International consensus (ICON) on the ENT role in diagnosis of obstructive sleep apnea syndrome.

During the 2017 IFOS ENT World Congress, an international expert panel was asked to clarify the role of ENT in the diagnosis process of the obstructive sleep apnea syndrome (OSA) in adults around the world. OSA is a major public health issue throughout the world. OSA is a highly prevalent disease with heavy clinical, social and economical outcomes. This high prevalence raises serious difficulties of diagnosis accessibility if only somnologists are able to confirm OSA diagnosis. First of all, the panellists reviewed the impact of OSA. Secondly, they defined the ENT role stressing ENT legitimacy, professional expertise and academic and institutional tasks. They also defined when somnologists were necessary. For the international panel, the ENT is a major player in the OSA diagnosis process.

Obstructive sleep apnoea syndrome: comparison between polysomnography and portable sleep monitoring based on jaw recordings.

INTRODUCTION: Obstructive sleep apnoea syndrome (OSAS) constitutes a new major public health problem because of its several pathophysiologic consequences such as cognitive disorders, excessive daytime sleepiness with risks of traffic accidents, cardiovascular implications, and decrease of quality of life. The necessity of a gold-standard polysomnography to ensure an accurate diagnosis implies an expensive, technical and time-consuming examination. Thus, it seems logical to develop new systems so as to diagnose SAS and to make it possible to detect apnoeas/hypopnoeas easily during sleep even at home. AIM OF THE STUDY: To assess a novel type-3 portable monitoring (PM) device, the Somnolter, and dedicated automatic analysis of several signals, one of which is the mandibular movement signal. METHOD: We studied patients suffering from OSAS. For all the patients, a nocturnal diagnosis polysomnography (PSG) was recorded in hospital settings, based on six EEG channels, two EOG channels, chin EMG channel, EKG, and respiratory parameters. At the same time, the Somnolter PM device recorded the physiological parameters from its own nasal prongs, thoracic belt, pulse oxymeter, body position, and jaw movement sensors. A visual analysis of PSG recordings was made leading to the detection of apnoea/hypopnoea index (AHI-PSG) and an automatic analysis of the Somnolter traces was performed to get automatic apnoea/hypopnoea index (AHI-A). The added value of the mandible movement signals was the particular jaw movements related to arousals, to respiratory efforts and to sleep/wake state. A comparison was made between the automatic and gold AHIs standard and the correlation was calculated between them. RESULTS: Ninety patients, aged between 47 and 70 years (mean age: 55.4±8.7) took part in the study. The linear regression and the correlation coefficient between AHI-PSG and AHI-A showed the good reliability of the automatic method. The Bland Altman analysis shows a correlation of 0.95 with a sensitivity of 83.6 and specificity of 81.8. CONCLUSION: The dedicated automatic analysis based on mandibular movements presents a good potential for the diagnosis of OSAS. The AHI computed by the automatic method is correlated with the AHI-PSG and the Somnolter could easily be used both in hospital, and in ambulatory settings.

Transitory increased blood pressure after upper airway surgery for snoring and sleep apnea correlates with the apnea-hypopnea respiratory disturbance index.

A transitory increase in blood pressure (BP) is observed following upper airway surgery for obstructive sleep apnea syndrome but the mechanisms implicated are not yet well understood. The objective of the present study was to evaluate changes in BP and heart rate (HR) and putative factors after uvulopalatopharyngoplasty and septoplasty in normotensive snorers. Patients (N = 10) were instrumented for 24-h ambulatory BP monitoring, nocturnal respiratory monitoring and urinary catecholamine level evaluation one day before surgery and on the day of surgery. The influence of postsurgery pain was prevented by analgesic therapy as confirmed using a visual analog scale of pain. Compared with preoperative values, there was a significant (P < 0.05) increase in nighttime but not daytime systolic BP (119 5 vs 107 3 mmHg), diastolic BP (72 4 vs 67 2 mmHg), HR (67 4 vs 57 2 bpm), respiratory disturbance index (RDI) characterized by apnea-hypopnea (30 10 vs 13 4 events/h of sleep) and norepinephrine levels (22.0 4.7 vs 11.0 1.3 g l-1 12 h-1) after surgery. A positive correlation was found between individual variations of BP and individual variations of RDI (r = 0.81, P < 0.01) but not between BP or RDI and catecholamines. The visual analog scale of pain showed similar stress levels on the day before and after surgery (6.0 0.8 vs 5.0 0.9 cm, respectively). These data strongly suggest that the cardiovascular changes observed in patients who underwent uvulopalatopharyngoplasty and septoplasty were due to the increased postoperative RDI.

Transitory increased blood pressure after upper airway surgery for snoring and sleep apnea correlates with the apnea-hypopnea respiratory disturbance index

A transitory increase in blood pressure (BP) is observed following upper airway surgery for obstructive sleep apnea syndrome but the mechanisms implicated are not yet well understood. The objective of the present study was to evaluate changes in BP and heart rate (HR) and putative factors after uvulopalatopharyngoplasty and septoplasty in normotensive snorers. Patients (N = 10) were instrumented for 24-h ambulatory BP monitoring, nocturnal respiratory monitoring and urinary catecholamine level evaluation one day before surgery and on the day of surgery. The influence of postsurgery pain was prevented by analgesic therapy as confirmed using a visual analog scale of pain. Compared with preoperative values, there was a significant (P < 0.05) increase in nighttime but not daytime systolic BP (119 ± 5 vs 107 ± 3 mmHg), diastolic BP (72 ± 4 vs 67 ± 2 mmHg), HR (67 ± 4 vs 57 ± 2 bpm), respiratory disturbance index (RDI) characterized by apnea-hypopnea (30 ± 10 vs 13 ± 4 events/h of sleep) and norepinephrine levels (22.0 ± 4.7 vs 11.0 ± 1.3 æg l-1 12 h-1) after surgery. A positive correlation was found between individual variations of BP and individual variations of RDI (r = 0.81, P < 0.01) but not between BP or RDI and catecholamines. The visual analog scale of pain showed similar stress levels on the day before and after surgery (6.0 ± 0.8 vs 5.0 ± 0.9 cm, respectively). These data strongly suggest that the cardiovascular changes observed in patients who underwent uvulopalatopharyngoplasty and septoplasty were due to the increased postoperative RDI.

A fractal approach to the features of speech consonants.

Fractal dimension (D) quantifies the roughness of a temporal signal and estimates its degree of freedom, allowing a good approach for its fluctuations. This present study of consonants follows the D-assessment of vowels which was presented at the Copenhagen Collegium Meeting. Using a 16 kHz time sampling the D-values of consonants were studied in the consonant-vowel context of the French language. Each consonant was pronounced four times by six males and six females. For D-measurement of long consonants the same method was used, i.e. the dyadic box-counting method and its 10 points of D-measurement (10pD) as that used for vowels. In the aim to approach infinitely small time scales, and to appreciate at least the tendency of the 10-point set, i.e. the D value to which tends this set, the slope of the three last points (3pD) was also calculated. For the plosion part of plosive consonants, a semi-continuous box-counting method devoted to the D-measurement of a short, single-dimension temporal signal was designed. This study consistently demonstrates that (i) there is a significant difference between males and females, as far as voiced and non-plosive consonants are concerned; (ii) plosive consonants are not fractal; (iii) among long consonants, D-value of fricatives are significantly different (p < 0.01), as far as 3pD measurement is considered; and (iv) in the case of nasal consonants [m] and [n], this categorization is efficient for both 3pD and 10pD measurements (p < 0.05). There results will be commented on and discussed with the aim of clinical use.

[Q.A.L.Y. index and assessment of cost efficiency of the cochlear implant in acquired profound deafness]. / Index Q.A.L.Y. et appréciation du rapport efficacité-coût de l'implant cochléaire chez l'adulte sourd profond post-lingual.

Cost utility analysis is a method of cost-effectiveness analysis which provides results in terms of cost per quality-adjusted life-year (Q.A.L.Y.). This method is progressively largely used for medical technology assessment. It permits cost-effectiveness comparisons between medical interventions. The cost per Q.A.L.Y. of cochlear implant was determined in 30 adult patients suffering from acquired profound deafness. This study indicates that this technology provides significant improvements and is quite cost-effective. However, as far as profound deafness is concerned, the reliability of Q.A.L.Y. needs to be improved.

A fractal approach to normal and pathological voices.

Using the box-counting method, we demonstrated recently that the stationary signal of vowels is not fractal, but provides the opportunity to design in the smallest scale a kind of signature for each vowel. This fractal approach to these components of speech allows us to quantify the roughness of the voice, between I (sinusoidal complex signal) and 2 (white noise). We used this method to compare these values in normal and pathological voices. We studied the speech of 10 normal speakers, 6 patients suffering from unilateral vocal fold palsy and 6 suffering from various other dysphonias. The meaning of this fractal measurement is discussed and compared with electroglottogram and spectrographic analysis.

A study of speech fractal dimensions.

The fractal dimension (D) of a signal gives an estimate of its degree of freedom, which allows estimation of its fluctuations. Using 16 kHz time sampling and the box counting method we studied the Ds of some of the main stationary parts of French speech, the phonemes [a], [e], [i], [o], [y], pronounced 4 times by 10 males and 10 females. Our study demonstrated that the stationary signal of vowels is not fractal, but may, at the smallest scale, provide a kind of signature for each vowel, though the present categorization is not totally significant. Since the box counting method objectifies and quantifies the roughness of the signal, this procedure may be useful for clinical applications. In case of dysphonia, moreover, these signatures could be perhaps be included in the speech signal processing of cochlear implants.

Slow-growing labyrinthine masses: contribution of MRI to diagnosis, follow-up and treatment.

We report the use of MRI in the diagnosis, follow-up and therapeutic management of three cases of intralabyrinthine Schwannoma. The diagnosis was based on the history and initial and follow-up MRI findings. The main feature suggesting the diagnosis was a nodular intralabyrinthine mass of low signal intensity on T2-weighted images, and high or isointense signal on T1-weighted images (relative to cerebrospinal fluid), which showed contrast enhancement. Follow-up imaging showed growth of the tumour in one patient. One patient underwent surgery for severe tinnitus. To detect these lesions, MRI should be focussed on the inner ear, using thin-section T2-weighted and T1-weighted images before and after contrast medium. MRI allowed informed surgical planning.

[Digital multi-filter auditory prosthesis: study of its efficiency in function of number of filters and their programming]. / Prothèse auditive numérique multifiltres: étude de l'efficacité en fonction du nombre de filtres et de leur programmabilité.

We designed a prototype of a 7-filter digital auditory prosthesis table prototype. For each of these filters frequency band width, amplification and compression were programmable in order to adapt these parameters to the deaf patient's audiometric particularities. We compared the hearing improvement it was possible to obtain either with the 3-analogue-filter auditory prosthesis Triton 3004 from Siemens, or with our prototype as a function of the number of filters (3, 4 or 7) and their frequency band width programmability. We tested 21 patients suffering from middle or severe neurosensory hearing loss. This study allows to demonstrate that to overpass the present analogue T004 device a 7 programmable-width-filter strategy seems to be the most appropriate. Further studies benefiting with material improvement of our prototype and finer audiometric adjustment of filter strategies as well as long term clinical studies have to be carried out.

[Cochlear implant and cerebral dominance]. / Implant cochléaire et dominance cérébrale.

On right handed people the right ear is considered to transmit speech information, and the left ear musical and cognitive information. These dominating ear properties are not exactly symmetrical in the left handed population, and are more consistent in females than in males. CI efficacy assessment is strongly based on speech intelligibility performances, because these criteria allow to measure the social reinsertion and communication possibilities. Consequently, one may ask if the relationship of the implanted side and the patient's handness could not be an important factor of this CI efficacy. We studied this relationship on 71 post-lingually deaf adult implantees. We measured patients handness using the Schachter's version of the so called Edimburg questionnaire described by Geschwind; this measurement has been moderated to take count of ambidextrous and mixed-handed population. Post operative performances has been assessed using the Francophone Protocol devoted to adults. We found that there is no significant correlation between these post-operative performances and the studied relationship. We estimate: 1) This absence of correlation is probably due to the high number of data which lead to determine the ear for implanting. 2) As far as this choice is feasible, dominating ear must nevertheless be elected, not only for theoretical reasons, but because the dominating hand may be easily employed for antenna adjustment. 3) As handness is strongly evident only after 4 y.o., and as left-handness seems to be more frequent on a congenitally deaf population, this choice is more problematic on less than 2 y.o. deaf children.

[Cochlear implant in the aged patient]. / L'implant cochléaire chez le sujet âgé.

Despite the fact that elderly people live frequently alone and frequently have difficulties of vision, is it reasonable to refuse to supply a patient with a cochlear implant only because he is too old? We compare the results of 87 post-lingually implantees as a function of age, less than 60 years (young) and 60 years or more (old). We assessed the implant efficacy using the Protocole Francophone d'Evaluation (PFE), appreciated the speech-therapist's opinion and the patient's satisfaction, and counted the number of hours per day the implant was used (H/D). The PFE score was significantly higher in young than old. However the speech-therapist's opinion and the patient's satisfaction as well as H/D did not differ significantly in the 2 series. Elderly people are supplied with a great benefit from cochlear implants. Therefore age is not a contraindication for implantation.

[Indications for the cochlear implant in partial deafness of the adult]. / Les indications de l'implant cochléaire dans les surdités incomplètes de l'adulte.

The last (may 1995) NHI Consensus Development Conference on cochlear implant recommends to extend the use of cochlear implant for adult patient suffering from bilateral acquired severe hearing impairment. Its indications are a severe-to-profound sensorineural hearing loss bilaterally presenting an open-set sentence recognition scores less than or equal to 30 percent under best aided conditions. We report the results of our 4 first implantees responding to these criteria, and discuss the mechanisms of the speech intelligibility improvement which has been obtained.

Auditory performances of a 3-4-7 programmable numeric filter hearing aid.

We designed a non-portable prototype seven-filter digital auditory hearing aid. For each of the filters, frequency bandwidth, amplification and compression were programmable in order to adapt these parameters to the deaf patient's audiometric characteristics. We compared the hearing improvement it was possible to obtain either with the three-analogue filter auditory prosthesis Triton 3004 hearing aid from Siemens or with our prototype as a function of the number of filters (three, four or seven) and their frequency bandwidth programmability. We tested 21 patients suffering from moderate to severe sensorineural hearing loss. This study allowed us to demonstrate that a seven programmable-width filter strategy seems to be more effective than the present analogue T004 device. Further studies with improvement of our prototype and finer audiometric adjustment of filter strategies, together with long-term clinical studies, need to be carried out.

Asynchronous interleaved stimulation (AIS): a new speech coding strategy for cochlear implant.

Cochlear implants use a fixed or F0 dependent stimulation rate, whatever the sound analysed (vowel or consonant) or procedure (fixed filters or FFT). We present a procedure which varies as a function of the input signal. This method is based on FFT analysis using a variable width analysis window. Short windows are applied on the transient part of the signal, providing poor frequency resolution but good time resolution; they permit us to accurately follow the speech signal in time during its fast temporal variations. Large windows are applied on the stationary parts of the signal, providing better frequency resolution but poor time resolution. Transient parts of the speech order this window switching; they are detected using the statistical properties of the FFT; moreover, the narrow windowing is coupled to an increase of the stimulation frequency. This strategy has been implemented using the DIGISONIC cochlear implant software, and clinically assessed in 6 regular cochlear implant users, on the basis of a consonant-vowel-consonant test. This Asynchronous-Interleaved-Stimulation (AIS) strategy provides the patients with better discrimination than fixed window FFT analysis. The coding protocol will be described and results presented.

[Nuclear magnetic resonance and cochlear implant]. / Résonance magnétique nucléaire et implant cochléaire.

Chou underlined that ive potential effects may be anticipated if MRI is realized on implantees: 1) force on the implant by strong magnetic field, 2) current induced by the implant in the radiofrequency (RF) field, 3) damage of implant by RF exposure, 4) MRI image distortion caused by the implant, 5) implant and adjacent tissue heating due to the absorption of RF energy. We studied the reality of the four first of these risks on the Digisonic cochlear implant from MXM using the Siemens Magneton 42 SP, which supplied the implants during 10 minutes with 1 Tesla magnetic field, RF 42 MHz, maximum intensity 10 kV. During T1 and T2 sequences we could notice that: 1) Provided the receiver is strongly attached in its skull niche as requested by normal surgical procedure, no deplacement may be observed: 2) No adverse current may been observed as well on the implanted electrodes as in the internal circuitry; 3) No damage or adverse magnetisation have been detected in the 3 studied receivers; 4) Cerebral imaging of the animal is moderately darkened by the implant. The volume of the shadow involved by the implant is approximately three times the volume of the implant. As Chou demonstrated that no observable heating could be detected after a long MRI sequence, and as Portnoy using Nucleus device observed also that neither adverse current nor implant damage could be detected, we estimate that there are no real contraindication to perform MRI on implantees, provided the surgical attachment has been correctly realised. Practical attitudes will be evoked and discussed.

[Imaging of ORL diseases in acquired immunodeficiency syndrome]. / Imagerie des pathologies ORL au cours du syndrome d'immunodéficience acquise.

More than 50% of patients with acquired immunodeficiency syndrome (AIDS) present a lesion affecting parotid gland, lymph nodes, paranasal sinuses, pharyngo-larynx or temporal bone. In about 20% out of cases affected patients present different head and neck lesions at the time of evaluation. Most often, clinical examination and endoscopy are sufficient to perform diagnosis and to manage the disease. Imaging studies (CT or MRI) are indicated when the nature of the disease is unknown or when a map of the process is mandatory for therapeutic approach. Some imaging features are strongly suggestive of HIV infection: parotid cysts associated with hyperplasia of the nasopharynx and cervical lymph nodes enlargement; labyrinthitis and multinevritis; and head and neck squamous cell carcinomas in non alcoolo-tobacco addicted patients. Such diseases suggest the need for knowledge of the patient's seropositivity status.

[Persistent facial paralysis: contribution of imaging to identification of perineural infiltrating tumor]. / Paralysie faciale persistante: contribution de l'imagerie à l'identification d'une infiltration tumorale périneurale.

To describe imaging features suggestive of retrograde perineural spread in progressive facial palsy without known tumoral origin. Two reports of perineural infiltration by salivary malignant tumors were diagnosed on abnormal enhancement of the facial nerve associated with an abnormal nerve enlargement (1/2). These unsuspected tumors were located in parotid gland (1/2) and the sub-maxillary gland (1/2). ENT tumors (especially adenoid cystic carcinomas) should be carefully searched in case of perineural spread, as these tumors may be misdiagnosed due to their size, location and signal. Therefore, imaging studies of facial palsy should include temporal bone, skull base, parotid gland, submaxillary gland and sub cutaneous areas of the face. A sub-maxillary gland tumor should be searched in case of facial palsy associated with glossodynia.

[Asynchronous sequential stimulation. A new signal treatment for cochlear implants]. / Stimulation séquentielle asynchrone. Un nouveau traitement du signal pour les implants cochléaires.

Cochlear implants use a fixed or FO dependent stimulation rate, whatever the sound analysed (vowel or consonant) and its analysis procedure (fixed filters or FFT). We present a procedure which varies as a function of the nature of the input signal. This method is based on FFT analysis using a variable with analysis window. Short windows are applied on the transient part of the signal, providing poor frequency resolution but good time resolution; they accurately permit to follow the speech signal in time during its fast temporal variations. Large windows are applied on the stationary parts of the signal, providing better frequency resolution, but poor time resolution. Transient parts of the speech order this window switching; they are detected using the statistical properties of the FFT; moreover the narrow windowing is coupled with an increase of the stimulation frequency. This strategy has been implemented using the Digisonic cochlear implant software, and clinically assessed on 6 regular cochlear implant users, owing to a consonant-vowel-consonant test. This Asynchronous-Interleaved-Stimulation (AIS) strategy provides the patients with better discrimination than fixed window FFT analysis. The coding protocol are described and results presented.

[Iatrogenic tinnitus and kophosis treated by cochlear implant. Apropos of a case]. / Bourdonnement sévère et cophose iatrogènes traités par implant cochléaire. A propos d'un cas.

A severe iatrogenic tinnitus has been successfully improved by cochlear implant, despite the hearing and intelligibility of the opposite ear were not profoundly impaired. This case report allows to discuss the eventual enlargement of the classic cochlear implant indications.