[Often not considered during Expert opinion: Patients after accidents or noise traumata - A patient-focused, complementary perspective]. / Bei der Begutachtung oft nicht bedacht: Unfallpatienten und Patienten nach einem Lärmtrauma ­ Eine patientenzugewandte, komplementäre Sichtweise.

Patients who have acquired tinnitus in the context of an accident, a noise trauma or other external influences have important distinctive features in treatment. Although their suffering was in general caused by external circumstances or other people and mostly without own fault, they suffer from a permanent damage, difficult to be realized externally. Additionally they must concentrate their remaining resources to deal adequately with their suffering from tinnitus and very often permanent hearing loss. Legal disputes and the assessment processes necessary in this context can have an unfavorable and perpetuating effect. These influences and patient's reception is laid down here.

[Hidden hearing loss-damage to hearing processing even with low-threshold noise exposure?] / "Hidden hearing loss" ­ Schäden der Hörverarbeitung auch bei niederschwelliger Lärmbelastung?

BACKGROUND: New research in animal models indicates that even at lower intensities, noise exposure can induce defects in the synapses of the auditory pathway. However, only very high levels of noise exposure lead to mechanical hair cell damage with lesions of the inner ear and measurable hearing loss (audiogram; distortion product otoacoustic emissions, DPOAE). This paper revises the literature, starting with a case study. CASE HISTORY: A 41-year-old patient suffered from hearing loss and tinnitus in the right ear following a car accident with airbag deployment. Hearing loss recovered partially, tinnitus and difficulties in speech discrimination persisted. Audiometry showed typical high-frequency hearing loss (40 dB) and tonal tinnitus (8 kHz). Although DPOAE and ABR potentials (auditory brainstem response, wave III and V) were completely normal 6 months after the accident, there was no detectable cochlear action potential (CAP) in electrocochleography (ECochG). DISCUSSION: These findings indicate recovery of initial hair cell damage, whereas synaptic transformation remains reduced and slight hearing loss and poor speech perception in complex listening situations persist. This phenomenon has been described as "hidden hearing loss" in newer literature. Although similar retrocochlear lesions in the auditory pathway could be detected in animal models, valid data in humans are currently lacking because no adequate diagnostic methods are available. CONCLUSION: Noise trauma initially results in hair cell damage. After recovery, hearing loss may persist, which can be due to synaptic lesions in the first neuron. An adequate testbattery has to be developped.

[Smartphone app-supported approaches to tinnitus therapy]. / Smartphone-App-gestützte Ansätze in der Tinnitusbehandlung.

In recent years, applications (apps) for medical purposes have been developed and introduced, including apps that perform diagnostics and documentation for hearing loss and tinnitus in combination with smartphones. Even therapeutic apps, particularly for chronic tinnitus, have been launched. This review discusses the existing scientific literature for these smartphone applications. For tinnitus, Internet-based cognitive behavioral therapy has been developed and evaluated. For tinnitus therapy, introduced apps combine acoustic stimulation and music, or serve acoustic stimulation of cortical regions around the tinnitus frequency. Although these apps appear very innovative, their effectiveness has not yet been scientifically proven. A general problem associated with using smartphone apps lies in their safety in terms of possible side effects and personal data protection. However, Internet programs and apps can be a useful supplement to multimodal tinnitus therapies.

Catamnesis results of an inpatient neuro-otologic and psychosomatic tinnitus therapy 1-5 years after discharge.

Treating tinnitus with the resources offered in hospitals can become necessary for patients suffering from complex tinnitus if a high symptom severity, usually accompanied by a corresponding psychosomatic comorbidity, is present. For such costly therapies, for example, the neuro-otologic psychosomatic tinnitus therapy (NPT) examined here, the long-term effect is particularly important; however, reliable catamnesis studies for inpatient treatments are not yet available. Data from 169 (from a total of 327 contacted) inpatients suffering from complex tinnitus were analysed here. To assess the tinnitus stress, the Mini-Tinnitus Questionnaire (Mini-TF12-In German language) according to Hiller and Goebel [1], and for the assessment of the anxiety and depression element, the German version of the Hospitality Anxiety and Depression Score (HADS) [2] were analysed at the start of the therapy, at the end of the therapy and at the earliest 1 year (up to 5 years) after discharge from inpatient treatment. The data were correlated with the current hearing status. In addition, the subjectively perceived effect factors of the therapy as well as the therapies continued outside of hospital were queried. On average, the therapy lasted 39.3 days (SD 13.6) = 5.6 weeks, and the mean of the follow-up time was 38.5 months (12-70 months) (SD 18). The therapy focused on daily neuro-otologic counselling, the improvement of the concrete hearing ability, an audio-therapy as well as frequent individual and group psychotherapy based on neuro-otology. 53.8 % of patients experienced relevant hearing loss (according to WHO criteria) which needed to be treated in addition to tinnitus. Both at the end of the therapy and the follow-up consultation, a significant improvement of the tinnitus stress and a continuing significant improvement of the depression and anxiety element could be achieved in the HADS with high effect levels ranging from 1 to 2.5. Patients who did not improve (n = 7) or even deteriorated (n = 2) demonstrated increased hearing impairment, requiring hearing aids. During the therapy, particularly, the neuro-otologic counselling, the psychotherapy, and the audio-therapy were experienced as effective. After discharge from hospital, especially, the progressive muscle relaxation according to Jacobsen was continued, as well as psychotherapy. With the corresponding symptomatic suffering, an inpatient hospitalisation and tinnitus therapy with neuro-otologic and psychosomatic alignment can achieve medium-to-high-grade therapeutic effects. This requires a disorder-specific approach, which also includes the elements of neuro-otologic counselling, psychotherapy as well as audio-therapy, and the possibility of providing hearing aids and an approach which aims at the continuation of the therapies experienced as helpful.

[Inner Ear Hearing Loss]. / Innenohrschwerhörigkeit.

Hearing loss is one of the most dominant handicaps in modern societies, which additionally very often is not realized or not admitted. About one quarter of the general population suffers from inner ear hearing loss and is therefore restricted in communicational skills. Demographic factors like increasing age play an important role as well as environmental influences and an increasing sound and noise exposure especially in leisure activities. Thus borders between a "classical" presbyacusis - if it ever existed - and envirionmentally induced hearing loss disappear. Today restrictions in hearing ability develop earlier in age but at the same time they are detected and diagnosed earlier. This paper can eventually enlighten the wide field of inner ear hearing loss only fragmentarily; therefore mainly new research, findings and developments are reviewed. The first part discusses new aspects of diagnostics of inner ear hearing loss and different etiologies.

[Evidence and Lack of Evidence in the Treatment of Tinnitus]. / Evidenz- und Evidenzlücken der Tinnitustherapie.

A broad variety of therapeutic regimen is proposed, introduced and sold against tinnitus, but most of these approaches lack scientific validation and evidence. Up to date a causal, tinnitus eliminating therapy is not available. Most probably this will not be possible at all, as the mechanism of tinnitus generation are multiple and include peripheral as well as central or cortical reactions. Like in fashion and design however, therapeutic medical interventions against tinnitus come in waves again and again over the last decades, without being able to prove lasting and scientifically evident effects.This review presents, discusses and assesses almost all available therapies regarding their evidence. Evidence should include besides external evidence through publications and available data also internal evidence, e.g. including experience of the therapist and needs of the patients.Almost all interventions that try to influence the inner ear or the auditory cortex either pharmaceutically or by direct stimulation or modulation do not reach evidence. However, there are procedures that have proven to be effective and show at least certain degrees of evidence with proven strength of effect. These are habituation therapies and psychotherapeutic interventions like cognitive behavioural therapy, especially when they are combined with concrete measures to improve auditory perception like hearing-aids, cochlear implants or hearing-therapy.

[Pre- and posttreatment results of an inpatient neurotologic and psychosomatic tinnitus therapy]. / Prä- und Post-Ergebnisse einer stationären neurootologisch fundierten und psychosomatischen Tinnitustherapie.

BACKGROUND: Inpatient treatment of chronic complex tinnitus can be necessary for patients with a high symptomatic strain, mostly accompanied by a corresponding mental comorbidity, and/or for patients that can only perceive their psychogenic suffering through somatization into tinnitus. METHODS: We report the results of 368 consecutively treated inpatients with chronic complex tinnitus. Patients' audiometric data were collected, and at the beginning and end of treatment, the Mini-Tinnitus Questionnaire (Mini-TQ12; Hiller und Goebel) was completed, as was the German version of the Hospitality Anxiety and Depression Score (HADS). Effect sizes were calculated for both questionnaires. Mean treatment duration was 38.8 days (standard deviation, SD: 13.6 days). The main therapeutic elements were intensive disorder-specific neurotologic counselling and psychoeducation; improvement of hearing by fitting of hearing aids, complemented by an individualized hearing therapy; and intensive individual and group-based psychotherapy. RESULTS: In addition to tinnitus, 82.1% of the patients had reduced hearing requiring rehabilitation with hearing aids. After hospitalization, a highly significant improvement in tinnitus strain could be demonstrated by the Mini-TQ12. Furthermore, a significant reduction in the depression and anxiety components of HADS was also achieved, with high effect sizes of 1.6 to 2.2. No reduction of tinnitus symptoms to a medium- or low-range level was experienced by 8.9% of patients. CONCLUSION: With corresponding symptomatic suffering, disorder-specific inpatient tinnitus treatment comprising neurotologic and psychosomatic alignment can achieve medium- to high-range therapeutic effects.

[On the interdisciplinary S3 guidelines for the treatment of chronic idiopathic tinnitus]. / Zur interdisziplinären S3-Leitlinie für die Therapie des chronisch-idiopathischen Tinnitus.

INTRODUCTION: Tinnitus is a frequent symptom, which, particularly in combination with comorbidities, can result in a severe disease-related burden. Chronic idiopathic tinnitus (CIT) is the most frequent type of tinnitus. A considerable number of treatment strategies are used to treat CIT-for many of which there is no evidence of efficacy. In order to enable scientific evidence-based treatment of CIT, German interdisciplinary S3 guidelines have recently been constructed for the first time. Here we present a short form of these S3 guidelines. MATERIALS AND METHODS: The guidelines were constructed based on a meta-analysis of the treatment of chronic tinnitus performed by the authors. Additionally, a systematic literature search was performed in the PubMed and Cochrane Library databases. Furthermore, a systematic search for international guidelines was performed in Google, as well as in the Guidelines International Network and National Guideline Clearinghouse (USA) database. Evidence was classified according to the Oxford Centre for Evidence-Based Medicine system. RESULTS: According to the guidelines, alongside counselling, manualized structured tinnitus-specific cognitive behavioral therapy (tCBT) with a validated treatment manual is available as evidence-based therapy. In addition, the guidelines recommend concurrent treatment of comorbidities, including drug-based treatment, where appropriate. Particularly important is treatment of anxiety and depression. Where a psychic or psychiatric comorbidity is suspected, further diagnosis and treatment should be performed by an appropriately qualified specialist (psychiatrist, neurologist, psychosomatic medicine consultant) or psychological psychotherapist. In cases accompanied by deafness or hearing loss bordering on deafness, cochlear implants may be indicated. CONCLUSION: No recommendations can be made for drug-based treatment of CIT, audiotherapy, transcranial magnetic or electrical stimulation, specific forms of acoustic stimulation or music therapy; or such recommendations must remain open due to the lack of available evidence. Polypragmatic tinnitus treatment with therapeutic strategies for which there is no evidence of efficacy from controlled studies is to be refused.

[Newest therapeutic approaches for chronic tinnitus]. / Neueste Behandlungsansätze bei chronischem Tinnitus.

In the majority of cases, tinnitus derives primarily peripherally, from damage to hair cells in the inner ear; suffering and annoyance, however, are caused by central cortical processing and functional networks of cerebral plasticity. Therefore, new therapeutic approaches aim to influence these structures; whether it be directly by magnetic radiation, or via direct or indirect electrical stimulation. However, these methods can only be efficient if they can integrate and rehabilitate the existing hearing loss. Effective habituation therapies consist of hearing therapy, rehabilitation of hearing loss by hearing aids and psychosomatic stabilisation. In this review, different therapeutic approaches are described and valuated.

Fibrinogen is not a prognostic factor for response to HELP-apheresis in sudden sensorineural hearing loss (SSHL).

Higher levels of fibrinogen or cholesterol were associated with improved hearing recovery in SSHL patients after treatment with HELP-apheresis (Heparin-induced extracorporeal LDL precipitation apheresis). The present trial was performed to demonstrate HELP-related effects on relevant metabolic and inflammatory parameters in the context of SSHL treatment. In the framework of a single arm non-controlled trial, we investigated the variation of metabolic and inflammatory parameters using HELP-apheresis for a defined group of 100 patients with SSHL. Based on cut off inclusion criteria (Serum LDL-cholesterol >1.6 g/l and/or fibrinogen >2.0 g/l, SSHL in minimum three frequencies more than 30 dB, time after event not longer than 6 days), the protocol followed a strict time line with one single shot HELP-apheresis and follow-up monitoring including laboratory parameters at six defined time points. If HELP-apheresis could not effect improvement of hearing on day 5, additional corticosteroid treatment was applied. Concentration of anti-inflammatory IL-10 increased while other proinflammatory parameters declined. Serum levels of all measured sterols and apolipoproteins decreased significantly. None of the investigated parameters were suitable to predict hearing improvement of the patients. Levels of fibrinogen and LDL-cholesterol were not prognostic for outcome after HELP-apheresis. A significant (p < 0.001) increase of anti-inflammatory IL-10 after apheresis was notable, while most of the proinflammatory parameters declined. Despite the limited validity of a single arm non-controlled trial, these alterations on immune modulating factors indicate possible secondary pleiotropic effects caused by HELP-apheresis.

Patients with long-lasting dizziness: a follow-up after neurotological and psychotherapeutic inpatient treatment after a period of at least 1 year.

Patients who experience chronic dizziness are considered to be difficult to treat. Persisting symptoms of vertigo can be caused by recurrent organic as well as a variety of psychogenic factors, the latter usually being part of anxiety and depression disorders. Psychotherapeutic interventions can achieve improvements, the effects, however, in general do not persist over a longer time. The purpose of this study is to investigate the long-term effects of a symptom-related indoor treatment including neurotological and psychotherapeutic approaches as well as vestibular and balance rehabilitation. 23 indoor patients 16 male patients and 7 female., mean age 56.6 years (SD 12) with chronic vestibular symptoms (longer than six months), who were treated with neurotological counseling, psychotherapy, vestibular and balance rehabilitation and-if necessary-antidepressant drugs during a lengthy hospital stay [average 40 days (SD 14)], were re-examined. After a time period of at least one year (average 32 months; SD 15) they were asked to answer a questionnaire concerning post-therapeutic status of dizziness, symptoms and coping strategies as well as the Hospital Anxiety and Depression Score (HADS D). 18 of 23 patients (78%) reported a sustained reduction in their vertiginous symptoms. Four patients did not report a persistent improvement and one even got worse. Patients with a chronic form of dizziness can improve through a coordinated neurotologic and psychotherapeutic approach including vestibular and balance rehabilitation.

[Detection of hearing loss in dementia patients : pilot study and literature survey]. / Detektion von Schwerhörigkeiten bei dementen Menschen : Pilotstudie und Literaturübersicht.

There is a higher incidence of dementia among people with hearing loss, although the complex interrelation is not yet understood. The potential influence of hearing rehabilitation is also unclear. A previously published retrospective study on this topic throws doubt on the ability of dementia patients to accomplish audiometric tests. Therefore, we conducted a pilot study to analyse the feasibility of applying conventional speech and pure tone audiometry in patients with dementia. In contrast to previously published data, we were able to achieve reproducible results in almost all patients. The difficulty associated with audiometric testing in dementia patients does thus not seem to lie in the application of pure tone and speech audiometry. On the basis of evidence indicating the importance of central hearing loss in the elderly, these tests alone do not appear sufficient. It is of greater interest to ascertain whether central hearing loss is relevant in patients suffering from dementia and whether corresponding audiometric tests are feasible.

[Dementia and otorhinolaryngologic practice]. / Der demente Patient in der HNO-Praxis.

The interaction between sensorial registration of peripheral stimuli and their central cognitive processing is not yet understood. The role of sensory deficits such as olfactory deterioration or hearing loss in the development of dementia is currently a focus of concern, with hopes of finding new diagnostic aspects and therapeutic options for multimodal treatment concepts in patients with dementia. The expertise of ENT specialists in the diagnostic and therapeutic fields of dysphagia, vestibular dysfunction and olfactory or hearing loss could make an important contribution to the development of future strategies for dealing with dementia. In this report we present up-to-date basic knowledge and ENT-specific aspects relating to the diagnostics and treatment of dementia.

[Hearing function and hearing loss in the elderly]. / Hörfähigkeit und Schwerhörigkeit alter Menschen.

Statistically, hearing function decreases with advancing age, but not all people are affected to the same extent. Environmental influences, such as noise exposure in particular, also play an important role in the development of hearing loss. Since the functional capacity of parts of the central auditory processing system can also diminish with age, these should also be evaluated in diagnostic procedures. Rehabilitative treatment of older people with hearing aids in particular, has to be improved. Audiotherapy can enhance the acceptance of hearing aids and optimize central auditory processing.

[Chronic stress as an influencing factor in tinnitus patients]. / Chronischer Stress als Einflussgröße bei Tinnituspatienten.

OBJECTIVE: Using the Trier Stress Inventory and based on a comparison between tinnitus and psoriasis patients, it is evaluated to what extent chronic stress is a definable influencing factor among tinnitus sufferers PATIENTS AND METHODS: Psychological assessment of 114 tinnitus and 103 psoriasis inpatients was conducted using a test battery consisting of the tinnitus questionnaire (Tinnitus-Fragebogen, TF), the Trier Stress Inventory (Trierer Inventar zum chronischen Stress, TICS), a questionnaire about social support (Fragebogen zur sozialen Unterstützung, F-SozU) and the Patient Health Questionnaire (PHQ). RESULTS: On average, hospitalized tinnitus patients have significantly higher values than the normative group on the following scales: social tensions, excessive work demands, chronic anxiety, professional strain, professional discontent, lack of social acceptance and social isolation, as well as on the overall screening scale. The measured stress values of tinnitus patients did not significantly differ from those of the comparison group, i.e. the hospitalized psoriasis patients. Although both groups show increased stress levels as measured by TICS, the hospitalized tinnitus patients had significantly more psychological comorbidities. No relationship exists between the raised stress values and hearing status. CONCLUSION: Stress also has an influence on tinnitus suffering and is therefore certain to be of therapeutic relevance. In this respect, there is no significant difference between tinnitus and psoriasis patients; stress alone cannot explain the psychological comorbidity.

[Utricular function. Correlation of three investigations carried out in routine practice]. / Utriculusfunktion. Korrelation von drei in der HNO-Praxis durchführbaren Untersuchungen.

BACKGROUND: For vestibular disorders competence in otorhinolaryngology (ENT) is required to diagnose disorders in the complete vestibular system. It seems difficult, however, to evaluate otolithic functions although the influence and importance regarding vestibular dysfunction could be relevant. Currently it is possible to unilaterally diagnose different functions of the saccule by recording cervically registered vestibular evoked myogenic potentials (c-VEMP). Partial functions of the utricle can be checked through the so-called turn-over manoeuvre during thermal examination, a gravitation-dependant caloric examination. Ocular recorded VEMPs and registration of the subjective visual vertical (SVV) are further tools for the discrimination of utricular function. This paper evaluates whether the results using these diagnostic tools are in agreement for distinct ENT-relevant vestibular disorders. PATIENTS AND METHODS: In this study 100 unselected patients attending the vestibular outpatient department of the tinnitus clinic Dr. Hesse in Bad Arolsen and who were suffering from various forms of dizziness were consecutively and prospectively examined. In addition to standard diagnostic examinations (i.e. caloric testing, rotary chair, optocinetics and posturography) the turnover manoeuvre during caloric testing, o-VEMP recording and registration of the SVV were also performed. RESULTS: For 62 % of the patients all 3 methods that measure partial functions of the utricle concurred. For an additional 6 % the results of the turnover manoeuvre and o-VEMP matched. The most conformity, with respect to sufficient utricular function was found for patients with non-vestibular dizziness, psychogenic vertigo and for the majority of patients with Menière's disease. CONCLUSIONS: In the context of specific vestibular examinations it is possible to test utricular function through o-VEMO recordings and the turnover manoeuvre during caloric (cold) testing which allow clear conclusions especially with sufficient (positive) function. With 68% conformity between o-VEMP and the turnover manoeuvre it is obvious that both tests give strong indications for possible utricular dysfunction but do not give complete proof alone. The SVV is easy to register but is discriminating for utricular function only in cases of acute disorders.

[Measuring the subjective visual vertical using a portable system: a comparison with the standard darkroom method]. / Bestimmung der subjektiven visuellen Vertikale mit einem portablen System: Vergleich mit der dunkelkammergebundenen Standardmethode.

OBJECTIVE: Assessing otolithic functions in the case of vertigo, although significant, is challenging from a practical point of view. A tilt of the subjective visual vertical (SVV) is a very sensitive sign of vestibular tonus imbalance in the roll plane. The standard method, a light bar in the dark, requires expensive, stationary equipment. However, portable equipment has been developed. The patient, who is in complete darkness afforded by a cover, sits in front of a monitor that can be seen by him and the examiner. Results obtained with this system were validated and compared with the standard application. PATIENTS AND METHODS: Measurements were taken in 100 unselected, consecutive patients suffering from dizziness treated at the Baumrain Klinik, Bad Berleburg as well as in 26 healthy volunteers. All were examined and diagnosed by an ENT physician. Measurements in all participants were taken first with the standard procedure (equipment Vertitest) followed by the portable procedure (Vertistar equipment). In each case the deviation of the absolute from the true vertical was measured and the mean differences between the two procedures calculated. These were then analyzed using a paired t-test with the help of the SPSS system. RESULTS: Comparative measurements in the dizziness group (n = 100), t(25) = 0.868, p = 0.394 and in the healthy control group (n = 26), t(99) = -0.192, p = 0.848 showed no significant differences in the distribution of SVV values while using the stationary or the portable version. Inter-test reliability was significantly positive (r = 0.852; p < 0.01, n = 126). CONCLUSIONS: The portable method for measuring SVV is practical, flexible and cost-effective and demonstrates the same diagnostic accuracy as the stationary method.