[Different patterns of velopharyngeal dysfunction in cleft palate patients]. / Formen der velopharyngealen Dysfunktion bei Spaltpatienten.

BACKGROUND: Velopharyngeal dysfunction (VPD) is generally known to be difficult to influence. Dysfunctional velopharyngeal motor patterns during speech were analyzed with the aim of optimizing the therapeutic strategies. METHODS: Velopharyngeal dysfunctions were videotaped and contextually analyzed during 89 speech sequences in 25 patients. Distinctive features of the motor patterns formed the basis of categorization by three therapists experienced in nasopharyngoscopy. There was a high inter-rater reliability of 94%. RESULTS: A total of four different function profiles were found: 1. VPD with retracted articulatory placement (compensatory articulation) (38%), 2. VPD with motor coordination problems characterized by mistiming of VP movements and voice onset/offset (15%), 3. VPD with verbal dyspraxia characterized by a silent positioning of VP closure before phonation started and a malregulation of muscle tonus (10%) and 4. phoneme-specific VPD (37%). CONCLUSION: Specific knowledge regarding the characteristics of dysfunctional speech motor patterns enables specifically tailored therapy.

[Implementation of the speech comprehension test for complex syntactic structures (after D.V. Bishop) in 6- and 8-year-old primary school children]. / Anwendung des "Sprachverständnistests für komplexe syntaktische Strukturen (nach D.V. Bishop)" bei 6- bis 8-jährigen Grundschülern.

Standardized tests for speech comprehension have been lacking for the diagnostic investigation of primary school children with problems in hearing and speech development. The informal speech comprehension test for complex syntactic structures ("Sprachverständnistest für komplexe syntaktische Strukturen", SKSS), a shortened and in Swiss German translated modification of the Test for Reception of Grammar of Bishop, was analyzed for its logical validity of content, difficulty indices, selectivity, reliability and standard values in percent. We conducted the SKSS on 64 primary school children (first grade, average age 6.9 years) and 84 primary school children (second grade, average age 8.2 years). Four test sentences were excluded because of their ambiguous nature. The remaining 26 test sentences most often indicated low difficulty. However, there was an obvious difference between the two groups in terms of difficulty as well reliability. Based on our results, the test proved to be useful for screening. It allows both quantitative and qualitative interpretations.

[Audiologic diagnosis in children. Applicability of different speech material]. / Audiologische Diagnostik bei Kindern. Verwendbarkeit von unterschiedlichem Sprachmaterial.

The aim of our study was to establish bench-mark values for speech intelligibility in noise for children. We also considered which of the two dichotic discrimination tests, Feldmann's or Uttenweiler's, would be most suitable for use within this age group. We examined 102 children aged between 7 and 10 years (second year, primary school), with an average age of 8 years. After confirming normal hearing acuity (examination of the ear, tympanometry and audiogram), speech perception was tested. This was performed with and without noise using the Göttingen Audiometric Speech Test for Children II and the monosyllables of the Freiburger Speech Intelligibility Test. The percentage of word intelligibility was recorded. Furthermore, dichotic hearing was tested using a combination of Feldmann and Uttenweiler dichotic discrimination tests. We rated the percentage of correct word pair repetitions with the correct article. The results showed that the best method for testing speech perception in noise for this age group was the Göttingen Test II for Children. Speech perception below 70% for word intelligibility should be considered as pathologic. For testing dichotic hearing, Uttenweiler's dichotic discrimination test for children was most suitable. In this test values below 80% should be considered as pathologic.

[On the diagnostics of structural deficits in dyslexia in clinical work: relationship between different achievement indicators]. / Zur Diagnostik struktureller Defizite bei Lese-Rechtschreib-Störungen in der klinischen Arbeit: Beziehungen zwischen verschiedenen Leistungsindikatoren.

BACKGROUND: The aim of the study is to research the relationship between different indicators used in the diagnosis of reading and writing disabilities in clinical work. METHODS: In addition to being tested for intelligence and writing ability, a total of 141 children in second and fourth grade were submitted to tests assessing their ability for speech intelligibility in noise, dichotic listening, phoneme discrimination, as well as auditory short-term memory for digits and non-words. In a partial sample of 40 children with average intelligence manifesting at least a standard deviation between their ability to write and their IQ a regression analysis was introduced to assess the predictive power of applied indicators for writing ability. RESULTS: Next to IQ testing, phoneme analysis as used in the Heidelberg Test of Phoneme Discrimination accorded for the variance in writing ability. However, the relationship between these indicators proved to be most important for the beginning of learning the written language. CONCLUSIONS: The diagnostic procedures used in clinical work are critically evaluated whereby the tests to assess speech intelligibility in noise and dichotic listening, as well as short-term memory appear to be clinically relevant too, however a standardized procedure and age-relevant norms are still needed.

[Brainstem acoustic evoked potentials in children with developmental disabilities--a useful tool for differential diagnosis]. / Frühe akustisch evozierte Potentiale bei Kindern mit Entwicklungsstörungen--eine sinnvolle Ergänzung der Diagnostik?

In a retrospective study brainstem acoustic evoked potentials (BAEP) were evaluated in 222 children with psychomotor retardation or dysmorphic signs. Registrations were done, when no clear response to acoustic stimuli of medium intensity (60-80 dBA) could be obtained during clinical examination. Only 118 children (53%) had normal BAEP. 50 patients (22%) suffered from hearing impairment. 39 children (17%) showed disturbances of neuronal conduction. In 15 cases (7%) a combination of both conditions occurred. The mean age of our children with hearing impairment was 33.1 months, no case having been diagnosed before. In 57% the impairment was of the conductive type with an amount of less than 40 dB nHL This type was predominant in children with skeletal dysplasias (43%), chromosomal aberrations (43%) and malformation syndromes (40%). Severe hearing deficits of the sensorineural type with more than 69 dB nHL were found in children with malformation syndromes (28%), perinatal injuries (23%) and cns malformations (16%). As far as reference data were available, the hearing impairment in the BAEP was confirmed in 92% by our pedaudiologists. As a consequence hearing aids were first prescribed in 10 children, their medium age being 33.6 months. In 18 cases grommets were inserted. 9 children required paracentesis and 4 adenotomy. Disturbances of neuronal conduction with increased interpeak latencies and deformed potentials were predominantly found in the group of children with neurometabolic diseases (67%) and cns malformations (32%). Early diagnosis of hearing impairment in children with psychomotor retardation remains a problem as it is in the general population. More attention in clinical examination and appropriate screening is necessary. BAEP provide a powerful tool for hearing screening and additional information for differential diagnosis especially in children with neurometabolic diseases.

[Evaluating the patient satisfaction questionnaire after inpatient treatment in phoniatrics and pediatric audiology--a contribution to quality control?]. / Fragebogenevaluierung der Patientenzufriedenheit nach stationärer Behandlung in der Phoniatrie und Pädaudiologie--ein Beitrag zur Qualitätskontrolle?

PURPOSE: In Germany public hospitals are compelled to evaluate patient satisfaction with their treatment as a part of quality management. The purpose of this study was to assess by means of a short questionnaire inpatient satisfaction with medical care in a phoniatric-paedaudiologic department. MATERIALS AND METHODS: From April 1995 until March 1997, 638 patients underwent inpatient treatment for phoniatric or paedaudiologic diseases in our department. A confidential questionnaire was handed out to the patients or to accompanying parents. 13 questions covered different aspects of hospital treatment, such as satisfaction with diagnostic and therapeutic measures, nursing care, accommodation, catering and administration. The participants were asked to rate on a scale of 1 (very good) to 6 (very poor). RESULTS: 306 (48%) of the patients returned their questionnaires. 16% of them expressed substantial dissatisfaction both with administration and accommodation. Only 2.7% of the patients conveyed a poor overall impression of their inpatient treatment. 3% asserted they would not want to be treated in the department again as the inpatient. However, the mean overall assessment indicated a high degree of patient satisfaction. CONCLUSIONS: Although the self-explaining 13-item questionnaire is easy to evaluate at low cost, it appears to be an inadequate measuring device for routine assessment of inpatient satisfaction since only 48% of the questionnaires could be analysed.

Late-onset sensorineural hearing loss in Coffin-Lowry syndrome.

The Coffin-Lowry syndrome (CLS) is a rare clinical entity where patients present with a characteristic facies, mental retardation and bone abnormalities. So far about 60 cases have been reported. Sensorineural hearing loss is not a characteristic symptom and a late-onset hearing loss has not been reported so far. We report on 4 brothers with CLS, aged 9-17 years, of whom 3 suffered from a severe sensorineural hearing loss with an onset during late childhood and adolescence after a normal hearing during early childhood. CT scans revealed no cochlear abnormalities. The boys were successfully equipped with hearing aids. It is suggested that in all CLS patients the hearing ability should be examined during early infancy and retested regularly in cases with normal hearing as these cases indicate that in CLS a late-onset hearing loss is possible during late childhood and adolescence.

[Auditory speech-evoked cerebral cortex potentials in patients with stuttering syndromes]. / Auditorische sprachevozierte Hirnrindenpotentiale bei Patienten mit Stottersyndromen.

BACKGROUND: The cause of stuttering is unknown. For clinical purposes it proved to be useful to assume a multifactorial genesis with organic psychological and social aspects. A longstanding organic theory focussed on the failure to develop left-hemispheric dominance for speech, whereas others favoured deficits of the speech motor system. Positron emission tomography (PET) studies support organic theories for the development of stuttering. The purpose of this study was to find out whether in stutterers auditory cortical potentials evoked by pure tones, noise and words are different to those of healthy controls. PATIENTS AND METHODS: 10 young adults having suffered from stuttering since infancy were examined. The potentials were measured and analysed as previously described. RESULTS: No correlation of clinical and electrophysiological findings were found. In one case the evoked potentials were normal, in all other patients heterogeneous results were obtained in respect of tone-evoked and both noise- and speech-evoked potentials. Cortical hemispheric differences could be detected. CONCLUSIONS: In agreement with PET findings reported in the literature the data obtained in this study indicate an organic, central nervous cause of stuttering. Obviously both speech motoric components and perception elements are affected. These facts have to be taken into account whenever a psychological cause of stuttering is suspected. Nevertheless, psychosomatic aspects of the disturbances must be considered since they influence the patients' ability to cope with their symptom.

[Chronic tinnitus in children and adolescents]. / Chronischer Tinnitus bei Kindern und Jugendlichen.

BACKGROUND: The problem of tinnitus in adults is reviewed systematically in nearly all standard otolaryngology reference works, whereas textbooks and monographs that focus on pediatric otorhinolaryngology or audiology and hearing in children and adolescents provide only little information concerning the epidemiology, etiology and therapy of tinnitus. The purpose of this study was to evaluate the psychosomatic aspects of chronic tinnitus in this younger age group. A rational diagnostic approach is discussed as to which diagnostic measures are necessary in the pediatric group for deciding which therapeutic option to chose. The therapeutic outcome of tinnitus counselling in non-severe cases and of parenteral lidocaine infusions in cases of a troublesome tinnitus is presented. PATIENTS AND METHODS: From January 1992 to December 1995, 31 children and adolescents in the age range from 6 to 17 years were treated for a chronic tinnitus without a measurable hearing loss. In 20 cases the tinnitus was bilateral; in 11 cases it was unilateral, without side preference. In 24 patients the case history gave no hint of a major annoyance by the tinnitus or significant psychological components. In these cases tinnitus counselling was carried out. In 7 cases-3 girls and 4 boys in the age range from 10 to 17 years-the kind and grade of symptom satisfied the ICD-10 criteria of a depressive episode. These patients were hospitalized for 10 days and a lidocaine infusion therapy (2 mg/kg Xylocain Cor in 500 ml HAES 6%) was performed as treatment for the somatic component of the disorder. Data were analyzed catamnestically using the patients' files. RESULTS: In all cases normal hearing threshold and speech intelligibility were ascertained by pure-tone and speech audiometry. Auditory evoked brainstem potentials gave no further information. The measurement of transient evoked otoacoustic emissions gave no consistent results in either of the two groups. Tinnitus measurement and audiometric masking could only be carried out in patients older than 10 years and showed non-reproducible results. In all cases with no major symptoms tinnitus disappeared. During a follow-up of 12-44 months, 4 cases treated with lidocaine achieved complete remission; in 3 cases the tinnitus eased off to such an extent that it was no longer regarded as annoying. In one girl of the lidocaine group a somatisation disorder developed independently of the tinnitus and was treated by psychotherapy. No side-effects of the lidocaine occurred. CONCLUSIONS: All aspects of chronic tinnitus in children and adolescents can be covered best when regarding this symptom as a psychosomatic disorder. The diagnostic approach in this age group has to include a detailed case history embracing both organic and psychological and social aspects. It should also include pure-tone and speech audiometry. Only in cases with an uncertain hearing threshold auditory evoked brainstem potentials have to be measured. Otoacoustic emissions give no further information about the development and therapeutic outcome of the tinnitus. In this age group tinnitus measurement and masking is of no diagnostic value. In patients with no signs of a hearing loss and no other organic symptoms there is no need for further diagnostic measures such as imaging or serological investigations. In cases with severe annoyance, tinnitus counselling is sufficient therapy. In cases with severe symptoms, lidocaine infusion therapy may be a therapeutic option for the somatic component of the disorder. In adolescents with chronic tinnitus psychotherapy will be necessary only in rare cases. The overall prognosis of this disorder is good.

[Early indications for surgical vocal cord medial relocation in unilateral recurrent nerve paralysis in advanced age]. / Frühzeitige Indikation zur operativen Stimmlippenmedianverlagerung bei einseitigen Recurrensparesen im fortgeschrittenen Lebensalter.

BACKGROUND: Unilateral vocal cord paralysis is usually treated conservatively. Phonosurgery is not indicated before 1 year after the onset of the palsy as during this period spontaneous recovery can be expected. In the elderly patient conservative voice rehabilitation is often limited by a restricted general condition. In these cases a severe communication disorder may result unless vocal cord function recovers spontaneously. PATIENTS AND METHODS: In 4 patients aged 68 to 79 years who had suffered from latrogenic unilateral vocal cord paralysis for 6 to 9 months, surgical medialisation of the paralysed vocal cord was carried out in local anaesthesia as an Isshiki-Type-I-operation after unsuccessful conservative treatment prior to surgery. RESULTS: In all cases a definite amelioration of voice function could be reached. There were no local or general complications. No spontaneous recovery of nerve function could be detected by electromyography between 6 to 9 months after the operation. Voice function remained stable during this period. CONCLUSIONS: We conclude that in elderly patients with unilateral vocal cord paralysis with no signs of spontaneous recovery and unsuccessful conservative treatment, surgical voice rehabilitation may be indicated before 1 year after the onset of the palsy.

Direct evaluation of high-speed recordings of vocal fold vibrations.

A digital high-speed camera system for the endoscopic examination of the larynx allows recording speeds of up to 5,600 frames/s. Recordings of up to 1 s duration can be stored and used for further evaluation. Combined with an image processing program the system is able to render x-t diagrams of vocal cord movement. Data acquired from different locations of each vocal cord can be plotted separately. All of the known objective parameters of the voice can be derived from highspeed glottograms.

[Specificity and sensitivity of transient click-evoked otoacoustic emissions (TEOAE)]. / Untersuchungen zur Spezifität und Sensitivität transienter click-evozierter otoakustischer Emissionen (TEOAE).

Transient click evoked otoacoustic emissions (TEOAE) have been shown to be a good test of hearing impairment especially when used for infant screening. However, occasional cases of false positive results--TEOAEs in spite of severe hearing loss--have been reported. This study encompasses 243 children whose hearing thresholds were known from subjective hearing tests and--in questionable cases--derived from additional auditory evoked potentials. The TEOAEs proved to have a high sensitivity (93%) and a reasonable specificity (67%), if the margin between good and bad hearing was set at 30 dB. However, four ears showed good TEOAEs in spite of poor hearing thresholds. In three cases, the children proved to have a central auditory hearing loss due to a cerebral disorder. One child with bilaterally superb TEOAEs had a unilateral deafness of unclear origin with no obvious retrocochlear or central disorder. Possible explanations under discussion included the presence of a retrocochlear lesion which was too small to show up in the tests used or that the defect was located just between the outer hair cells and the first neuron, for example in the inner hair cells. Additionally, efferent inhibition might cause a functional deafness as described by Rajan (1989) for the guinea pig. The results also show that TEOAEs should always be used in the differential diagnosis of hearing impairment in generally disabled children. The need for hearing aids and especially their adjustment has to be discussed in case of good TEOAEs, i.e., normal peripheral hearing.(ABSTRACT TRUNCATED AT 250 WORDS)

[Velopharyngeal closure in adolescents after repair of cleft lip, jaw, palate or isolated cleft palate]. / Velopharyngealer Abschluss bei Jugendlichen nach Verschluss einer Lippen-Kiefer-Gaumen- oder isolierten Gaumenspalte.

We examined two groups of teenagers (between 13 and 21 years of age) who had been surgically treated as small children for congenital cheilognathouranoschisis or cleft palate. A group of 62 teenagers had been treated by the Dept. of Orthodontics at the University of Erlangen-Nuremberg, the other group of 61 by the Dept. of Orthodontics at the University of Rostock. There were differences between the two departments in sequence and time of the surgical closure as well as in the frequence of velopharyngoplasties. The velopharyngeal closure was examined in all patients by means of a flexible fibre endoscope which was pushed forward endonasally up to the choanae. Simultaneously we judged the audibility of the nasal perflation while pronouncing /k/. A residual gap during articulation of /k/ with clearly audible or alternately clearly and discreetly audible nasal perflation was noted in 8 subjects in Erlangen and 14 subjects in Rostock. In subjects whose velum moved only anterior-posteriorly, closure was likely to be less good than in those with a circular closing mechanism of velum and lateral and/or posterior parts of the pharyngeal musculature. In rare cases we found a good velopharyngeal closure in spite of a large gap between the velum and the posterior pharyngeal wall at rest. This was the case when the velum moved more against the upper than the posterior wall of the nasopharynx. Velopharynxplasty did not reduce nasal airflow in case of insufficient function of the velar muscles. Differences in the mode of velopharyngeal closure might be due to statistically significant regional differences in skull structure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transitory evoked otoacoustic emissions in patients with cerebellopontile angle tumors]. / Transitorisch evozierte otoakustische Emissionen (TEOAE) bei Patienten mit Kleinhirnbrückenwinkeltumoren.

Click-evoked transitory otoacoustic emissions (TEOAE) were recorded in 34 patients suspected of having an acoustic neuroma with consequent hearing loss. Measurements took place one day prior to transtemporal removal of tumor. The evoked otoacoustic emissions were compared to hearing thresholds of the pure-tone audiogram. In 31 of the 34 patients tested, the spectrum of the emissions corresponded to the audiogram, in that an emission was not detectable at frequencies with a hearing loss exceeding 30 dB HL. Three patients showed good emissions in spite of a demonstrable hearing loss. This can be expected when only retrocochlear lesions are present. These results suggest that in most cases the hearing loss accompanying a retrocochlear process is combined with secondary lesions of the cochlea and is rarely due to isolated retrocochlear malfunction.

[Click-evoked otoacoustic emissions and acoustic brain stem potentials in early detection of hearing disorders in premature and newborn infants after neonatal critical care]. / Click--evozierte otoakustische Emissionen und akustisch evozierte Hirnstammpotentiale in der Früherkennung von Hörstörungen bei Früh- und Neugeborenen nach neonataler Intensivtherapie.

Evoked otoacoustic emissions (EOAE) and brainstem acoustic evoked potentials (BAEP) were recorded from 78 children following neonatal intensive care. In 23% no EOAE could be obtained. Hearing impairment in the BAEP was found in 9%. In 22% negative EOAE were found in spite of normal BAEP. According to the latency-intensity function of waves I and V all children with abnormal BAEP were classified having a conductive hearing loss. In accordance in no case a narrowing of the emission spectrum could be found in the EOAE. In both methods the rate of hearing impairment was highest in children with birth weights of less than 1000 g. A screening of all infants after neonatal intensive care using EOAE is recommended. BAEP should be done additionally in cases with deficient EOAE.

[Ear manifestations in adolescents after closure of lip-jaw-palate- or isolated palatal clefts]. / Ohrbefunde bei Jugendlichen nach Verschluss einer Lippen-Kiefer-Gaumen- oder isolierten Gaumenspalte.

We examined two groups of teenagers who had been surgically treated as small children for cleft palate. Most patients were between 13 and 21 years of age. One group had been looked after by the Dept. of Orthodontics at the University of Erlangen-Nürnberg, the other by the Dept. of Orthodontics at the University of Rostock. There were differences in sequence and time of the surgical closure between the two departments. Additionally, 60% of the people treated in Rostock had a velopharyngoplastic, which was rarely the case in Erlangen. In both groups only a few patients had been seen by an ENT-doctor regularly. Only some patients had been previously treated with tubes. There was one patient in each group with a bilateral, most likely genetically determined, sensorineural hearing loss. In Erlangen we examined 66 teenagers (132 ears). Six ears had been previously treated with one or more tympanoplasties. 10 ears needed further treatment due to a seromucotympanon, adhesions, perforations of the ear drum, suspicion of cholesteatoma or insufficient improvement of hearing after previous tympanoplasty. Another 18 ears showed signs of former inflammations. The control group in Rostock included 63 patients (i.e. 126 ears). 14 of the ears examined had undergone one or more tympanoplasties previously. 13 other ears needed further treatment for seromucotympanon, adhesions, perforations of the ear drum, insufficient improvement of hearing after tympanoplasty or cholesteatoma. Residuals due to prior inflammations were found in another 26 ears. Possible reasons for the different occurrence of middle ear problems in both groups are discussed.

Simultaneous recording of brainstem and cortical acoustic evoked potentials in children: methodical aspects and normative data.

Early and late acoustic evoked responses were simultaneously recorded from 42 children aged 3-17 years by means of a computer-based device using self-developed software. Filling the interstimulus intervals of late acoustic evoked potentials with clicks leads to an increase of latencies and a decrease of amplitudes of N1 and P2 components. Age-dependent normal values for various recording conditions are given.

[The quality of velopharyngeal closure in relation to facial morphology in CLP patients]. / Die Qualität des velopharyngealen Abschlusses in Abhängigkeit von der Gesichtsmorphologie bei LKG-Spalten.

Employing nasal endoscopy a follow-up study of 59 adult CLP-patients was conducted for the purpose of investigating velopharyngeal functions both during swallowing and during phonation of the letter "K". The results were subsequently compared with cephalometric values. In relation to phonation, the velopharyngeal activity could be subdivided into two groups, one demonstrating predominantly circular muscular activity and the other velar muscular activity. Both groups exhibited differing but, overall, a high quality of velopharyngeal closure. When swallowing all patients experienced complete velopharyngeal closure. It was striking to note, however, the slight muscular activity of the Passavant ridge during both swallowing and phonation. Significant relations were found to be present between facial morphology and velopharyngeal functions in terms of inclination of both the basis of maxilla and the mid-basicranium.

[Otosclerosis in the elderly. The effect of stapes-plasty on hearing ability and hearing aid management]. / Otosklerose im Alter. Der Einfluss der Stapesplastik auf Hörvermögen und Hörgeräteversorgung.

We examined 105 patients who underwent partial stapedectomies at the age of 65 years or older as treatment for combined hearing losses due to otosclerosis. Among other things investigated was the influence of the operation on the hearing of both the operated and unoperated ears, as well as on tinnitus existing preoperatively and the use of a hearing aid. Findings showed that tinnitus decreased or vanished in 75% of the cases. Sixty-one percent of the patients needed a hearing aid continuously preoperatively, with 48% not needing it post-operatively and 13% using it only occasionally. The degree of sensorineural hearing loss had by the other patients was so severe that the use of a hearing aid was also necessary post-operatively. However, in some of these cases, a successful use of a hearing aid became possible for the first time due to the surgical improvement in hearing.