[The Freiburg monosyllabic speech test in noise]. / Der Freiburger Einsilbertest im Störschall.

BACKGROUND: Since 2017, the Freiburg monosyllabic speech test can be used in hearing aid evaluation with background noise in Germany. The results are used to compare the aided versus the unaided condition. However, there is currently no reference speech recognition curve for a comparison to listeners with normal hearing. OBJECTIVE: The goal is to establish a reference speech recognition curve for listeners with normal hearing and to analyze the perceptual equivalence of the test lists in continuous CCITT noise (according to Comité Consultatif International Téléphonique et Télégraphique). MATERIALS AND METHODS: The measurements were conducted at two different sites with 90 participants in total. Monosyllables and CCITT noise were presented at different signal-to-noise ratios by one loudspeaker from the front (S0N0). Individual and test-list specific discrimination functions were fitted to differentiate between the sites and among test lists. RESULTS: The reference speech recognition curve and its region of tolerance were established. Three perceptively deviating test lists (1, 3, 20) were identified. CONCLUSION: The reference speech recognition curve enables quantification of hearing difficulties with Freiburg monosyllables in noise and an estimation of the rehabilitation with hearing aids. This reference curve is only valid for frontal stimulus presentation (S0N0) and continuous CCITT noise. Perceptually deviating test lists were different to those in quiet, but partly correspond to literature data.

[CAS-System MKM(R): use and results in lateral skull base surgery]. / Einsatz des Navigationssystems MKM(R) im Bereich der lateralen Schädelbasis.

BACKGROUND: Computer assisted surgery has reached an advanced stage of development and offers new possibilities in daily surgical procedures. METHODS: The MKM(R) - is a navigation system fitted with a laser-guided, autofocus-microscope for referencing purposes. The coordinates can be set using various marker systems and a special workstation is used for preoperative planning. It is possible to add landmarks and display them in the surgeon's eyepiece. The clinical integration, the time required for the use of the navigation system and the intraoperative accuracy of the system were evaluated on the basis of 136 lateral skull base procedures. RESULTS: The degree of accuracy is determined by the type, amount and positioning of markers. The adjustment of reference points should be carried out following macrosurgery in order to avoid shifting factors. For an additional increase in accuracy, an improvement in the spatial resolution of the CT scans is required, with a section thickness of 1 mm and a pixel size of 0.5mm. The bone-anchored structures of the temporal bone do not underlie shifting or extensive intraoperative swelling. Skull base surgery is, therefore, ideally suited for the application of CAS. We found that registration was accurate to less than 1 mm (0.68 mm +/- 0.17 mm) and that the MKM(R) system made an additional contribution to surgical safety by identifying important structures. CONCLUSIONS: A practical accuracy found to be approximately one millimetre suggests that the non-invasive referencing system may be effective, accurate and useful for computer assisted identification of vital structures. We expect navigation systems to improve the quality and reduce the risks of surgical intraventions.

Transsphenoidal computer-navigation-assisted deflation of a balloon after endovascular occlusion of a direct carotid cavernous sinus fistula.

SUMMARY: A 49-year-old woman with a direct posttraumatic carotid cavernous fistula (CCF) was treated with detachable balloons via a transcarotid route. After the procedure, her intracranial bruit, conjunctival injection, and orbital congestion were cured, but the preexistent sixth nerve palsy deteriorated. CT showed one balloon positioned in the posterior portion of the right cavernous sinus and was regarded to be responsible for nerve compression. After surgical exposure by use of a transnasal-transsphenoidal approach under 3D navigation control, this balloon was deflated by puncture with a 22-gauge needle. The previously described symptoms resolved after balloon deflation. This report presents a rare complication of endovascular treatment of direct CCF and a new microsurgical approach to a balloon in a case of nerve compression.

The Nucleus Contour electrode array: a radiological and histological study.

OBJECTIVES: To evaluate the handling and insertion trauma of the recently developed Nucleus perimodiolar Contour electrode array (Cochlear Ltd., Pty, Lane Cove, New South Wales, Australia) in human temporal bones compared with the Nucleus standard straight electrode array. STUDY DESIGN: E-perimental control group. METHODS: Twenty-nine fresh-frozen bones were implanted with different electrode arrays by an experienced cochlear implant surgeon, and evaluated both radiologically and histologically. RESULTS: Intracochlear insertion of the standard Nucleus straight electrode array was found to be atraumatic, confirming previous findings in the literature. Insertion of the Nucleus Contour electrode array resulted in instances of localized basilar membrane penetration causing the electrode array to move from the scala tympani into the scala vestibuli. However, this trauma did not result in any observable damage to the osseous spiral lamina or the modiolus. Basilar membrane penetration was observed in six of eight cochlear bones when a standard cochleostomy size (approximately 0.8 mm) and site (anterior and superior to the round window) were used. However, when the surgical technique was modified to use a slightly larger cochleostomy ( approximately 1.8 mm) situated closer to the round window and employ a partial stylet withdrawal technique during electrode insertion, the frequency of penetrations was restricted to two of seven bones. This trauma rate is comparable to that observed with other cochlear implants designs. CONCLUSIONS: Following our results, the design of the Nucleus Contour electrode appears to fulfill the safety requirements for an intracochlear electrode array, provided that the surgical insertion technique is modified in the manner outlined.

Low-dose high-resolution CT of the petrous bone.

PURPOSE: To show that CT of the petrous bone can be realized using a low-dose technique. MATERIAL: and methods: A high-contrast phantom was scanned with 1.5 mm slice thickness and 60-510 mAs using the reconstruction algorithms standard, bone and edge. In 50 patients, the petrous bone was examined using the standard protocol at 510 mAS. Additionally, selected slices were made at 120 or 210 mAs. The resolution of relevant structures was compared. Phantom studies were repeated on a second CT-device; images of patients scanned with 80 mAs were analyzed in regard to resolution of osseous details. RESULTS: With the first CT-device structures of the phantom up to 0. 5 mm were depicted using 510 mAs and the edge kernel. With 120 mAs and the bone kernel structures of 0.6 mm could be distinguished. Although the same resolution was achieved with 60 mAs and the edge kernel, patient examinations showed a profound image noise. The results achieved with 120 mAs and the bone algorithm, however, were equal to that of 510 mAs. With the second device the same image quality was realized with only 80 mAs. CONCLUSION: CT-examinations of the petrous bone can be effected without loss of diagnostic information using only 15% of the radiation dose used for a standard brain examination.

Supratentorial primitive neuroectodermal tumours: diffusion-weighted MRI.

We report the clinical and pathological findings of supratentorial primitive neuroectodermal tumours (PNETs). These are rare, poorly differentiated, highly malignant neoplasms occurring primarily in young individuals. They frequently show dissemination to the spinal cord and sometimes also beyond neuraxis. Preoperative radiological diagnosis is difficult, due to the nonspecific CT and MRI characteristics. Our findings indicate that diffusion-weighted imaging (DWI) can be used to show the solid portion of the tumour preoperatively and to monitor postsurgical recovery. We describe the MRI findings in three patients with histologically confirmed supratentorial PNET, focussing on the role of DWI for improving the specificity of radiological diagnosis.

Diagnostic value of the fast-FLAIR sequence in MR imaging of intracranial tumors.

The aim of this study was to quantify imaging characteristics of fast fluid-attenuated inversion recovery (FLAIR) sequence in brain tumors compared with T1-postcontrast- and T2-sequences. Fast-FLAIR-, T2 fast spin echo (FSE)-, and T1 SE postcontrast images of 74 patients with intracranial neoplasms were analyzed. Four neuroradiologists rated signal intensity and inhomogeneity of the tumor, rendering of cystic parts, demarcation of the tumor vs brain, of the tumor vs edema and of brain vs edema, as well as the presence of motion and of other artifacts. Data analysis was performed for histologically proven astrocytomas, glioblastomas, and meningiomas, for tumors with poor contrast enhancement, and for all patients pooled. Only for tumors with poor contrast enhancement (n = 12) did fast FLAIR provide additional information about the lesion. In these cases, signal intensity, demarcation of the tumor vs brain, and differentiation of the tumor vs edema were best using fast FLAIR. In all cases, rendering of the tumor's inner structure was poor. For all other tumor types, fast FLAIR did not give clinically relevant information, the only exception being a better demarcation of the edema from brain tissue. Artifacts rarely interfered with evaluation of fast-FLAIR images. Thus, fast FLAIR cannot replace T2-weighted series. It provides additional information only in tumors with poor contrast enhancement. It is helpful for defining the exact extent of the edema of any tumor but gives little information about their inner structure.

TSE-sequences with spin-echo contrast.

The article presents a discussion of the basic signal behavior of contrast-modified RARE(TSE,FSE...)-sequences which have been modified such that the echo train used for image encoding is preceded by a long echo interval in order to introduce the T(2)-contrast of conventional spin-echo sequences while maintaining the high imaging speed of TSE. Sequences aimed at breathhold abdominal imaging as well as for the detection of hemorrhages in the CNS have been implemented and optimized. The significant difference in image contrast at identical echo times compared to unmodified TSE is demonstrated for different tissues.

Contribution of low-dose CT-scan protocols to the total positioning error in computer-assisted surgery.

PURPOSE: To quantify the contribution of a computed tomography (CT) scan to navigation accuracy in computer-assisted surgery. METHODS: Eighty-eight patients undergoing computer-assisted facial or skull-base surgery were fitted preoperatively with 4 to 12 markers, either attached to the skin (n = 20) or fixed in the osseous skull (micro-screws; n = 68). Low-dose high-resolution spiral CT was achieved with 25-cm field of view (FoV), 1-mm slice thickness, 2-mm table increment, 1-mm reconstruction interval, 140 kV, 40 mA, bony reconstruction algorithm, and 180 degrees reconstruction profile (effective slice thickness = 1.8 mm). During surgery, navigation accuracy was evaluated using two navigation systems. RESULTS: Mean error was 0.66 mm for osseous markers and 1.58 mm for cutaneous markers. Both values are markedly smaller than the effective slice thickness of the scan protocol used. Radiation exposure of the patient for the entire examination never exceeded that necessary for one single 10-mm slice in a standard brain examination. Despite the reduced dose, landmarks and fiducials were precisely identified in all cases. CONCLUSIONS: The CT-induced positioning error in the Z-axis is considerably reduced by overlapping raw data reconstruction. For 1-mm slices and a 25-cm FoV, the average scan-induced positioning error is about 0.3 mm. Spatial resolution is not affected by the low dose applied. For MRI-based navigation, a 1 mm3 voxel size is the best compromise between signal-to-noise ratio, spatial resolution and scan time.

A syndrome of psychosis following discontinuation of an estrogen-progestogen contraceptive and improvement following replacement: A case report.

Mild forms of psychosis associated with low estrogen levels during the perimenopause are relatively frequent. There is scarce data on severe forms of psychosis in these conditions. We report the case of a 51-year-old woman with no previous psychiatric history who amputated her hand in a 'psychotiform' state after discontinuation of her contraceptive medication. Having subsequently jumped out of a window, she suffered a fracture of the dens with central spinal cord injury and symptoms of cruciate paralysis. The patient stabilized under a combined therapy with estrogen-progestogen substitution, antipsychotic medication and add-on oxcarbazepine.

Comparison of the late results of mandibular reconstruction using nonvascularized or vascularized grafts and dental implants.

PURPOSE: This study evaluates contour restoration in segmental defects of the mandible and the survival rate of endosseous implants placed into these reconstructions. PATIENTS AND METHODS: Forty-four patients with 23 nonvascularized grafts and 21 patients with vascularized bone flaps were included in the study. The lateral and the sagittal extension of the contour of both the mandibular bone and the overlying soft tissues was determined from serial computed tomography (CT) scans in defined planes through the reconstructed mandible. The success rate of dental implants was determined by a life-table analysis. RESULTS: Average lateral deviation of the reconstructed side from the nonreconstructed side was 4.3 mm (nonvascularized grafts) and 5.6 mm (vascularized grafts). The soft tissue contour followed the skeletal contour quite closely, with slightly smaller degrees of deviation. Asymmetry was greatest in the area of the horizontal ramus. In some cases, skeletal deviation was intentionally produced to compensate for a soft tissue deficit on the reconstructed side. However, in some cases, a major deviation of bone contour was associated with considerable deviation of the soft tissue contour (maximum, 10.5 mm). The cumulative implant success rate was 100% after 5 years and 60.3% after 10 years. None of the seven implant failures accounted for prosthetic failure. CONCLUSIONS: Although there are minor differences, both nonvascularized and revascularized grafts allow for satisfactory contour restoration in segmental reconstructions of the mandible. Implants placed into these grafts provide a reliable basis for dental rehabilitation.

Compositional, structural, and functional alterations in pulmonary surfactant in surgical patients after the early onset of systemic inflammatory response syndrome or sepsis.

OBJECTIVES: Sepsis is one of the most important predisposing factors for the development of the acute respiratory distress syndrome (ARDS). Alterations of pulmonary surfactant contribute in the pathogenesis of ARDS. However, little is known about surfactant in patients with less severe grades of lung injury related to sepsis or systemic inflammatory response syndrome (SIRS). Therefore, the purpose of this study was to characterize endogenous surfactant in surgical intensive care patients with sepsis or SIRS. DESIGN: Prospective, observational study. SETTING: University-affiliated, interdisciplinary intensive care unit. PATIENTS: Eleven patients after major surgery with SIRS or sepsis included within 12 hrs of onset and 11 controls without infection or lung disease. INTERVENTIONS: Operating room and standard intensive care unit management. MEASUREMENTS AND MAIN RESULTS: Four serial bronchoalveolar lavage samples (BAL) were recovered over 7 days from the patients and single BAL samples were obtained from controls. BAL cells, total protein, surfactant-associated protein A (SP-A), surfactant alveolar transition forms, and surface activity were analyzed. Two of 11 patients met criteria for acute lung injury and six of the 11 patients met ARDS consensus conference criteria but acute lung injury or ARDS was not persistent. The mean Pao2/F(IO)2 for the patients over 7 days was 253.2+/-15.1 (SEM) and Murray's lung injury score was 1.12+/-0.12, indicating mild-to-moderate lung injury. BAL neutrophil counts were increased (p< .01), and the ratio of poorly functioning light aggregate surfactant to superiorly functioning heavy aggregate surfactant was increased compared with controls (0.32+/-0.06 vs. 0.09+/-0.01, p < .05). SP-A was decreased (1.9+/-0.4 vs. 3.5+/-0.6 microg/mL of BAL, p< .05) and there were increases in the ratios of phospholipid to SP-A (p < .05), protein to SP.A (p < .01), and protein to phospholipid (p < .05). The surface tension-lowering ability of purified heavy aggregate surfactant was significantly impaired (15.6+/-1.6 vs. 2.8+/-0.6 milliNewtons/m, p< .05). CONCLUSIONS: These observations show that surgical patients with SIRS or sepsis who have mild-to-moderate lung injury develop surfactant dysfunction detectable within 7 days of onset. We propose, therefore, that therapeutic strategies to modulate these severe surfactant abnormalities should be considered, as these strategies may have the potential to reduce lung injury, which is associated with a high mortality in sepsis.

[Window width as a dosage-relevant factor in high-contrast structures in CT]. / Fensterweite als dosisrelevanter Faktor bei Hochkontraststrukturen in der CT.

PURPOSE: To establish the relationship between window width and dose to be applied in low-dose high-resolution (HR) computed tomography (CT). MATERIAL AND METHODS: Low-dose HR CT-scans of the petrous bone displayed with different window values were analyzed for identification of osseous details. For two homogeneous phantoms, standard deviation of CT-numbers were measured in order to calculate the fraction of pixels not displayed within the correct grey level. RESULTS: The broadest window used (4000 HU) allowed the best distinction of osseous structures. Standard deviation of CT-numbers in the phantoms varied between 28.5 and 43.2 (mean = 33.6) HU. Thus, only 26.6% of all pixels are displayed in the correct grey level for a 1000 HU-window, but 82.3% for a 4000 HU-window. CONCLUSION: When using low doses and HR-reconstruction algorithms, large window widths allow for an optimal assessment of high-contrast structures. Under these conditions, even high standard deviations of the CT-numbers will not compromise image evaluation. Due to the restricted number of grey-levels that can be distinguished by the human eye, image noise is compressed into a smaller number of discernable grey-levels. Because of the inverse square root function between dose to be applied and window width used (derived in the article), an even minor enlargement of window permits considerable reductions of patient exposure while the discernable image noise remains constant.

[Facial asymmetry after vascular pedicled muscle transfer. Additional criterion for evaluating outcome in managing chronic facial paralysis]. / Gesichtssymmetrie nach gefässgestieltem Muskeltransfer. Zusätzliches Kriterium zur Erfolgsbeurteilung bei der Versorgung langbestehender Fazialisparesen.

Today neurotization and muscle transplantation are considered an ideal method of reconstructing the function of the facial nerve and the mimetic muscles in long-established facial palsy. Transplantation of the gracilis muscle as a segmental muscle provides an appropriate size for the face; however, determining the amount of muscle is difficult in order to obtain the desired dynamic and symmetric results. Prompted by the question of an "ideal" transplant size, a retrospective study was undertaken. Since 1991, 11 microneurovascular gracilis muscle transfers have been performed in 10 patients with long-established facial palsy (one patient underwent an additional transfer due to excessive scarring in a severe case of neurofibromatosis). Computed axial tomography scans were performed on six patients using a method for obtaining muscle-volume measurements of corresponding areas in each individual by using bony landmarks for reference. Cross-section area measurements by a digitalized mode were obtained from each scan, determining 20-70 Hounsfield units as appropriate for muscle tissue. Muscle-volume measurements ranged on the transplantation sites between 3.85 and 62 cm3 compared to 1.4 and 22.3 mm3 for the corresponding sites. The increments in muscular tissue by a factor between 2 and 3 are due to an increase in each single scan of the corresponding sides: when comparing the corresponding operated and unoperated sides in each patient, soft-tissue volumes were significantly (P < 0.005) elevated on the operated side. The findings presented in this study demonstrate not only encouraging functional results, but also show significant improvement of facial symmetry at rest. The results of our investigation support those of other authors, who also saw the main difficulty as determining the appropriate graft size. Secondary corrective procedures of the muscle puts the pedicle at risk of vascular and neural damage. Meticulous shaping of the graft and proper fixation and suspension technique cannot be overemphasized.

[Preserving and improving the profile in primary and secondary orbital reconstruction]. / Profilerhalt und -verbesserung bei primärer und sekundärer Orbitarekonstruktion.

Computed tomographies in 15 patients following reconstruction of multiple-wall defects of the orbit following trauma and tumor demonstrate a correlation between moderate overcorrection of the orbital bony frame and a good aesthetic profile. Reconstruction of the deep orbital cone, the transition level between the orbital floor and medial orbital wall, as well as the convex shape of the medial orbital wall, are of great importance for good results.

Percutaneous superselective coil-embolization of intrarenal arteriovenous fistulas. Case reports.

PURPOSE: To evaluate the role of percutaneous transcatheter coil-occlusion in the management of uncontrollable postoperative hematuria due to iatrogenic arteriovenous (AV) fistulas. MATERIAL AND METHODS: In 2 patients, AV fistulas were occluded with percutaneous catheter-guided superselective coil embolization. RESULTS: In both cases, occlusion of the AV fistulas was successful. Only small parts (less than 10%) of the parenchyma had to be sacrificed. No hypertension occurred. CONCLUSION: Percutaneous coil embolization is a useful alternative to surgery in cases of postoperative AV fistulas. Hematuria can be effectively controlled without resulting hypertension.