ECM proteins might act as bioactive CI substrates to optimize the electrode-nerve interface and to improve efficacy of these implants. In the present study, we focused on the ECM glycoproteins Tenascin-C (TN-C), Laminin (LN), and Fibronectin (FN), which show a prominent expression along the growth route of SGNs and the niche around HCs during murine postnatal development in vivo. We compared their influence on adhesion, neurite length, and neurite number of SGNs in vitro. Moreover, we studied the expression of the chondroitin sulfate proteoglycan (CSPG) dermatan sulfate-dependent proteoglycan-1 (DSD-1-PG), an interaction partner of TN-C. In sum, our in vitro data suggest that TN-C acts as an anti-adhesive and inhibitory factor for the growth of SGNs. The DSD-1 carbohydrate epitope is specifically localized to HC stereocilia and SG fibers. Interestingly, TN-C and the DSD-1-PG exhibit a mutually exclusive expression pattern, with the exception of a very restricted region beneath the habenula perforata, where SG neurites grow through the basilar membrane (BM) toward the HCs. The complementary expression of TN-C, LN, FN, and the DSD-1 epitope suggests that TN-C may act as an important boundary formation molecule in the developing postnatal mouse inner ear, which makes it a promising candidate to regulate neurite outgrowth in the light of CIs.

[Health-related Quality of Life After Oropharyngeal Cancer Treatment]

BACKGROUND

Oropharyngeal cancer is a diagnosis which means a change in life and even after successful treatment a tremendous reduction in the quality of life. Aim of this study is to analyse the health-related quality of life in patients with oropharyngeal cancer dependent on different treatment options.

METHODS AND PATIENTS

Charts of 256 patients treated for oropharyngeal cancer between 1997 and 2007 were analysed in a retrospective study. Inclusion criteria for this study has been fulfilled by 98 patients, 82 of these completed the study. Therefore, standardised questionnaires (EORTC QLQ-C30 und EORTC QLQ-H&N35) have been used and 2 groups were compared: patients with primary radiochemotherapy (pRCT) vs. patients treated by an operation and adjuvant radiation.

RESULTS

Most of the health-related quality of life domains in our patients were significantly reduced compared to the general population. There have been just very few significant differences in the quality of life domains in between the 2 groups.

CONCLUSIONS

Health-related quality of life after treatment of oropharyngeal cancer is significantly compromised for these patients compared to the general population, but there have been no obvious differences depending on the compared treatment options. Only regarding the items "physical and cognitive functioning" patients after primary radiochemotherapy showed significantly better results and thus a better quality of life, despite the fact, that this group has a significantly advanced cancer stadium.

[Diseases of the middle ear in childhood]

Middle ear diseases in childhood play an important role in daily ENT practice due to their high incidence. Some of these like acute otitis media or otitis media with effusion have been studied extensively within the last decades. In this article, we present a selection of important childhood middle ear diseases and discuss the actual literature concerning their treatment, management of complications and outcome. Another main topic of this paper deals with the possibilities of surgical hearing rehabilitation in childhood. The bone-anchored hearing aid BAHA® and the active partially implantable device Vibrant Soundbridge® could successfully be applied for children. In this manuscript, we discuss the actual literature concerning clinical outcomes of -these implantable hearing aids.

[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.

Sweet taste and chorda tympani transection alter capsaicin-induced lingual pain perception in adult human subjects

Sweetness signals the nutritional value of food and may moreover be accompanied by a sensory suppression that leads to higher pain tolerance. This effect is well documented in infant rats and humans. However, it is still debated whether sensory suppression is also present in adult humans. Thus, we investigated the effects of sweet taste on the perception of the painful trigeminal stimulus capsaicin in two groups of healthy adult human subjects. A solution of 100 μM capsaicin was applied to the tip of the subject's tongues in order to stimulate trigeminal Aδ- and C-fiber nociceptors. When swallowed, 1M sucrose reduced the capsaicin-induced burning sensation by 29% (p ≤ 0.05) whereas a solution of similar taste intensity containing 1 μM quinine did not. Similarly, sucrose application to the frontal hemitongue suppressed the perception of the burning sensation induced by contralaterally applied capsaicin by 25% (p ≤ 0.01). We furthermore investigated the effects of documented unilateral transection of the chorda tympani nerve on capsaicin perception. In accordance with the ipsi-to-contralateral effect of sucrose on capsaicin perception in healthy subjects, hemiageusic subjects were more sensitive for capsaicin on the tongue contralateral to the taste nerve lesion (+38%; p ≤ 0.01). Taken together, these results argue I) for the existence of food intake-induced sensory suppression, if not analgesia, in adult humans and II) a centrally mediated suppression of trigeminal sensation by taste inputs that III) becomes disinhibited upon peripheral taste nerve lesion.

[The incidence of Frey syndrome following parotidectomy: results of a survey and follow-up]

BACKGROUND

Frey's syndrome (FS) is defined as facial sweating due to gustatory stimuli following surgery or trauma of the parotid gland. Concomitant symptoms may occur in the area of the auriculotemporal nerve: swelling, facial flushing, and paresthesia. A misguided re-innervation of perspiratory glands by secretory parasympathetic fibres is likely responsible in the pathogenesis. The reported incidence in the literature varies considerably from 1.7% to 97.6%. The present study aims to clarify the incidence of FS.

PATIENTS AND METHODS

A questionnaire was sent to 221 consecutive patients who underwent parotidectomy between 07/2005 and 07/2008. No selection for type of parotidectomy or histological result was made. Patients were invited to undergo a follow-up examination including Minor's iodine starch test.

RESULTS

A total of 135 of 221 (61%) questionnaires were available for evaluation. In all, 82 patients took part in the follow-up, with a follow-up period of 2.8 years (15-51 months). According to the questionnaire, 54% of patients claimed to be free of symptoms. Sweating following gustatory stimuli was reported by 23% of patients. Of the 82 Minor's tests performed, 62.2% were positive. All patients with subjective presence of FS had a positive Minor's test. In 27%, Minor's test was positive although patients did not suffer from facial sweating subjectively ("subclinical FS"). In all, 39% had no subjective complaints and Minor's test was also negative. Cases with a positive Minor's test showed no statistically significant relation to the patients' age, gender or to the histological diagnosis or type of parotidectomy.

CONCLUSION

The clinical incidence of FS in our study is 23%, although a positive Minor's iodine starch test was observed in 62% of cases. Therefore, it seems justifiable to differentiate between a symptomatic or clinical FS and a merely asymptomatic or subclinical FS. No correlation was observed between epidemiological factors and the occurrence of FS.

Positive family history of idiopathic sudden sensorineural hearing loss

Idiopathic sudden sensorineural hearing loss (ISSNHL) is a heterogenic disease. Multiple factors influencing aetiology and prognosis are discussed. A retrospective clinical characterisation and analysis of family history of ISSNHL patients was performed to investigate influences on the disease. 186 inpatients diagnosed with ISSNHL were characterised by health records and a standardised questionnaire. Audiograms were observed. 75 controls that had never experienced an event of ISSNHL were questioned about family members being affected by ISSNHL. 63.4% of all patients could be assigned to at least one group with similar causes of ISSNHL (noise exposure, positive family history, infectious diseases, hypothyroidism and fibromuscular dysplasia). A positive family history for ISSNHL has not been reported so far. Therefore, we accentuated the characterisation of patients with positive family history. 21.4% affirmed a positive family history. In ten families, at least two family members were reported as ISSNHL patients. In comparison with patients with negative family history, they tend to be younger, experience more events of ISSNHL and show less improvement of hearing abilities under therapeutic treatment (non-significant). Differences intensified between smokers with positive family history and non-smokers with negative family history. Differences concerning average age were statistically significant (p = 0.001). Within 75 controls 11 families were reported with one member being affected by ISSNHL. In the control group we did not detect any family with more than one ISSNHL patient. The results indicated that patients with positive family history tend to have an aggravated course of ISSNHL. Further studies should help to confirm these results and to identify environmental or genetic factors leading to ISSNHL. This might support a better understanding of the aetiology of ISSNHL and offer new possibilities for prevention and therapy.

[The relevance of anatomical courses in ENT-education]

BACKGROUND

Dissection-courses have become an important element in ENT-education. They are offered covering different subjects. Until now no study exists that verifies the acceptance and efficiency of those courses.

METHODS

We consulted the trainees of three surgical anatomical courses with a multiple choice form for their opinion on courses visited in the past. The acquired data was analyzed quantitatively and examined for statistically significant correlation between age, gender and professional experience.

RESULTS

In our study 73 participants filled in our questionnaire. The average age was 32 years. The satisfaction concerning the currently offered courses is high. The dissection-exercises were rated as 'good' and 'very good' by 72%. The strongest point of criticism (49%) related to the price of the dissection-courses. The improvement of surgical skills showed to be the main motivation for visiting anatomical dissection-courses (46%). Most respondents had registered for dissection-courses of the temporal bone and the paranasal sinuses. A correlation between professional experience and the type of courses visited could be found for the courses on nerval- and blood vessel reconstruction.

DISCUSSION

The courses offered currently in ENT are appreciated as beneficial and effective. The fact that these courses are visited frequently and that the benefit in daily practice is highly appreciated indicate a well thought out educational concept. It seems unlikely that fees for these courses can be reduced as hoped for by many participants. The economic pressure on the organizational team is very high. Surprisingly the interest in CME-points is relatively low.

[Mucormycosis in paranasal sinuses]

Three patients with mucormycosis of the paranasal sinuses were treated in the University ENT departments in Bochum and Essen in recent years. All patients were immunocompromised for different reasons and had reduced resistance against microorganism infection. They presented with symptoms of orbital complications of sinusitis. The further progress of these life-threatening fungal infections with a mortality rate between 35 and 70% depends on early and definitive diagnosis and radical surgical therapy to reduce the amount of infectious agent. The difficulties of early diagnosis by imaging, histology, microbiology, or molecular biology and postoperative therapeutic options especially with amphotericin B, liposomal amphotericin B, and posaconazole are illustrated and discussed.

[The temporal bone of lamb and pig as an alternative in ENT-education]

BACKGROUND

Usually temporal bone dissections are done with human temporal bones. Unfortunately human donors are rare. The analysis of animals' ear morphology might help to improve the quality of surgical training.

MATERIAL AND METHODS

Temporal bones of the lamb and pig were drilled and measured under surgical aspects. The analysis focused on the outer morphology, the external ear canal, the mastoid and the middle ear. The data was compared to human anatomy in order to verify the lamb's and pig's temporal bone concerning suitability in ENT-education.

RESULTS

The temporal bone of the young sheep is smaller than the human one. The hypotympanon is pronounced in a bullous manner. Tympanic membrane and middle ear are very similar to the human one. The outer ear canal is smaller and shorter. The pig has a long and narrow external ear canal but a very similar middle ear anatomy compared to humans. The mastoid in both animals is not pneumatized.

DISCUSSION

The middle ear and the tympanic membrane of both animals are morphologically equal to the structures found in human ears. The lamb's middle ear can be used for teaching anatomy although some structures are smaller than in human ears. The pig's ear is not useful for training mastoidectomy but can be used for surgical exercises on the ossicular chain.

[Value of nerve monitoring in thyroid surgery]

Aim of this study is to investigate the influence of nerve monitoring for protection of recurrent nerve function in thyroid surgery. We analysed retrospectively the data of 369 patients, who underwent thyroid surgery at our clinic between 2000 and 2006. In 129 cases (35%) a hemithyroidectomy and in 236 cases (64%) a total thyroidectomy were performed. A single node in the isthmus was removed in 4 patients. In thyroidectomy we strove for identification of the recurrent nerve. This was performed successful in 96% (577 of 601) of the cases. In 94% of all thyroid surgeries nerve monitoring (NIM-Response/Medtronic) to watch the recurrent nerve were used. In 5 cases (0.83%) a permanent recurrent laryngeal nerve paralysis occurred. There was temporary recurrent laryngeal nerve paresis in 11 cases (1.84%). The use of nerve monitoring could not significantly lower the risk for laryngeal nerve paralysis or paresis (Fischer's exact test, p>0.05). As expected we found no influence of nerve monitoring on other surgical complications. The apply of intraoperative nerve monitoring is a useful tool in thyroid surgery and is described to lower the risk of recurrent laryngeal nerve damage, but to our opinion it does not replace the intraoperative preparation of the recurrent laryngeal nerve. Sound anatomical knowledge of the head- & neck region is an important requirement for save thyroid surgery.

The common pig: a possible model for teaching ear surgery

Anatomical dissection of the human temporal bone is an essential element in the education of ear surgeons. Unfortunately, the acquisition of human temporal bones can be difficult. As an alternative, temporal bones of animals might help. The temporal bones of ten common pigs taken out of a butcher's daily routine were drilled and dissected under clinical aspects. The resulting anatomy was analyzed and measured. Especially, the mastoid, the external ear canal and the middle ear were incorporated. The preparation was done following a strict order of steps relevant to typical work of an ENT surgeon. Our results were compared with known data of the human temporal bone and effectiveness concerning surgical training was verified. We could see that the temporal bone of the pig had a totally different appearance compared to the human one, especially regarding the length and location of the external ear canal. Also, the mastoid is difficult to identify. It is hidden by the atlanto-occipital joint and has no pneumatization. The anatomical landmarks as the arcades and the facial nerve are congruent to the human anatomy although not all structures are accessible via the mastoid. The pigs' middle ear showed to be very similar to the human one. The incus showed a shortened long process. This study showed that the temporal bone of the pig might be an alternative regarding some aspects of surgical training in ENT education. A complete replacement is not possible. After some modification, it might be an efficient model for endaural techniques and ossicular manipulation.

The ciliary beat frequency of middle ear mucosa in children with chronic secretory otitis media

The chronic secretory otitis media (CSOM) is a common disease in children. Its cardinal symptoms are recurrent middle ear effusions and conductive hearing loss. Until today, the pathophysiological mechanism of this disease remains unknown. The correlation with adenoids and tubal dysfunction during childhood seems to be obvious, but the origin of middle ear effusions still has to be clarified. It is known that the CSOM affects the mucociliary system in several ways. In order to find out more about these correlations, the ciliary beat frequency was examined in 123 samples of infantile middle ear mucosa suffering from CSOM. Samples were surveyed using a stroboscopic microscopy method. The results of this study showed a significant decrease of ciliary beat frequency (CBF) to an average of 7.4 s(-1) in children with a CSOM. The healthy group of control showed a frequency of 10.1 s(-1). The measured CBF dataset was correlated with microbiological findings. We found a typical bacterial profile in nearly all the cases that were examined but were unable to find a specific bacterium decreasing CBF. This study provides evidence for the diminution of CBF in cases of CSOM in comparison to a healthy control group. Our findings emphasize the importance of stopping the vicious circle of recurrent effusions by paracentesis or grommet insertion.