Superimposed high-frequency jet ventilation (SHFJV) for endoscopic laryngotracheal surgery in more than 1500 patients.

BACKGROUND: Superimposed high-frequency jet ventilation (SHFJV), which does not require any tracheal tubes or catheters, was developed specifically for use in laryngotracheal surgery. SHFJV uses two jet streams with different frequencies simultaneously and is applied in the supraglottic space using a jet laryngoscope and jet ventilator. METHODS: Between 1990 and 2004, SHFJV was studied in 1515 consecutive patients (including 158 children requiring laryngotracheal surgery) prospectively. Ventilation was performed with an air/oxygen mixture and anaesthesia was administered i.v. RESULTS: Adequate oxygenation and ventilation was achieved in 1512 patients. Arterial blood gas analyses (BGA) were performed between 1990 and 1994; thereafter BGA was only performed in patients with high-grade stenosis of the larynx/trachea or high-risk patients [n=623, mean Pa(O(2)) 133.8 (39.4) mm Hg and mean Pa(CO(2)) 42.3 (10.1) mm Hg]. There were no significant changes in Pa(O(2)) or Pa(CO(2)) during the entire period of SHFJV. No complications secondary to the ventilation technique were observed; in particular, no barotrauma occurred. Three patients required tracheal intubation. SHFJV was also successfully used for laser surgery (n=312). It proved to be a safe mode of ventilation without any complications such as airway fire, major haemorrhage, or aspiration of debris. CONCLUSION: SHFJV is an advanced ventilation mode playing a pivotal role in the (open) ventilatory support/ventilation of patients with laryngotracheal stenosis. It is particularly indicated in cases of severe stenosis and offers optimal conditions for laryngotracheal surgery, including laser surgery and stent implantation techniques.

[Management of oropharyngeal dysphagia. Current status]. / Management oropharyngealer Dysphagien. Eine Standortbestimmmung.

The diagnostics and therapy of oropharyngeal dysphagia fall within the competence of ENT, phoniatrics and speech language pathology. Due to etiologic diversity, interdisciplinary management is necessary in many cases. After taking a thorough history, focused on swallowing, dynamic instrumental examination methods, i.e. videoendoscopic and videofluoroscopic swallowing studies, allow an evaluation of the morphology and function of the act of swallowing. Videoendoscopic swallowing studies enable the ENT specialist/phoniatrician to decide on further diagnostic steps, to establish a therapy and to recommend the type of feeding (oral, non-oral). Therefore, in clinical routine, knowledge of the diagnostics and therapy of swallowing disorders is indispensable for the ENT specialist/phoniatrician.

Complications after laryngeal surgery: videofluoroscopic evaluation of 120 patients.

AIM: Videofluoroscopic assessment of the spectrum and incidence of swallowing complications after state-of-the-art laryngeal cancer surgery. MATERIALS AND METHODS: We retrospectively studied videofluoroscopic examinations of 120 patients (94 men, 26 women; mean age, 58 years) with suspected complications after laryngeal resection (partial laryngectomy, 65; total laryngectomy, 55). Swallowing function (i.e., oral bolus control, laryngeal elevation and closure, presence of pharyngeal residue, aspiration) and structural abnormalities such as strictures, fistulas and tumour recurrence were assessed by videofluoroscopy. RESULTS: Abnormalities were found in 110 patients, including strictures in nine, fistulas in six and mass lesions in 13 patients. Aspiration was found in 63 patients overall (partial laryngectomy, 61/65; total laryngectomy, 2/55), occurring before swallowing in five, during swallowing in 34, after swallowing in nine and at more than one phase in 15 patients. Pharyngeal paresis was detected in three and pharyngeal weakness in 19 patients. Pharyngo-oesophageal sphincter dysfunction was observed in 10 cases. CONCLUSION: Aspiration is a very common complication after partial laryngeal resection. It is mainly caused by incomplete laryngeal closure, sphincter dysfunction or pharyngeal pooling. Videofluoroscopy is the only radiological technique able to identify both disordered swallowing function and structural changes after laryngeal resection. Detection of these complications is crucial for appropriate further therapy.Kreuzer, S. H. (2000). Clinical Radiology55, 775-781.

[Cochlear implantation and auditory feedback]. / Cochlear-Implantation und auditive Rückkopplung.

The aim of the present study was to evaluate the short term effect of cochlear implantation on the fundamental frequency and the articulation of 13 patients. This investigation objectives for the first time the changes of fundamental frequency and articulation in cochlear implant patients. All postlingual deaf patients were provided with a Combi 40+ cochlear implant. Voice recording was performed pre- and three months post-implantation. The voice data was analyzed using the "X-Tool" software. The results show that 38% of the patients had a significant (p < 0.05) decrease of F0 mean three months after implantation. A postoperative decrease of F0 towards the normal range was observed generally in all patients. Spectographs pre- and post-implantation showed that the articulation improved already 3 months after partial restoration of auditory feedback. A large variability of F0 was noticed among the deaf subjects, but no correlation to the duration of deafness could be established.

Cervical osteophytes impinging on the pharynx: importance of size and concurrent disorders for development of aspiration.

OBJECTIVE: This study evaluated the clinical significance of cervical osteophytes impinging on the pharynx in patients with dysphagia and the importance of concurrent disorders that may affect swallowing function. MATERIALS AND METHODS: On videofluoroscopy, anterior cervical osteophytes were found in 55 (32 men, 23 women; mean age, 69 years) of 3318 patients with dysphagia (1.7%). Coexisting diseases that affected swallowing function were found in 28 patients (stroke, n = 7; thyroidectomy, n = 7; tongue base or laryngeal cancer surgery, n = 5; other diseases, n = 9). Swallowing function was assessed with videofluoroscopy evaluating epiglottic tilting, laryngeal closure, impression of the hypopharynx, pharyngeal residue, and aspiration. RESULTS: With advancing age, the probability of aspiration (odds ratio, 1.07; p < 0.05) and of enlarging osteophytes (odds ratio, 1.26; p < 0.01) increased; the probability was higher for osteophytes at more than one vertebrae (odds ratio, 8.00; p < 0.01) and for concurrent diseases (odds ratio, 8.02; p < 0.01). Aspiration was found in 75% of patients with osteophytes larger than 10 mm and in 34% with osteophytes smaller than or equal to 10 mm. In 88% of patients with small osteophytes who aspirated, other diseases affected swallowing function. CONCLUSION: Aspiration is common in patients with dysphagia and cervical osteophytes larger than 10 mm. Aspiration is rare in patients with osteophytes smaller than or equal to 10 mm unless these patients suffer from other disorders that may affect swallowing.

Radiographic detection of achalasia: diagnostic accuracy of videofluoroscopy.

AIMS: To retrospectively evaluate the accuracy of videofluoroscopy in the diagnosis of achalasia. MATERIALS AND METHODS: Videofluoroscopic studies of the oesophagus of 53 patients (25 males, 28 females; mean age, 49 years) with manometrically revealed diagnosis of achalasia were retrospectively evaluated. The videofluoroscopic examinations had been carried out with one swallow of low-density barium suspension in the erect and up to three swallows in the prone oblique position. Videofluoroscopically, a diagnosis of achalasia was made in 31 of the patients (58%) with manometrically proven achalasia, of whom only nine had oesophageal dilatation. Non-specific oesophageal motor abnormalities were diagnosed radiographically in 18 patients (34%) and a normal motility in four patients (8%). CONCLUSION: Videofluoroscopy is a valuable and sensitive technique for the detection of disordered oesophageal motility in achalasia.

[Physiology of the larynx]. / Physiologie des Larynx.

The larynx consists of the cartilaginous-osseous framework, elastic membranes and ligaments, joints, muscles, nerves, vessels, and interior cavity. The laryngeal functions are the protection of the airway during swallowing, respiration (i.e. maintainance of the airway) and phonation. During the pharyngeal phase of swallowing the swallow reflex induces a laryngeal closure in three levels and a superior-anterior movement of the larynx and hyoid bone. The laryngeal airway is maintained by the circumference of the cricoid cartilage. Phonation is the phylogenetically recent function of the larynx and was made possible by the laryngeal descent. The sound production is explained according to the myoelastic-aerodynamic theory. The diagnostics of laryngeal diseases is performed in close cooperation between otorhinolaryngology and radiology. For diagnostic purposes, the physiology of the larynx requires to take into account not only morphological, but also functional aspects.

[Diagnosis and therapy of laryngeal carcinoma]. / Diagnostik und Therapie des Larynxkarzinoms.

Therapeutic choice in laryngeal carcinoma is influenced by the nature of the tumor and a variety of factors involving the patient and physician. Small (T1) and exophytic (T1, T2) tumors are suitable for radiotherapy. Limited lesions (T1, T2) can be cured by functional endoscopic resection techniques or external partial laryngectomies. Extensive tumors (large T2; T3) are treated by total laryngectomy or by primary irradiation, especially in the case of a good response to induction chemotherapy. When radiation treatment fails, surgery succeeds in more than half of the cases. Tumors infiltrating or transgressing the laryngeal framework (T4) can only be cured by total laryngectomy followed by radiotherapy. Subtotal or circular ablation of the adjacent pharynx or esophagectomy needs repair with visceral or myocutaneous grafts. Lymphatics are preferentially treated with the same modality as used in the primary disease. Inconspicuous lymphatics should be treated electively in most cases, with the exception of early glottic cancer.

[Stroboscopy and imaging in interdisciplinary diagnosis of early stages of laryngeal carcinoma]. / Stroboskopie und Bildgebung in der interdisziplinären Diagnostik von Frühstadien des Larynxkarzinoms.

The laryngostroboscopy is regarded to be the most important functional investigation in laryngologic and phoniatric diagnostics. She allows an analysis of vocal fold vibrations during phonation. Stroboscopic evaluations permit to early detect infiltrative processes of the vocal folds. Superficial alterations of the mucous membrane that invade into the muscle cause a phonatory "standstill" of the vocal fold in the stroboscopy, i.e. a complete lack of vibratory motion. If such a phonatory standstill persists for more than 2 or 3 weeks, a biopsy via microlaryngoscopy is indicated for diagnostic purposes. In comparison to stroboscopy, imaging techniques are not of such great significance in early laryngeal cancer. But in case of suspected infiltration of the tumor a further diagnostic evaluation with CT or MRI is necessary to detect possible neoplastic invasion of the laryngeal cartilage or of extralaryngeal structures. In this paper, we present the principle of laryngostroboscopy, the examination procedure and the stroboscopic parameters. Case reports of early laryngeal cancer illustrate the interdisciplinary diagnostic procedure with CT, MRI and stroboscopy.

[Postoperative complications after larynx resection: assessment with video-cinematography]. / Postoperative Komplikationen nach Larynxresektion: Abklärung mittels Videocinematographie.

In past decades, the surgical techniques for treating laryngeal carcinoma have been vastly improved. For circumscribed tumors, voice-conserving resections are possible and for extensive neoplasms, radical laryngectomy, sometimes combined with chemoradiation, has been developed. Postoperative complications regarding swallowing function are not uncommon. Radiologic examinations, especially pharyngography and videofluoroscopy, are most often used to evaluate patients with complications after laryngeal surgery. An optimized videofluoroscopic technique for evaluation of complications is described. The radiologic appearance of early and late complications, such as fistulas, hematomas, aspiration, strictures, dysfunction of the pharyngoesophageal sphincter, tumor recurrence, and metachronous tumors is demonstrated.

Does choir singing cause noise-induced hearing loss?

Although health problems in musicians have been previously reported; not much is known about noise-induced hearing loss due to choir singing. However, there are data to show that peak levels of more than 110 dB SPL are produced in choir singing, and major parts of sound energy can be found below 1 kHz and even 500 Hz but not below 100 Hz. To find out about possible hearing loss due to professional choir singing, we measured the hearing threshold level of 62 choir singers in a large opera choir. Most publications about noise-induced hearing loss report that the high-frequency region is impaired most. However, in our study the low frequency region was affected most, when compared with normative data (especially ISO 7029). Control groups of women and men with normal auditory function did not show pure-tone hearing thresholds different from ISO 7029. The permanent threshold shifts at 250 Hz and above are most likely noise induced with choir singing as noise source. However, hearing losses at 125 Hz and possibly partial at 250 Hz are caused by some other effect. An (unproven) hypothesis is that singing might lead to increased endolymph pressure, and thus might cause hearing loss especially in the low-frequency region. Whether more choirs show similar hearing impairment and whether singing raises cerebrospinal fluid pressure will be the subject of further investigations.

Prognostic factors for swallowing rehabilitation following head and neck cancer surgery.

Thirty-two head and neck surgical patients with prolonged moderate to severe aspiration were assessed with videoendoscopic and videofluoroscopic swallowing studies to reveal all components of dysphagia and aspiration. All patients received functional swallowing therapy, and 75% of the patients regained full oral intake diet. The duration of non-oral feeding varied widely. The outcome of swallowing rehabilitation (success or failure, duration of non-oral feeding) was statistically correlated with preoperative tumour stage, patients' age, therapy onset, severity of aspiration and the results of the videofluoroscopic measurements of oral and pharyngeal transit time, pharyngeal delay time, duration of laryngeal closure and cricopharyngeal opening, hyoid and laryngeal elevation, presence or absence of a stenosis at the pharyngoesophageal segment. The following factors proved to be statistically significant for the prognostic estimate of swallowing rehabilitation: preoperative tumour stage, therapy onset, and severity of aspiration. For postoperative swallow recovery, an early therapy onset after thorough diagnostics with videoendoscopic and videofluoroscopic swallowing studies is recommended. Videofluoroscopic measurements will yield some prognostic estimate of oropharyngeal dysphagia and aspiration. Videoendoscopy, by it's availability and immediacy, proved to be useful for monitoring the course of rehabilitation.

Videoendoscopic biofeedback: a simple method to improve the efficacy of swallowing rehabilitation of patients after head and neck surgery.

The value of flexible videoendoscopy as a biofeedback tool in conservative swallowing rehabilitation of patients suffering from aspiration after head and neck surgery was examined. For this purpose, the outcomes of conventional swallowing therapy and of swallowing therapy with support of videoendoscopic biofeedback were compared. In the first 40 days of swallowing therapy, videoendoscopic biofeedback significantly increased the chance of therapeutic success, shortening the period of functional rehabilitation in comparison to conventional swallowing therapy. Limitations of this visual biofeedback procedure are poor cognitive skills of the patient, rejection of the procedure by the patient and local factors that make the positioning of the endoscope difficult.

Caroverine in tinnitus treatment. A placebo-controlled blind study.

This study was performed to examine whether a single infusion of caroverine, a quinoxaline-derivative, can be used successfully in the treatment of inner ear tinnitus. Microiontophoretical experiments in guinea-pigs have shown that caroverine acted as a potent competitive alpha-amino-3-hydroxy-5-methyl-4-isoxazone-proprionic acid (AMPA) receptor antagonist and, in higher dosages, a non-competitive N-methyl-d-aspartate (NMDA) antagonist. According to our working hypothesis of the pathophysiology of inner ear tinnitus (cochlear-synaptic tinnitus), these forms of tinnitus occur when the physiological activity of the NMDA and AMPA receptors at the subsynaptic membranes of inner hair cell afferents is disturbed. In total, 60 patients with inner ear tinnitus of assumed cochlear-synaptic pathophysiology were included in the study: after computerized randomization, 30 were treated with caroverine and 30 with placebo. For a response to have occurred, tinnitus had to show a reduction in both subjective rating and psychoacoustic measurement (tinnitus matching). In the caroverine group, 63.3% responded to therapy immediately after the infusion. In the placebo group, none of the patients treated showed a significant response according to the defined success criteria. The results confirm our working hypothesis on the genesis of cochlear-synaptic tinnitus.

Globus sensation: value of static radiography combined with videofluoroscopy of the pharynx and oesophagus.

Pharyngo-oesophageal abnormalities are found in a high proportion of patients with globus sensation. This study compares the diagnostic value of static single- and double-contrast radiography of the pharynx and oesophagus with videofluoroscopy and with videofluoroscopy combined with static radiography in these patients. Pharyngeal and oesophageal morphology and motor function were studied in 130 consecutive patients with globus sensation (46 males, 84 females; mean age, 47 years) by means of static single and double-contrast radiography and by videofluoroscopy. Videofluoroscopy revealed significantly more functional and structural abnormalities compared to static radiography. Pharyngeal and/or oesophageal disorders were found in 89 vs. 47 patients (chi2 [1] = 19.82, P = 0.0001), pharyngeal abnormalities in 54 vs. 27 patients (chi2 [1] = 13.5, P < 0.0002), and oesophageal abnormalities in 72 vs. 27 patients (chi2 [1] = 28.13, P < 0.0001). Videofluoroscopy combined with static radiography revealed significantly more abnormalities than videofluoroscopy alone (chi2 [1] = 4.23, P < 0.05), and assessed mucosal details more reliably than videofluoroscopy alone. The most frequent abnormalities found were nonspecific oesophageal motor disorders, pharyngo-oesophageal sphincter dysfunction, pharyngeal stasis, achalasia, and laryngeal penetration or aspiration of barium. In most patients with globus sensation, pharyngeal and/or oesophageal abnormalities can be detected radiographically. Videofluoroscopy revealed significantly more functional but not morphological abnormalities than did static radiography. Videofluoroscopic studies combined with static radiography had a higher diagnostic value than videofluoroscopic studies alone.

The Vienna Cochlear Implant in patients with obliteration of the cochlea.

Twelve deaf patients with obliterated or ossified cochleas received the extracochlear version of the Vienna Cochlear Implant. Four patients, 1 of them a child, developed open speech comprehension. Obliteration of the cochlea could not always be predicted by conventional tomography of the temporal bone. Short duration of deafness, wide dynamic range, and good ability of time resolution (small temporal difference limen [TDL]) are predictors for good postoperative results. Obliteration or ossification of the cochlea per se is no contraindication to cochlear implantation.

[Ultrasound diagnosis of cervical lymph node tuberculosis]. / Sonographische Diagnostik der Halslymphknotentuberkulose.

Lymph node tuberculosis is the most frequent tuberculous manifestation in the otorhinolaryngological area. In 13 patients with histologically verified tuberculous lymphadenitis cervical sonographic examinations revealed characteristic findings. The sonographic features typical for this disease were multiple, enlarged, conglomerating roundish and oval lymph nodes. These lymph nodes were hypoechoic, exhibited dorsal sound amplification and had sharp margins. With caseation, however, there were blurred borders. In cold abscesses an inhomogeneous texture with inhomogeneous shadows was found. Differential diagnosis included non-specific abscess-forming lymphadenitis, lymph node metastases and malignant lymphoma. A tentative diagnosis of cervical lymph node tuberculosis may be made due to the polymorphous sonographic pattern if history and clinical findings are taken into account. A proper histological and microbiological work-up is still essential for confirmation of the sonographic diagnosis.

Surgical voice rehabilitation after laryngopharyngectomy. Functional results of tracheo-hypopharyngeal shunts by jejunal transplantation.

For surgical voice rehabilitation after pharyngolaryngectomy we use the technique of placing a siphonlike jejunal interposition in order to create a tracheohypopharyngeal shunt. In this paper we present the functional benefits of this method of voice rehabilitation. The best results achieved are compared with a normal voice using the following test parameters: electroacoustic sound analyses and voice status. The findings show that the siphon voice is adequate for everyday purposes and can achieve useful social verbal communication.

[Tinnitus: causes, diagnosis, therapy]. / Tinnitus: Ursachen, Diagnostik, Therapie.

The symptom tinnitus may be due to a number of causes. Pathological processes within the sense-organ "ear" as well as non-otologic diseases may result in tinnitus. Therefore a thorough ENT diagnosis is necessary. The evaluation of the patient includes the history, ENT-status examination, audiological and vestibular findings, imaging investigations and, if necessary, examinations by other specialists. The therapy of tinnitus is difficult. If possible, the therapy should be causally orientated. Mostly, this is only the case with tinnitus caused by diseases of the external and middle ear. The therapeutic aim is the compensation of tinnitus. The most common type of tinnitus is of cochlear-synaptic origin. According to results of inner ear research new possibilities of pharmacologically influencing the cochlear synapse have been found. By intravenous application of the specific Quisqualate antagonist glutamic acid diethyl ester (GDEE) 77.2% of our patients with cochlear synaptic tinnitus noted a tinnitus reduction.