Serendipity in oto-rhino-laryngology.

INTRODUCTION: Serendipitous findings are findings that were initially unsought but nevertheless contribute to the development of the discipline. This article reviews eight serendipitous findings in oto-rhino-laryngology important to its advancement. METHOD: The following serendipitous findings are discussed: the accidental discovery of the laryngeal mirror and indirect laryngoscopy by Garcia (1854), the invention of direct oesophagoscopy by Kußmaul (circa 1868), Czermák's (1863) development of diaphanoscopy, the unintentional emergence of bronchography from a clinical error made by Weingartner (1914), adenotomy by Meyer (1869), the discovery of the causes of unbalance related to the vestibular nerve by Flourens (1830), Bárány's (1914) finding that the semi-circular canal reflex is involved in equilibrium, and the relationship between gastroesophageal reflux and middle-ear infections by Poelmans and Feenstra (2002). DISCUSSION: Based on these case studies we conclude that serendipity, defined as the art of making an initially unsought find, does not always appear out of nowhere. Often the researcher is already wrestling with a problem for which the serendipitous finding provides a solution. Sometimes the serendipitous finding enables the application of a known solution to a new problem. And sometimes a serendipitous finding is not recognized as such or considered unimportant. Since observations tend to be theory-loaded, having appropriate background knowledge is a conditio sine qua non to elaborate an unanticipated observation.

[Industrial wind turbine noise: the association with human health]. / Geluid van industriële windturbines.

Climate targets will provide the Netherlands with more and higher industrial wind turbines that produce various 'side effects', including noise pollution and annoyance. Especially low-frequency noise and infrasonic vibrations can be detected more than 10 km away. In neighbouring residential areas, long-term exposure, especially at night, leads to sleep disturbances, with secondary symptoms, that may be associated with, for example, delay in cognitive development of children. More research is needed.

Diagnostics of halitosis complaints by a multidisciplinary team.

AIM: The study objective was to collect diagnostic data, to explore correlations between diagnostic variables, to provide an accurate initial diagnosis, and to provide appropriate management in consecutive subjects consulting with a multidisciplinary halitosis team because of a halitosis complaint. METHOD: Nine hundred and fifty-four subjects with halitosis complaints applied for consultation. Subjects' history data were collected and organoleptic measurements and a physical examination were performed. Finally, genuine halitosis or pseudo-halitosis/halitophobia was diagnosed initially and management was provided. RESULT: Genuine oral halitosis was diagnosed initially in 93% of cases. Using oral cleaning materials, performing mechanical tongue cleaning, and periodical dentist consultation were over-represented in women, whereas men were more likely to have observable biofilm and carious lesions than women. Female gender was associated with tongue coating. Positive associations were found between age and performing mechanical tongue cleaning, organoleptic measurement scores as well as poor oral health. Educational level was positively associated with oral self care behaviours. Performing mechanical tongue cleaning was not associated with periodical dentist consultation. CONCLUSION: In nearly all subjects complaining of halitosis, an oral cause could be detected.

Laryngotracheal reconstruction with porous titanium in rabbits: are vascular carriers and mucosal grafts really necessary?

Laryngotracheal reconstruction requires a supportive structure with a mucosal lining, which needs a vascular supply in order to regenerate properly. We investigated the necessity of a vascular carrier and mucosal graft when using porous titanium for laryngotracheal reconstruction. Surgical defects of the laryngotracheal complex in 22 rabbits were reconstructed with: (a) porous titanium implanted on a vascularized fascia combined with a buccal mucosal graft (first stage) before transposing to the neck area (second stage); (b) porous titanium implanted on a vascularized fascia (first stage) combined with a mucosal graft (second stage); (c) porous titanium on a pedicled fascia flap; and (d) porous titanium alone. The grafts were tolerated well. Re-epithelialization occurred in all groups. Normal mucosa with a submucosal layer containing vital cells was noted using the titanium implants. Blood vessels were grown in the pores of the titanium scaffold to supply the overlying mucosa. The scaffold was well integrated in the adjacent tracheal cartilage and surrounding tissues, except in the two cases that showed titanium displacement. Inflammation and granulation formation were seen in most rabbits in groups III and IV, initiated probably by the use of buccal mucosal grafts. Reconstruction of a rabbit's trachea using composites of porous titanium, mucosal grafts and a fascia flap is feasible. Titanium seems to meet the requirements needed for closing a small defect of the tracheal wall and allows for re-epithelialization. For larger defects, a vascular carrier with a mucosal graft is probably indispensable to ensure the process of re-epithelialization.

Tracheal reconstruction: mucosal survival on porous titanium.

OBJECTIVE: To investigate whether porous titanium can provide a better support for revascularization of a mucosal graft ideal for tracheal reconstruction. In patients with laryngotracheal stenosis or tumor, the mucosa with supporting structures can be damaged, resulting in a defect that has to be reconstructed. Autologous tissues like cartilage and mucosa have been used for reconstruction. The main problem has been incomplete mucosal reepithelialization. DESIGN: In the first experiment, porous titanium or ear cartilage was combined with mucosa and implanted subcutaneously in athymic mice for different periods of time. In the second experiment, using rabbits, surgically created defects were reconstructed with porous titanium and mucosa on a pedicled fascia flap using a 2-stage procedure. The implants were analyzed with emphasis on angiogenesis and mucosal survival. SUBJECTS: Male New Zealand white rabbits and nude athymic mice (BALB-c nu/nu). RESULTS: Normal mucosa having a submucosal layer with vital cells was noted on top of the titanium. Multiple blood vessels were observed extending from the muscle layer through the titanium. Cytokeratin expression was detected in the suprabasal and basal layers of the mucosal epithelium. In contrast, the mucosa on cartilage showed no vital cells and no cytokeratin expression. In the rabbit experiment, all animals survived the reconstruction. The titanium was well integrated to the adjacent tracheal cartilage and surrounding tissues, supporting a fully vital mucosa. CONCLUSIONS: Porous titanium is an inert biomaterial that provides support and allows easy revascularization of a mucosal graft. Titanium, in combination with viable autologous tissues, is a good alternative for tracheal reconstruction.

Bile acids identified in middle ear effusions of children with otitis media with effusion.

OBJECTIVES/HYPOTHESIS: Several studies have shown the presence of pepsin in the middle ear effusions of children with otitis media with effusion (OME). When gastric reflux is the cause, other noxious reflux products might be present. We therefore investigated the presence of bile acids in the middle ear effusions of children with OME. STUDY DESIGN: We evaluated 38 children (63 samples of middle ear secretions (ME samples)) in a prospective study at a tertiary care children's hospital. METHODS: ME samples were collected from children with OME during ventilation tube insertion. Most ME samples were diluted with albumin. The presence of bile acids was measured with the 3alpha-hydroxy steroid dehydrogenase enzymatic method. A ME sample was considered positive when it contained at least 5 mumol/l bile acids, independent of dilution. Blood samples were taken simultaneously as a reference to determine bile acids serum levels. RESULTS: We found bile acids in 32 % (20/63) of all ME samples and in 42% (16/38) of all children. Bile acids concentrations of 12 well-soluble ME samples ranged from 5.9-40.9 mumol/L and were 3.1-19.7 times higher than the serum concentrations. In 4 of the corresponding serums, no bile acids were measurable at all. CONCLUSIONS: Bile acids are present in a number of the ME samples of children with OME. Because of dilution, it is possible that more ears contain bile acids. Bile acids are known to be noxious to mucosal cells at a higher (pH) than pepsin and, therefore, might play a role in the pathology of OME.

Self-reported disability and handicap after hearing-aid fitting and benefit of hearing aids: comparison of fitting procedures, degree of hearing loss, experience with hearing aids and uni- and bilateral fittings.

Self-reported outcome on hearing disability and handicap as well as overall health-related quality of life were measured after hearing-aid fitting in a large-scale clinical population. Fitting was performed according to two different procedures in a double-blind study design. We used a comparative procedure based on optimizing speech intelligibility scores and a strictly implemented fitting formula. Hearing disability and handicap were assessed with the hearing handicap and disability inventory and benefit of hearing aids with the abbreviated profile of hearing aid benefit. Effects on health-related quality of life and depression were assessed with the EuroQol-5D questionnaire and the geriatric depression scale. We found that hearing-aid fitting according to either procedure had a significantly positive effect on disability and handicap associated with hearing loss. This effect lasted for several months. Only the effect on disability persisted after 1-year of follow-up. Self-reported benefit from hearing aids was comparable for both fitting procedures. Unaided hearing disability was more pronounced in groups of participants with greater hearing loss, while the benefit of hearing aids was independent from the degree of hearing impairment. First-time hearing aid users reported greater benefit from their hearing aids. The added value from a bilateral hearing-aid fitting was not significant. Overall health-related quality of life and incidence of depression did not alter after hearing-aid fitting.

Atelectasis of the middle ear in pediatric patients: safety of surgical intervention.

OBJECTIVE: There is no consensus amongst clinicians regarding the best treatment strategy for pediatric atelectasis of the middle ear. It is the policy in our pediatric otolaryngology department to intervene early in the disease process. In an attempt to provide evidence regarding the safety of early intervention we have analyzed the audiological outcome following surgery in different stages of the disease. STUDY DESIGN: Retrospective case note review. METHODS: We undertook a retrospective study of children with atelectasis treated surgically at a Dutch tertiary referral centre. Disease severity was classified according to the Erasmus Classification of Pediatric Atelectasis, and pre- and postoperative four frequency ac and bc thresholds were compared. RESULTS: The study group consisted of 169 ears in 127 patients. The mean age at surgery was 9.6 years. There was an improvement in the average air-bone gap (ABG) for all stages. No deterioration in mean bone conduction thresholds was found following surgical intervention and there were no dead ears postoperatively. CONCLUSION: This study demonstrated that surgical intervention had a favourable effect on hearing level across all stages, though hearing was markedly worse in stage V, and that a policy of intervention early in the disease process cannot be rejected on the grounds of risk of iatrogenic sensorineural hearing loss.

The extraordinary healing properties of the pediatric tympanic membrane: a study of atelectasis in the pediatric ear.

OBJECTIVES: Traumatic perforations of the eardrum are generally treated conservatively as they tend to heal spontaneously. Retraction pockets of the eardrum, leading to atelectasis of the middle ear and often ultimately though unpredictably, to cholesteatoma formation, are treated in a variety of ways including complex grafting procedures. On the premise that a surgically resected retraction pocket is in essence a traumatic perforation, we examined the results of spontaneous healing of the resected retraction pocket. METHODS: Retrospective case note study. PATIENTS: A group of 86 ears in 62 patients who had undergone simple excision of the atrophic segment of the eardrum and who had no grafting procedure of the resultant defect, were followed at 6 days, 6-7 weeks and then every 6 months to determine the incidence of spontaneous healing of the eardrum. Audiograms were taken preoperatively, at 7 weeks and between 7 and 15 months postoperative. RESULTS: 94.2% of the eardrums (81 out of 86 ears) healed spontaneously without any form of grafting within 7 weeks. Air bone gap showed improvement in 53 patients. Only one of the four ears that failed to achieve closure had postoperative ear discharge. There were no other complications. In 17 ears (19.8%) there was a recurrence of the atelectasis. CONCLUSION: Excision of retraction pockets in pediatric ear atelectasis, in principle does not require grafting, as the great majority will heal spontaneously. The spontaneous healing in this study is comparable to reported studies of spontaneous healing of traumatic perforations. Irrespective of the size of the atrophic part of the membrane, recurrence rates for the atelectasis after simple excision is similar to that described in other studies. Retraction pockets may be excised and allowed to heal without risk to the hearing.

Comparison of speech intelligibility in quiet and in noise after hearing aid fitting according to a purely prescriptive and a comparative fitting procedure.

We compared two different types of hearing-aid fitting procedures in a double-blind randomized clinical study. Hearing aid fittings based on a purely prescriptive procedure (the NAL-RP formula) were compared to a comparative fitting procedure based on optimizing speech intelligibility scores. Main outcome measures were improvement of speech intelligibility scores in quiet and in noise. Data were related to the real-ear insertion responses that were measured after fitting. For analysis purposes subgroups were composed according to degree of hearing loss, characterized by unaided speech intelligibility in quiet, previous experience with hearing aids, unilateral or bilateral fittings and type of hearing aid. We found equal improvement of speech intelligibility in quiet, while fitting according to the prescriptive formula resulted in a somewhat better performance as expressed by the speech-to-noise ratio in comparison to the comparative procedure. Both procedures resulted in comparable real-ear insertion responses.

The interobserver and test-retest variability of the dysphonia severity index.

OBJECTIVE: The purpose of this study was to investigate the interobserver variability and the test-retest variability of the Dysphonia Severity Index (DSI), a multiparametric instrument to assess voice quality. METHODS: The DSI was measured in 30 nonsmoking volunteers without voice complaints or voice disorders by two speech pathologists. The subjects were measured on 3 different days, with an interval of 1 week. RESULTS: The difference in DSI between two observers (interobserver difference) was not significant. The intraclass correlation coefficient for the DSI was 0.79. The standard deviation of the difference between two duplicate measurements by different observers was 1.27. CONCLUSION: Differences in measurements between different observers were not significant. The intraclass correlation coefficient of the DSI was 0.79, which is to be considered good. Differences in DSI within one patient need to be larger than 2.49 to be significant.

The relationship between perceptual evaluation and objective multiparametric evaluation of dysphonia severity.

SUMMARY: The purpose of this study was to investigate the usefulness of the Dysphonia Severity Index (DSI) as an objective multiparametric measurement in assessing dysphonia. The DSI was compared with the score on Grade of the GRBAS scale. Investigated was also whether the DSI is related to severity of dysphonia, which was represented by different diagnosis groups. Furthermore, it was investigated whether the DSI can differentiate between a group of patients and a control group. A total of 294 patients with different voice pathologies were included. A control group consisted of 118 volunteers without any voice complaints. The voices of all participants were perceptually evaluated on Grade, and the DSI was measured. The groups of patients with voice complaints have a lower DSI and higher scores on Grade than the control group. The DSI was significantly lower when the score on Grade was higher. The DSI discriminates between patients with nonorganic voice disorders, vocal fold mass lesions, and vocal fold paresis/paralysis. To determine whether the DSI discriminates between patients and controls, the sensitivity and specificity for different DSI cutoff points were calculated. With a DSI cutoff of 3.0, maximum sensitivity (0.72) and specificity (0.75) were found. We conclude that the DSI is a useful instrument to objectively measure the severity of dysphonia.

Comparative studies on hearing aid selection and fitting procedures: a review of the literature.

Although a large number of fitting procedures have been developed and are nowadays generally applied in modern hearing aid fitting technology, little is known about their effectiveness in comparison with each other. This paper argues the need for comparative validation studies on hearing aid fitting procedures based on the design of a randomized clinical trial and carried out in a large-scale clinical population. These studies are hard to conduct but can provide detailed information on the various aspects of the rehabilitation with hearing aids. The design of several recently reported comparative studies of hearing aid fitting procedures will be reviewed. This gives rise to a number of comments on aspects like, study design, composition of the study population and definition of outcome measures rather than on the outcome or conclusions of these studies themselves.

A review of the current literature on aetiology and measurement methods of halitosis.

OBJECTIVES: This work reviews the current knowledge of aetiology and measurement methods of halitosis. DATA: Halitosis is an unpleasant or offensive odour emanating from the breath. The condition is multifactorial and may involve both oral and non-oral conditions. SOURCES: A private, monthly with keywords halitosis, malodo(u)r, (a)etiology, measurement, and management from Medline and Pubmed updated database of literature was reviewed. CONCLUSIONS: In approximately 80-90% of all cases, halitosis is caused by oral conditions, defined as oral malodour. Oral malodour results from tongue coating, periodontal disease, peri-implant disease, deep carious lesions, exposed necrotic tooth pulps, pericoronitis, mucosal ulcerations, healing (mucosal) wounds, impacted food or debris, imperfect dental restorations, unclean dentures, and factors causing decreased salivary flow rate. The basic process is microbial degradation of organic substrates. Non-oral aetiologies of halitosis include disturbances of the upper and lower respiratory tract, disorders of the gastrointestinal tract, some systemic diseases, metabolic disorders, medications, and carcinomas. Stressful situations are predisposing factors. There are three primary measurement methods of halitosis. Organoleptic measurement and gas chromatography are very reliable, but not very easily clinically implemented methods. The use of organoleptic measurement is suggested as the 'gold standard'. Gas chromatography is the preferable method if precise measurements of specific gases are required. Sulphide monitoring is an easily used method, but has the limitation that important odours are not detected. The scientific and practical value of additional or alternative measurement methods, such as BANA test, chemical sensors, salivary incubation test, quantifying beta-galactosidase activity, ammonia monitoring, ninhydrin method, and polymerase chain reaction, has to be established.

Palliative care for head and neck cancer patients in general practice.

CONCLUSION: The findings of this study justify the goals of the Expert Centre such as the improvement of somatic and psychosocial care and consultation. OBJECTIVE: A recent review showed that little attention is paid to palliative care for head and neck patients. The Erasmus MC has initiated an Expert Centre of Palliative Care Head and Neck Oncology with special interest in patient care, consultation and research. In this study the experience of general practitioners (GPs) in their care of palliative head and neck cancer patients before the start of the Expert Centre is assessed. The aim of the study was to find possible gaps in care and communication and to use GP's ideas to improve the centre's functioning. MATERIALS AND METHODS: Fifty-five GPs with a patient in their practice who died from head and neck cancer between January 2003 and July 2004 after being treated in the Erasmus MC were included. The GPs were asked to fill out a questionnaire regarding their experience in the care of palliative head and neck cancer patients, the communication between first- and third-line care providers and the work of both the GP and the specialist involved. RESULTS: The response rate was 75%. The palliative stage lasted approximately 4 months. The GPs felt that symptom control was generally not sufficient. Also improvements were necessary in psychosocial care and in the communication between first- and third-line care providers. They also experienced gaps in their knowledge of specific head and neck oncologic palliative care.

Influence of age and gender on the dysphonia severity index. A study of normative values.

Attempts have been made to find objective parameters for assessing voice quality for many years. Objective measurements such as the dysphonia severity index (DSI), using four parameters (highest frequency, lowest intensity, maximum phonation time and jitter), appear to correlate well with perceptual evaluation. The aim of this study was to investigate the influence, if any, of age and gender on the DSI. The DSI of 118 non-smoking adults (69 females, 49 males, age range 20-79 years) without voice complaints was measured. Age has a significant effect on the DSI and on its parameters highest frequency and lowest intensity (only in females). Gender has no effect on the DSI, although it has a significant effect on the parameters highest frequency and maximum phonation time. To be able to distinguish between the effects of (normal) ageing and a voice disorder, normative data of a wide age range are essential. As a result of this study normative DSI values for gender and age have been made available.

Interaction between ocular stabilization reflexes in patients with whiplash injury.

PURPOSE: In the past few decades, the automobile has become an increasingly more popular means of transport, which has led to an increasing number of rear-end collisions and consequently has resulted in more patients with whiplash-associated disorders (WADs). Recently, it was found that the gain of one of the ocular stabilization reflexes-the cervico-ocular reflex (COR)-is elevated in patients with whiplash injury. The COR responds to proprioceptive signals from the neck and acts in conjunction with the vestibulo-ocular reflex (VOR) and the optokinetic reflex (OKR) to preserve stable vision on the retina during head motion. Therefore, an investigation was conducted to determine whether the reported elevation of the COR in WADs is accompanied by changes in VOR or OKR. METHODS: Eye movements of 13 patients and 18 age-matched healthy controls were recorded with an infrared eye-tracking device. RESULTS: Analysis confirmed a significant increase in COR gain in whiplash patients. Meanwhile the VOR and OKR gains remained the same. No correlation was found between the gains of the reflexes in individual patients. This is in contrast to earlier observations in elderly subjects and subjects with labyrinthine defects, who showed increases in COR gain and decreases in VOR gain. CONCLUSIONS: Impaired neck motion, altered proprioception of the neck, or disorganization in the process of VOR plasticity could explain the lack of change in VOR gain.

Determinants of long-term outcome of patients with reflux-related ear, nose, and throat symptoms.

Gastroesophageal reflux disease (GERD) is present in up to 75% of patients with chronic refractory ear, nose, and throat (ENT) symptoms, and proton pump inhibitor (PPI) therapy induces symptom relief in the majority of these patients. It has been suggested that endoscopic findings and quantification of esophageal acid exposure may help to predict the long-term outcome of medical therapy, but prospective studies that confirm this hypothesis are lacking. The aim of the present study was to investigate the relationship of endoscopic findings and quantification of reflux with long-term outcome in patients with reflux-related ENT symptoms. One hundred six consecutive patients with chronic refractory unexplained ENT symptoms underwent upper GI endoscopy, 24-hr dual-channel esophageal pH and Bilitec (n = 35) monitoring, and esophageal manometry. Subsequently, all were treated with omeprazole, 20 mg b.i.d., and patients were followed at 2-week intervals until symptom relief. Four weeks later, omeprazole therapy was gradually decreased and the lowest effective omeprazole maintenance dose, if any, was determined. Eighty-one patients (49 men; mean age, 50) experienced a clear or excellent therapeutic response after, on average, 4 weeks of omeprazole, 20 mg b.i.d. In 36 patients (44%; group A), PPI treatment could be stopped completely, 27 patients (33%; group B) required a maintenance dose of omeprazole, 20 mg/day, and 18 patients (22%; group C) required maintenance with omeprazole, 40 mg/day. The prevalence of reflux esophagitis was significantly lower in group A patients, who also had significantly lower distal esophageal acid exposure, proximal esophageal acid exposure, and esophageal duodenogastroesophageal reflux exposure compared to groups B and C. Multivariate analysis identified the presence of esophagitis and pathological distal esophageal acid exposure as risk factors for the need of maintenance therapy. In patients with reflux-related ENT symptoms, initial findings on upper GI endoscopy and 24-hr pH-metry help to predict the need for maintenance therapy.

Reproducibility of the Dutch version of the Voice Handicap Index.

OBJECTIVE: To investigate the reproducibility of the Dutch translation of the Voice Handicap Index (VHI) by performing a test-retest study. To determine the relationship between the test-retest differences and the VHI scores. PATIENTS AND METHODS: A group of 104 patients (56 male, 48 female) with voice complaints completed the VHI twice with a mean interval of 13 days. RESULTS: There were no differences in scores between male and female patients. There was a good correlation between the first and the second measurement (r=0.95). The difference between two VHI scores of any one patient and the total score were not related. We found that a 14-point difference in total score of the Dutch VHI for 1 patient at two points in time is significant. CONCLUSION: The Dutch version of the VHI has a good reproducibility. When used for clinical evaluation studies of patients with voice complaints, a difference of 14 points between two measurements is significant.

Characteristics and clinical relevance of proximal esophageal pH monitoring.

OBJECTIVE: It is well established that various ENT disorders and symptoms may be a manifestation of gastroesophageal reflux disease (GERD). Measuring proximal esophageal acid exposure might be useful in the evaluation of patients with suspected reflux-related ENT manifestations, but the limited available data are conflicting. The aim of the present study was to study the determinants of proximal esophageal acid exposure (PR) and to evaluate the clinical usefulness of ambulatory proximal pH monitoring. METHODS: Twenty healthy controls and 346 patients with suspected reflux disease underwent typical and atypical GERD symptom assessment, endoscopy, esophageal manometry and ambulatory combined dual esophageal pH, and Bilitec duodeno-gastro-esophageal reflux exposure (DGER) monitoring. The presence of pathological PR and its relation to symptom pattern and distal esophageal acid exposure (DR) and DGER exposure were analyzed. RESULTS: Fifty-seven patients (16%) had pathological PR. Demographic characteristics, symptom pattern, and manometric findings did not differ in patients with normal or pathological PR. Patients with pathological PR had significantly higher DR and DGER. The multivariate analysis identified only pathological DR as an independent risk factor for the presence of pathological PR (odds ratio 4.515, 95% CI 2.48-8.23, p < 0.0001). Only 20 patients (6%) had pathological proximal reflux without pathological distal acid reflux. CONCLUSION: The findings of the present article do not support routine proximal esophageal pH monitoring as a clinical tool: PR does not differentiate patients with typical or atypical GERD manifestations and depends mainly on DR.