Closing sounds and related complaints after heart valve replacement with St Jude Medical, Duromedics Edwards, Björk-Shiley Monostrut, and Carbomedics prostheses.

OBJECTIVE: To measure the noise produced and related subjective complaints after implantation of four different mechanical heart valve prostheses and to identify further factors related to the patient and prosthesis that influence noise generation and complaints. DESIGN: Sound pressure was measured 5 and 10 cm and 1 m from the point of maximal impulse on the body surface by a calibrated meter in quiet rooms with either a decibel(A) filter or octave filters. The patients were asked about their complaints and examined physically. SETTING: The measurements were conducted in silent rooms of ear, nose, and throat departments. The patients had been operated on either in a university hospital or a community hospital. MAIN OUTCOME MEASURES: Sound pressures of frequency bands and sound pressures measured in dB(A) at various distances. Complaints registerd were: sleep disturbance, disturbance during daytime, "wants a less noisy prosthesis," and "can hear the closing click". PATIENTS: 143 patients after heart valve replacement with St Jude Medical (n = 35), Duromedics Edwards (n = 38), Carbomedics (n = 34) and Björk-Shiley Monostrut (n = 36) prostheses operated on between 1984 and 1988 were matched for valve position, ring size, and body surface area. RESULTS: Duromedics Edwards (33.5 (6) dB(A)) and Björk-Shiley Monostrut valves (31 (4) dB(A)) were significantly louder than St Jude Medical (24 (4) dB(A)) and Carbomedics (25 (6) dB(A)) prostheses (p = 0.0001) (mean (SD)). The louder valves were significantly more often heard by the patients (p = 0.0012) and caused more complaints both during sleep (p = 0.024) and during the daytime (p = 0.07). Patients with these valves were more likely to want a less noisy valve (p = 0.0047). Patients with symptoms were younger, had better hearing, and were more likely to be in sinus rhythm. As well as the type of prostheses, the valve diameter and body height also had an effect on sound emission. CONCLUSIONS: The intensity of the closing click of mechanical valve prostheses was significantly different for various designs. Patient complaints were related to the objectively measured sound pressure. Noise production should be considered when a mechanical valve is selected.

[Does the use of free transplanted jejunum segments in advanced laryngeal and hypopharyngeal cancer prolong survival? A matched-pair analysis]. / Bewirkt der Einsatz frei transplantierter Jejunumsegmente beim fortgeschrittenen Larynx- und Hypopharynxkarzinom eine Lebensverlängerung? Eine matched-pair Analyse.

The effect of free transplanted jejunum autografts, inserted after resection of extensive squamous cell carcinoma of the larynx and hypopharynx is evaluated in terms of survival and the development of local and regional recurrences. In a matched-pair analysis, 22 patients with jejunum transplants were compared with 44 patients with the same performance status, in whom after laryngopharyngectomy, the pharynx had been closed with local mucosa. The cumulative survival rate was calculated using the Kaplan-Meier method; the statistical comparison of the survival curves of the two groups was made with the Mantel-Haezel test. Patients of the study group had a statistically significant (p less than = 0.01) better survival rate than those of the control group, the 50% survival rate being 36 and 11 months, respectively. Local recurrences occurred in 9.1% of the patients in both the study group and in controls, and regional recurrences in 40.8 and 43.2%, respectively. This militates against the possibility that the surgery in patients in whom reconstruction with jejunum was possible might have been more radical. Further, it may be speculated that the statistically significant better survival rate is due to the jejunum itself, presumably to a tumourprotective effect of the lymphatic tissue of the transplant.

Specificity of auditory brainstem response audiometry criteria in acoustic neuroma screening as a function of deviations of reference values in patients with cochlear hearing loss.

On the basis of 79 patients with cochlear hearing loss, the statistical distribution of two criteria commonly used in auditory brainstem response audiometry (ABR) was analyzed: the interaural V latency difference (ILD V) and the interaural difference of I-V interpeak interval (ID I-V). The distribution of both criteria was Gaussian. By evaluating their standard deviations the percentages of statistical false-positives were estimated. The estimated results were 24% false-positive findings using the decision criterion ILD V greater than 0.2 ms and 5.4% false-positive findings using ID I-V greater than 0.3 ms. This corresponds closely to the actual false-positive ABR rates obtained in this sample: 21.5% and 6.3%, respectively. In a separate series of 301 unselected cases with asymmetric sensorineural hearing loss, 29 ABRs were suspect for retrocochlear pathology. In 20 patients, ABRs were absent due to severe hearing loss. Retrocochlear pathology could be confirmed in only 2 cases (both from the group with ABR present). Thus, 47 ABRs (15.7% of 299) were false-positive.

Closing click of St Jude Medical and Duromedics Edwards bileaflet valves: complaints created by valve noise and their relation to sound pressure and hearing level.

The metallic clicking sound created by mechanical heart valve prostheses frequently bothers patients. To test whether sounds generated by different bileaflet valves correlate to complaints related to the prosthetic clicking 73 patients were investigated after valve replacement with Duromedics Edwards (DE) (n = 38) and St Jude Medical (SJM) (n = 35) valves. The patients were asked about their complaints, sound pressure levels were recorded and audiometry was performed. Sixty-five percent of patients could hear their valve, 18% had sleeping disturbances, 5% felt bothered during daytime and 12% would prefer a less noisy valve. In symptomatic patients, sound pressure levels were higher than in asymptomatic patients (valve audible 45 +/- 8 db(A) vs not audible 39.9 +/- 10 db(A) at 10 cm; P = 0.016). These differences were most apparent in the high frequency bands, corresponding to the metallic click. Symptomatic patients had better hearing and were younger than patients without complaints. Fifty-one percent could hear their valve by conduction through the body, after eliminating air conduction by the use of headsets. The DE prostheses were louder than the SJM valves in general (47.4 +/- 7 vs 39.8 +/- 5 db (A) at 10 cm; P = 0.001) and in each valve position. Patients with DE prostheses had significantly more complaints. The intensity of the closing click of mechanical valves correlates to the complaints caused by prosthetic clicking and thus sound emission should be considered when a mechanical heart valve prosthesis is selected.

[Noise origin and noise-induced complaints after heart valve replacement with mechanical prostheses]. / Lärmentwicklung und lärmabhängige Beschwerden nach Herzklappenersatz mit mechanischen Prothesen.

143 patients were investigated in order to determine whether there is a difference in the intensity of the closing click between different mechanical heart valve prostheses. 35 had St. Jude Medical (SJM), 38 Duromedics Edwards (DE), 36 Björk Shiley Monostrut (BSM) and 34 had Carbomedics prostheses implanted. Sound pressure level determined at 1 meter distance was significantly higher for the DE 33.5 +/- 6 dB(A) and BSM 31 +/- 4 dB(A) than for the SJM 24 +/- 4 dB(A) and CM 25 +/- 6 dB(A) prostheses (p = 0.0001). Valves developing higher sound pressures were more frequently audible for the patients (p = 0.0012), caused more sleep disturbances (p = 0.024) and more complaints during daytime (p = 0.07). Significantly more patients carrying such valves wished to have a less noisy valve implanted (0.0047). Symptomatic patients wear louder valves, were younger, had better hearing and were more frequently in sinus rhythm. Valve diameter correlated with the developed sound pressure level. 349 patients answered a questionnaire after valve replacement with DE (256) or BSM (93) prostheses. 5% registered their noise-related complaints as being severe, but more than one third wished to have a less noisy valve implanted. The noise created by the closing click of mechanical prostheses causes significant complaints and this factor should be considered when a mechanical valve is selected.

Noise level and perception of the closing click after heart valve replacement with St. Jude Medical and Björk Shiley Monostrut prostheses.

The metallic click generated by the closure of mechanical heart valve prostheses may severely bother patients, but generated sound energy and the extent of complaints after implantation are not known. In 62 patients, after valve replacement with St. Jude Medical (SJM) (n = 35) and Björk Shiley Monostrut (BSM) (n = 27) prostheses, sound energy was recorded with a calibrated noise level analyzer at 5, 10, and 100 cm distance from patients and correlated with their complaints. At a distance of 100 cm, the BSM valves produced a significantly higher sound pressure level, 30.5 +/- 5 db(A), compared to the SJM valves, 24.1 +/- 4 db(A) (p = 0.0001). There was no significant difference at shorter distances. After splitting into frequency bands the highest sound pressure levels were observed in the high frequency ranges (8 to 16 kHz) representing the metallic click. BSM valves produced higher sound levels in all frequency ranges at 1 m distance. Seventy-three percent of all patients were aware of the noise generated by the valve; 20% had disturbed sleep; and 26% preferred a less noisy valve type. Twelve of 27 patients with BSM valves wanted less noisy valves, whereas only 4 of 35 patients with SJM valves wished to have a less noisy valve type (Chi-square p = 0.003). In patients who could hear their valve measured, sound level was higher than in patients who could not. In 9 of 27 patients with BSM (33%), versus 3 of 35 with SJM prostheses (9%), the clicking caused sleep disturbances.(ABSTRACT TRUNCATED AT 250 WORDS)

[Therapy of juvenile angiofibroma]. / Zur Therapie des juvenilen Angiofibroms.

We describe 12 juvenile angiofibromas treated predominantly by surgical excision. The course of the disease and therapy are analysed. Four interventions on 3 patients were done after pre-operative embolization. Superselective digital subtraction arteriography allowed detailed analysis of all feeding vessels, and a search for anastomoses between extra- and intracranial arteries and endarterial occlusion of tumour vessels. Intra-operative blood loss was reduced and visibility in the field of operation was improved.

[What happens to vocal cord dysplasias in variable smoking behavior?]. / Wie verhalten sich Stimmbanddysplasien bei unterschiedlichen Rauchgewohnheiten?

UNLABELLED: The influence of smoking with regard to the development and course of laryngeal dysplasias was examined. The case histories of 63 patients with histologically proven dysplasias of the larynx were evaluated in the light of their answers to a questionnaire covering their lifetime smoking habits. RESULTS: 1. The percentage of smokers in the patient group significantly exceeds the percentage of smokers in the general population. 2. The disease is more likely to lead to deteriorated histological findings in smokers. 3. A change in smoking habits at the time of diagnosis has no significant effect on the further course of disease. 4. Non-smokers have higher levels of dysplasia at first biopsy, but the disease is less likely to progress. The development of malignancy was not observed in the non-smoker group.

[The latency behavior of early auditory evoked potentials in high frequency hearing loss]. / Uber das Latenzverhalten der frühen akustisch evozierten Potentiale bei Hochtonstörungen.

We evaluated the auditory evoked brainstem responses of 53 patients with unilateral or bilateral (79 ears) high-frequency hearing loss of cochlear origin, to see whether the reduction of I-V latency difference in high-frequency hearing loss that has been described by several authors, was present in our patients. We were able to confirm that in high-frequency hearing loss wave I-latency is significantly positively correlated with the degree of hearing loss. The I-V latency difference is significantly negatively correlated with the degree of hearing loss at 2000 Hz.

Risk of vocal chord dysplasia in relation to smoking, alcohol intake and occupation.

The significance of tobacco smoking, alcohol consumption and occupation as risk factors for the development of vocal chord dysplasia was evaluated in a case-control study. Twenty-seven male patients with dysplasia of the vocal chords were chosen from the I. ENT-University Clinic in Vienna (1985-1988) and compared with 54 controls. The main results are: The relative risk (RR) of a smoker compared to that of a non-smoker for vocal chord dysplasia is 7.27 (6.81-7.73); the RR adjusted for occupation is 3.58 (2.31-4.84). The most important risk factor, however, is occupational exposure. The relative risk of a blue collar worker compared to that of a white collar worker is 11.04 (10.61-11.46), which is reduced only to 10.02 (10.61-11.46) after stratification according to smoking habits.

Optimizing of electroneuronography of the facial nerve.

The amplitude ratio between the paretic and the normal side as determined by electroneuronography is used as a basis for estimating the prognosis of facial palsy. Several methods have been described of placing the surface electrodes and of finding the supramaximal impulse strength. We investigated 16 normal test persons with the aim (1) of optimizing the procedure of neuronography with regard to the possible variations of electrode placement and stimulus intensity and (2) of finding out the right/left difference in normal test subjects. Following our results, the best positions of the recording electrodes are the nasal alae. Even under these most favorable test conditions we found an average side difference of the bilaterally recorded electroneurograms of normal test persons of 22%.

[Subjective noise perception and objective measurement of loudness following heart valve replacement with the St. Jude Medical and Duromedics Edwards bileaflet prostheses]. / Subjektive Geräuschempfindung und objektive Lautstärkemessung nach Herzklappenersatz mit St.-Jude-Medical-und Duromedics-Edwards-Doppelflügelprothesen.

The performance of heart valve prostheses is generally judged by the rate of valve-related complications and the hemodynamic performance. Patients may be severely bothered by the metallic click generated by the closure of the valve. In 74 patients after valve replacement with Duromedics Edwards (DE) (n = 38) and St. Jude Medical (SJM) (n = 36) prostheses the sound energy was recorded and correlated to the complaints of the patients. At a distance of 10 cm the DE valves produced a significantly higher sound pressure with 47 +/- 7 db(A) compared to the SJM valves with 39.8 +/- 5 db(A) (p = 0.001). The noise level was also different for the valves in aortic or mitral position. After splitting into frequency bands the highest sound pressure was observed in the high frequency ranges (8 to 16 kHz) which represents the metallic click. 65% of patients were aware of the noise generated by the valve, 16% had sleep disturbances and 22% would prefer a more silent valve type. 12 of 38 patients with DE valves and 4 of 36 patients with SJM valves wished to have a less noisy valve type (Chi square p = 0.003). In annoyed patients the valves produced a higher sound amplitude of 49 +/- 8 db(A) as compared to undisturbed patients with 42 +/- 6 db(A) (p = 0.002). The noise level of mechanical heart valves should be considered before selection of a prosthesis, because the metallic click bothers patients and the complaints correlate with measured sound energy.

[Value of sonomorphologic criteria in the identification of regional metastases of squamous cell cancers of the ENT area]. / Wertigkeit sonomorphologischer Kriterien bei der Identifikation regionärer Metastasen von Plattenepithelkarzinomen des HNO-Bereiches.

We compared the preoperative ultrasound findings with the histological results of 127 neck dissections for squamous cell carcinoma of the head and neck. We checked several sonomorphological criteria (size, shape, boundary, echo structure, arrangement, mobility) to assess their value in identification of metastatic disease. If all nodes found on ultrasound were classed as metastases, the specificity was 30%, because many lymph nodes showed nonspecific reaction only. Lymph nodes with a rupture of the capsule or central necrosis or being larger than 3 cm, proved to be metastatic in all cases. Round or oval nodes with a size of more than 2 cm were found to be metastatic with an accuracy of 89%. The almost certain (97%) identification of necks with no metastatic lymph nodes allows elective neck dissection to be avoided.

[Objective determination of auditory threshold in the child]. / Zur objektiven Hörschwellenbestimmung beim Kind.

In children who are difficult to test with dubious behavioural-audiometric results, brainstem electric response audiometry (BERA) is today the method of choice for accurate determination of hearing threshold. Oral sedation with the shortacting neuroleptic chloroprothixene allows BERA to be performed on an outpatient basis. Thirty-six girls and 41 boys aged between 11 weeks and 12 years (median age 40 months) with inconsistent behavioural-audiometric findings were examined. Frequency-following responses were searched for in flat fast response curves. BERA proved to be a very sensitive method compared with behavioural audiometry and was reliable even for children who are difficult to evaluate clinically, and for asymmetrical auditory thresholds. In conjunction with the standard pedaudiological test battery, BERA improves diagnostic accuracy and causes little disturbance as an outpatient procedure.

[Clinical experiences with digital video image analysis procedures in the assessment of endoscopic ENT video findings]. / Klinische Erfahrungen digitaler Videobildanalyseverfahren zur Auswertung von endoskopischen HNO-Video-Befunden.

Recent developments in data processing enable digital information to be obtained from video frames, leading to the possibility of computerised analysis of endoscopic ENT videos (e.g. in laryngology). Two simple pilot systems ("Genlock Computer with Superimposer" and "Videodigitizer") are presented, as basis for a discussion of the advantages and disadvantages of these methods.

[Initial results of digital video image analysis procedures in the evaluation of endoscopic ENT findings]. / Erste Ergebnisse digitaler Videobildanalyseverfahren zur Auswertung von endoskopischen HNO-Befunden.

Recent developments in data processing allow transformation of video frames into digital information. This makes it possible to perform computerised analysis of endoscopic ENT-videos. Two simple pilot systems ("Genlock Computer with Superimposer" and "Videodigitizer") are shown to discuss the advantages and drawbacks of these methods.