Selected ENT symptoms in functional disorders of the upper cervical spine and temporomandibular joints.

This paper discusses otorhinolaryngological symptoms associated with functional disorders of the upper cervical spine. Hints aimed to avoid misdiagnoses of cross-organ otorhinolaryngological symptoms as phobic or psychogenic disorders are presented. Clinically relevant neuroanatomical convergence of the upper cervical spine (occiput to C3) is fundamental for the interpretation of functional otorhinolaryngological symptoms. Based thereon, evidence for the most common cervical differential diagnoses of dizziness, tinnitus, dysphagia, and craniomandibular dysfunction is presented separately. The corresponding therapeutic options and their contraindications are discussed in the concluding chapter. The importance of interdisciplinary cooperation in related fields is emphasized.

[The subjective perception of the vertical-a valuable parameter for determination of peripheral vestibular disorder in Menière's disease in the chronic phase?] / Die subjektive Vertikalenwahrnehmung ­ ein wertvoller Parameter für die Bestimmung der peripher vestibulären Störung bei M. Menière in der chronischen Phase?

The perception of verticality is mainly based on utricular afferent signals and central processing of the transmitted signals. However, there are also extracranial receptors that make a considerable contribution to the perception of verticality. With the subjective visual vertical (SVV) for the utricle and the subjective trunk vertical (STV), two different parameters are available that are not fully understood in terms of their response to physiologic and pathologic changes. The aim of this work was to determine SVV and STV under certain positions of the head and trunk as well as under the influence of Menière's disease (MD) as a chronic vestibular disease. In a prospective clinical study, 26 patients with MD and 39 healthy volunteers were recruited. Subjects were examined with C­SVV glasses and with the three-dimensional trunk excursion chair, while head and torso positions were varied. In both groups, SVV determination is clearly more accurate with an earth-vertical head alignment than with a lateral head tilt (right: MM and control group: p = 0.001; left: MM p = 0.001, control group p = 0.000). If the torso is deflected laterally and the head is held straight, the SVV is significantly more accurate (left p = 0.003, right p = 0.015). The SRV was not affected by the presence of unilateral MD, while pathologic SVV values, if present, indicated the affected side. The results of our study support the assumption that in addition to SVV, SRV is an independent parameter for verticality perception and differs from the SVV in terms of lateralizing a peripheral vestibular deficit. These results suggest that the STV may depend not only on utricular function but also on extracranial afferent signals, and not be significantly altered by the presence of a hydropic peripheral vestibular lesion.

[Pilot study: Determination of the subjective trunk vertical in upright head position]. / Pilotstudie: Bestimmung der subjektiven Rumpfvertikalen in lotrechter Kopfposition.

BACKGROUND: Consensus has been established that the subjective vertical (SV) is a result of multimodal sensory integration. In order to be able to calculate the vestibulocervical sensory competence for the SV, the isolated subjective trunk vertical axis (STV) was measured under conditions of vertical head fixation. MATERIALS AND METHODS: Young, healthy volunteers (n = 49) were compared to older, healthy volunteers (n = 50) on a three-dimensionally deflectable (tilt, torsion, pitch) trunk excursion chair in which the volunteer's head remains in an upright position. Another young, healthy group was divided into a placebo (n = 27) and a monophasic cervical transcutaneous electrical nerve stimulation (C-TENS; n = 22) group to examine verticality perception. RESULTS: In the STV after trunk pitch, age was a significant variable (p = 0.021). The older, healthy group of subjects missed the physical vertical by an average of 1.8° more than the younger group. Only the placebo group showed an average improvement in STV of 4.3° after torsion. CONCLUSION: Apart from the macular organs the vestibulocervical sensory afference is involved in finding the trunk vertical. A difference in age to the disadvantage of the older healthy subjects was observed, as well as a lack of learning success after applied C­TENS. The presented pilot study was able to confirm that a correct vertical trunk sensation is caused by vestibulocervical sensory afference in upright head position.

[Selected otorhinolaryngological symptoms in functional disorders of the upper cervical spine and temporomandibular joints]. / Ausgewählte HNO-Symptome bei funktionellen Störungen der oberen Halswirbelsäule und der Kiefergelenke.

This paper discusses otorhinolaryngological symptoms associated with functional disorders of the upper cervical spine. Hints aimed to avoid misdiagnoses of cross-organ otorhinolaryngological symptoms as phobic or psychogenic disorders are presented. Clinically relevant neuroanatomical convergence of the upper cervical spine (occiput to C3) is fundamental for the interpretation of functional otorhinolaryngological symptoms. Based thereon, evidence for the most common cervical differential diagnoses of dizziness, tinnitus, dysphagia, and craniomandibular dysfunction is presented separately. The corresponding therapeutic options and their contraindications are discussed in the concluding chapter. The importance of interdisciplinary cooperation in related fields is emphasized.

Impact of Mixed Xenogeneic Porcine Hematopoietic Chimerism on Human NK Cell Recognition in a Humanized Mouse Model.

Mixed chimerism is a promising approach to inducing allograft and xenograft tolerance. Mixed allogeneic and xenogeneic chimerism in mouse models induced specific tolerance and global hyporesponsiveness, respectively, of host mouse natural killer (NK) cells. In this study, we investigated whether pig/human mixed chimerism could tolerize human NK cells in a humanized mouse model. Our results showed no impact of induced human NK cell reconstitution on porcine chimerism. NK cells from most pig/human mixed chimeric mice showed either specifically decreased cytotoxicity to pig cells or global hyporesponsiveness in an in vitro cytotoxicity assay. Mixed xenogeneic chimerism did not hamper the maturation of human NK cells but was associated with an alteration in NK cell subset distribution and interferon gamma (IFN-γ) production in the bone marrow. In summary, we demonstrate that mixed xenogeneic chimerism induces human NK cell hyporesponsiveness to pig cells. Our results support the use of this approach to inducing xenogeneic tolerance in the clinical setting. However, additional approaches are required to improve the efficacy of tolerance induction while ensuring adequate NK cell functions.

[The vestibular craniovertebral joints]. / Die vestibulären Kopfgelenke.

INTRODUCTION: The significance of cervical proprioception for human balance has thus far not been sufficiently elucidated. The aim of this study was to provoke selective cervico-vestibular stimulation using the trunk excursion test (TET) we ourselves constructed. This chair is designed to enable evaluation of cervico-ocular reactions during isolated trunk excursion and possible effects of aging. METHODS: The previously used head excursion test (HET) was statistically compared to the TET. In both methods, 100 healthy subjects of two age groups (group(26): median age = 26 years, n = 50; group(50): median age = 50 years, n = 50) were randomized for comparison of similar neck-to-trunk-positions. RESULTS: HET enabled detection of significant nystagmus modulation in horizontal and vertical dimensions; whereas in pure cervical stimulation using the new TET, this was only evident in the horizontal dimension and only during trunk torsion. Comparison of the two methods confirmed significantly stronger nystagmus modulation through head excursion. In terms of the HET, group(50) showed significantly more vertical nystagmus activity than group(26). However, no significant difference was found between the groups in terms of their reactions to trunk excursion in the TET. In a group-specific comparison of the methods, group(26) showed a significant increase in horizontal nystagmus in head compared to trunk excursion, whereas group(50) generally displayed a significantly greater response to provocation by head excursion in HET. Analysis of the significant vertical nystagmus modulation produced with the TET method showed predominance of upbeat- (UBN) over downbeat-nystagmus (DBN). Through head excursion with the HET, DBN was more frequently evoked in group(50) than in group(26). No significant age-dependent difference could be derived in UBN. CONCLUSION: The results of the pilot study indicate that head-to-trunk provocation is a suitable means of evaluating cervicotonic provocation nystagmus. Only by evaluation of adequate excursion limits and consistent analysis of patients with cervical deficiency can the effects of the method be further assessed.

[Somatosensoric tinnitus]. / Somatosensorischer Tinnitus.

Tinnitus can be caused or triggered by functional disorders of the cervical spine, temporomandibular joint or any other musculoskeletal structure of the neck or head. This special form of tinnitus is called somatosensory tinnitus and represents a discrete subgroup among the different kinds of tinnitus. Distinctive for this kind of tinnitus are alterations in volume and frequency during movement or the stimulation of certain muscles and joints. This can be evaluated using a structured testing method. To be able to easily perceive tinnitus modulations, the test must be performed in total silence. Effective treatment modules are physiotherapy, osteopathy, neural therapy, and Qigong for self-help.

[Direct hearing aid provision by ENT specialists: Recommendations for prevention and treatment of complications after taking ear impressions]. / HNO-ärztliche Hörgeräte-Direktversorgung: Empfehlungen zur Vermeidung und Behandlung von Komplikationen bei der Ohrabdrucknahme.

In times of budgeting, rising costs and monetary losses, an increasing number of ENT specialists considers the hearing system sector due to the distinct undersupply and the expected demographic development to be a market of the future and appropriate to enlarge their field of competence. Exact prevalence of direct hearing aid provision by German otorhinolaryngologists as well as its complication rate are not well-known. Retrospectively, all patients were evaluated who presented at our department with complications in the context of outpatient direct hearing aid supply within the last 3 years. Inappropriate fitting contains the danger of malformed or displaced ear impressions with various injury patterns comprising the external auditory canal, tympanic membrane and ossicular chain. Practical advices for prevention of complications include the accurate modeling and placement of sufficient impression pads behind the second bend of the auditory canal, using an adequate type of impression material as well as performing the correct application procedures. Recommendations for diagnostic patterns and treatment of complications after taking ear impressions are presented, the differences between German "traditional" and "direct" hearing aid provision are critically discussed.

High-dose intravenous interferon beta in patients with neutralizing antibodies (HINABS): a pilot study.

BACKGROUND: Neutralizing antibodies (NABs) against interferon beta (IFNbeta) are associated with a loss of IFNbeta bioactivity and clinical effectiveness. To date, there are no anti-NAB strategies available. The primary objective of this trial was to investigate whether intravenous IFNbeta-1b can restore bioactivity in NAB-positive patients with MS. METHODS: NAB-positive patients with MS were treated with 8 MIU IFNbeta-1b s.c., 8 MIU i.v., and 16 MIU i.v. Each application was preceded by a wash-out period of 1 week. Blood samples were collected before, 3, 12, and 24 h after each administration. Myxovirus protein A (MxA) RNA and protein levels were determined. The study has been approved by the local ethics committee. RESULTS: Five patients completed the study. NAB titers ranged from 42 to 4482 neutralizing units. Median MxA protein (1821, range 12-3234) and RNA (2186, range 114-7525) area under the curve levels for the four measurements at each IFNbeta injection were significantly higher after i.v. application of 16 MIU as compared with both 8-MIU dosages, which were 743 (0-2709) for MxA protein after 8 MIU i.v. and 254 (0-1200) after s.c., and 1763 (25-7188) for MxA RNA after 8 MIU i.v., and 557 (5-2265) after s.c. applications. NAB titers decreased significantly and transiently after infusion of 16 MIU IFNbeta-1b but not after both forms of 8 MIU applications. Typical side effects could be controlled by paracetamol. No allergic reaction was observed. DISCUSSION: The results indicate that i.v. administration of IFNbeta can restore bioavailability of IFNbeta in patients with NABs.

[Influence of different head-trunk positions to the upbeat-nystagmus]. / Einfluss der Kopf-Rumpf-Positionsänderung auf den Upbeat-Nystagmus.

The neck torsion test (NTT) can be used to evaluate the cervico-ocular reflex (COR). We think there are two main reasons why NRT has failed to gain general acceptance in clinical practice: the test does not fully exploit the somatosensory examination potential, and electronystagmography has been most commonly used but is inferior to videonystagmography for a very low-amplitude nystagmus. These considerations have led us to develop a modified neck torsion test (mNTT) with three-dimensional video-oculographic (3D-VOG) recording. Sensors on the video glasses enable three-dimensional and continuous registration of the head position. Horizontal, vertical and rotatory eye movements are determined in six different head-body positions (right/left head tilt, ante/retroflexion of the head, and right/left body rotation). The basis for assessing the mNTT is described in detail. We used the mNTT to examine prospectively compensated, vestibularly deficient (n = 52), and cervically deficient (n = 93) patients with vertigo against a control group (n = 22). Our results show that upbeat-nystagmus (UBN) significantly differentiated the groups. This occurs most frequently in the tonic analysis phase of head inclination and reclination. UBN is differential-diagnostically discussed on the basis of these examination findings, and its cervical origin is elucidated with the aid of model conceptions. We conclude that our modified NRT is an improved instrument for COR determination. A suspected cervical somatosensory reduction warrants testing particularly for UBN.

[Cervicoproprioceptive provocation of horizontal and vertical nystagmus in test subjects]. / Zervikopropriozeptive Provokation von horizontalen und vertikalen Nystagmen bei Probanden.

BACKGROUND: The cervico-ocular reflex (COR) has been confirmed in numerous animal experiments. On the other hand, its clinical assessment is disputed. Anteflexion and retroflexion of the head are among the main movements of the atlanto-occipital joint. We investigated whether these head movements produce neck proprioceptive stimulation in the vestibular system. SUBJECTS AND METHOD: We investigated 50 students under the experimental conditions of strictly cervical provocation. The trunk was rotated, anteflexed, and retroflexed into its end positions for 60 s under video-oculographic control without changing the head-space relationship. During the cervical provocation, horizontal, vertical, or rotational nystagmus within a time window of 5-30 s after the start of the provocation was detected as a target parameter. RESULTS: The results showed that, compared to the baseline, there was a significant increase in vertical and horizontal nystagmus after the cervical provocation. The horizontal nystagmus reaction, rather than the vertical, was increased significantly by the maximum trunk rotation. In addition, we found a significant amount of vertical rather than horizontal nystagmus under trunk flexion provocation. CONCLUSION: Under cervical provocation of test subjects, we were able to elicit horizontal and vertical nystagmus (upbeat nystagmus) via cervico-ocular roots. Due to a neck proprioceptive activation of the vestibular system we interpret our result as a "cervico-tonic provocation nystagmus".

[Picrotoxin in the treatment of Menière's disease]. / Picrotoxin in der Therapie des Morbus Menière.

OBJECTIVE: In medical long-term treatment of Menière's disease picrotoxin suppositories are an uncommon method of prophylaxis. In spite of its empirical benefit in clinical use and its lack of side effects, there are few clinical studies about the therapeutical effect of picrotoxin. In this study we evaluate the effectiveness of picrotoxin compared to the therapy with betahistine in Menière's disease. MATERIAL AND METHODS: In a prospective clinical trial we examined 41 patients, 18 of them were treated with betahistine 3x12 mg, 23 had a therapy with picrotoxin-suppositories at 0.001 g three times a week. Frequency and intensity of the vertigo attacks were evaluated before and under treatment. Mean follow up time was 12 months. RESULTS: In both groups a reduction of the attacks' frequency and intensity could be noticed, which was statistically significant for all the two groups. Thus, in the course of the treatment we observed a significant stronger effectiveness of picrotoxin, regarding the frequency and intensity of vertigo attacks. Discussing our own results we review the state of the art in medical long-term treatment in Menière's disease. CONCLUSION: Because of its clinical benefit and the lack of side effects Picrotoxin is a reasonable alternative in medical long- term treatment of Menière's disease, which should have an important role in the treatment cascade.

[Investigations concerning the head-trunk-coordination]. / Untersuchungen zur Kopf-Körper-Koordination.

BACKGROUND: In the assessment of vertigo patients with suspected cervicocephalic somatosensory deficit, the studies published thus far have focused on reflectory systems like the cervico-ocular reflex or the postural systems. Our study examines the cervicocephalic kinesthetic sensibility of head and body coordination. We therefore introduce two preliminary test series: the "subjective zero chin-knee-angle of the occipital joints" and the "saccadic repositioning during trunk rotation". METHODS: Subjective recordings of dizziness complaints were done using the Dizziness Handicap Inventory. PATIENTS: The study population consisted of 24 patients with palpatory cervicocephalic somatosensory deficit (group I) and 23 patients with a central vestibular compensated unilateral vestibular deficit (group II). Twenty-two healthy patients served as controls. The aim of the study is to provide a detailed examination of the "subjective zero chin-knee-angle of the occipital joints" as well as a detailed discussion of "saccadic repositioning with trunk rotation" by three-dimensional videooculography (3D-VOG). RESULTS: We were able to separate patients with a cervicocephalic somatosensory deficit with the first test procedure and differentiate them from groups II and III. The second test procedure shows a significant difference between groups I and III. CONCLUSION: We conclude from the group difference that the recording of cervicocephalic kinesthetic sensibility is a further indication of disturbed cervical proprioception.

Low-frequency distortion product otoacoustic emission test compared to ECoG in diagnosing endolymphatic hydrops.

Previous studies assumed that specific audiometric measures like low-frequency biasing were noninvasive and inexpensive techniques for diagnosing endolymphatic hydrops (EH). The aim of this study was to compare the results of low-frequency DPOAE (LF-DPOAE) with those of transtympanic electrocochleography (ECoG) in patients with Menière's disease (MD). The prospective study included 50 patients, 22 to 72 years old, who were diagnosed with Menière's disease according to the criteria laid down by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) in 1995. LF-DPOAE and ECoG were performed on the same day after standard audiometry. Enlarged amplitude of summation potential to action potential ratio was used as the diagnostic criterion for EH. The results were compared to those of LF-DPOAE. In this audiometric examination we used the modulation index (MI) to detect EH if MI < 0.5. ECoG yielded a result in 46 of the 50 patients examined. An enlarged SP/AP ratio was found in 23 patients (50%). The results of 33 patients could be compared, i.e. assessable results in both tests. The two tests yielded the same results in 13 patients and different ones in 20 patients. ROC analysis and Mann-Whitney statistics showed no significant correlation between the two tests. With ECoG as the gold standard for verifying EH, we found that LF-DPOAE is not yet a suitable method for diagnosing EH.

[Is orbital exenteration indicated for extensive primary mucosal melanomas of the sinunasal system?]. / Ist eine Exenteratio orbitae bei einem ausgedehnten primären Schleimhautmelanom des sinunasalen Systems angezeigt?

Primary mucosal melanomas are most frequently localized in the sinunasal system. Orbital involvement must be excluded in the mostly advanced tumor stage. The aim of our study was to find possible indications for orbital exenteration in the T3-4 sinunasal tumor stage. We evaluated 14 treatment courses at our department from 1988 to 2004. The analysis disclosed orbital involvement in 43 % of the patients. The one patient submitted to orbital exenteration had a survival of only 28 months, which was not relevantly longer than in the other 9 patients with a T3-4 tumor stage (median survival of 27 months) or to the two patients with purely palliative treatment (survival of 10 and 21 months). We conclude that, due to the high generalized metastasis rate, radical surgical procedures can only prolong survival in individual cases of advanced-stage sinunasal tumors. Orbital decompression should be considered with reference to the quality of life.

Spatial organisation of microbiota in quiescent adenoiditis and tonsillitis.

BACKGROUND: The reasons for recurrent adenotonsillitis are poorly understood. METHODS: The in situ composition of microbiota of nasal (5 children, 25 adults) and of hypertrophied adenoid and tonsillar tissue (50 children, 20 adults) was investigated using a broad range of fluorescent oligonucleotide probes targeted to bacterial rRNA. None of the patients had clinical signs of infection at the time of surgery. RESULTS: Multiple foci of ongoing purulent infections were found within hypertrophied adenoid and tonsillar tissue in 83% of patients, including islands and lawns of bacteria adherent to the epithelium, with concomitant marked inflammatory response, fissures filled with bacteria and pus, and diffuse infiltration of the tonsils by bacteria, microabscesses, and macrophages containing phagocytosed microorganisms. Haemophilusinfluenzae mainly diffusely infiltrated the tissue, Streptococcus and Bacteroides were typically found in fissures, and Fusobacteria,Pseudomonas and Burkholderia were exclusively located within adherent bacterial layers and infiltrates. The microbiota were always polymicrobial. CONCLUSIONS: Purulent processes persist during asymptomatic periods of adenotonsillitis. Most bacteria involved in this process are covered by a thick inflammatory infiltrate, are deeply invading, or are located within macrophages. The distribution of the bacteria within tonsils may be responsible for the failure of antibiotic treatment.

Snoring noise pollution--the need for objective quantification of annoyance, regulatory guidelines and mandatory therapy for snoring.

Habitual snoring without episodes of apnea or hypoventilation and without respiratory related arousals is considered to be annoying and without any need for treatment. However, studies seem to suggest an enormous psychosocial impact of annoyance for the bed partner. Apart from subjective questionnaires there still exists no generally accepted mode of measurement that can describe snoring objectively. We therefore adapted methods developed for environmental medicine and established a new snore score using psycho-acoustic parameters. For quantification of snoring noise we conducted nocturnal measurements in 19 habitual snorers. Free-field snore sounds were acquired with two low-cost non-contact microphones and transferred to a PC (sampling frequency 11 kHz). The data were recorded, analysed and stored automatically using a MATLAB script. Following the analysis of sound characteristics and levels, the score was computed from relevant parameters containing the rating level (L(R)), maximum level, two percentile levels for frequent maxima (L(5)S; L(1)) and snoring time. The determined values substantially exceeded the prescribed limits defined by WHO noise guidelines, and mainly affected the equivalent continuous sound exposure level, rating level and the immission standard values of brief noise peaks, whose maximum was exceeded by up to 32 dB(A). The Berlin snore score illustrated the objective acoustic annoyance on a scale from 0 to 100. It allows inter-individual comparison and objectifies the need for therapy. The clinical applicability of evaluating the reduction of snoring after surgical therapy is discussed exemplarily. The presented measuring method was found to be suitable for quantifying snoring noise and can be easily integrated into existing polysomnographic applications. In the case of habitual snoring with objective evidence of psychosocially disturbing acoustic annoyance, health fund providers should assume the costs of mandatory medical therapy.

[The ti-epiplating system in bone anchored hearing AIDS]. / Das Ti-Epiplating-System für die Knochenverankerung von Hörhilfen.

The advent of bone-anchored hearing aids with titanium implants has markedly improved patient management. There are two systems on the market for performing the requisite osseointegration. The aim of our study was to evaluate the Ti-Epiplating system, since no data have been published on this in the literature thus far. Between November 2002 and March 2005, we anchored the BAHA snap coupling via the Ti-Epiplating system in 8 patients in a single session. The patients were followed-up at regular intervals to assess clinical and audiometric results and subjective satisfaction. The postoperative hearing threshold with the BAHA was in the former bone conduction range. In the Freiburg speech test, a significant improvement was found for monosyllables (free-field), and the hearing loss for numbers showed a mean reduction from 75 to 30 dB. There has been no implant loss in our collective thus far. Good to very good results were evaluated for the quality of life in the "International Inventory of evaluation of hearing aids" (IIEH). Clinics that use Medicon's osteosynthesis system can safely and reliably achieve inexpensive and audiometrically successful BAHA management by a comparatively simple surgical procedure.

[Problems of hyomandibulopexia in patients with OSAS]. / Probleme der hyomandibulären Pexie bei Patienten mit OSAS.

In cases of obstructive sleep apnea syndrome (OSAS) with intolerance of n-CPAP (nasal continuous positive airway pressure) treatment, hyoidthyroidpexia (synonym: hyoid suspension) has recently been advocated by some authors as a valuable surgical option. Despite a basically positive assessment, there is a risk of hindrance to the speaking and swallowing function. Moreover, the thyroid cartilage seems to be too weak for fixation of the hyoid with its complex muscular attachments. This reduces the likelihood of achieving positive long-term results. Considering aspects of preserving laryngeal function, we are reporting on 7 patients submitted to a hyomandibulopexia. This intervention counteracts the tendency of the tongue base to collapse by ventrolateral traction on the hypoglossal muscle via the severed greater horn of the hyoid. We have thus far had to correct our surgical procedure three times because of methodological problems in the postoperative phase. Specific problems with surgical materials like steel wire or Goretex are discussed. In conclusion, we explain why we consider a bone anchored Kevlar suture (FASTak of Arthrex) to be suitable for this operation. Considering functional aspects, our polysomnographic and phoniatric follow-up examinations point to a less traumatic surgical procedure with promising treatment results.