Neue Terminologie für Sprachentwicklungsstörungen?

Hintergrund

Sprachtherapeutisch-linguistische Fachkreise empfehlen die Anpassung einer von einem internationalen Konsortium empfohlenen Änderung der Nomenklatur für Sprachstörungen im Kindesalter, insbesondere für Sprachentwicklungsstörungen (SES), auch für den deutschsprachigen Raum.

Fragestellung

Ist eine solche Änderung in der Terminologie aus ärztlicher und psychologischer Sicht sinnvoll?

Material und Methode

Kritische Abwägung der Argumente für und gegen eine Nomenklaturänderung aus medizinischer und psychologischer Sicht eines Fachgesellschaften- und Leitliniengremiums.

Ergebnisse

Die ICD-10-GM (Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme, 10. Revision, German Modification) und eine S2k-Leitlinie unterteilen SES in umschriebene SES (USES) und SES assoziiert mit anderen Erkrankungen (Komorbiditäten). Die USES- wie auch die künftige SES-Definition der ICD-11 (International Classification of Diseases 11th Revision) fordern den Ausschluss von Sinnesbehinderungen, neurologischen Erkrankungen und einer bedeutsamen intellektuellen Einschränkung. Diese Definition erscheint weit genug, um leichtere nonverbale Einschränkungen einzuschließen, birgt nicht die Gefahr, Kindern Sprach- und weitere Therapien vorzuenthalten und erkennt das ICD(International Classification of Disease)-Kriterium, nach dem der Sprachentwicklungsstand eines Kindes bedeutsam unter der Altersnorm und unterhalb des seinem Intelligenzalter angemessenen Niveaus liegen soll, an. Die intendierte Ersetzung des Komorbiditäten-Begriffs durch verursachende Faktoren, Risikofaktoren und Begleiterscheinungen könnte die Unterlassung einer dezidierten medizinischen Differenzialdiagnostik bedeuten.

Schlussfolgerungen

Die vorgeschlagene Terminologie birgt die Gefahr, ätiologisch bedeutsame Klassifikationen und differenzialdiagnostische Grenzen zu verwischen und auf wertvolles ärztliches und psychologisches Fachwissen in Diagnostik und Therapie sprachlicher Störungen im Kindesalter zu verzichten.

[Diagnostic Accuracy of the LiSe-DaZ for Children with Specific Language Impairment]

OBJECTIVE

Currently, only few tests for the development of speech and language exist for bi- or multilingual children in Germany. One of those, the LiSe-DaZ (Linguistic performance measurement - German as a second language), was examined in a prospective study regarding its practicability and the sensitivity to detect children with specific language impairment in a group of children aged 5 to 7 who suffered from a severe language impairment according to clinical tests.

MATERIAL AND METHODS

74 children (mean age: 60 months; 46% monolingual German-speaking; 54% bi- or multilingual) with severe specific language impairment were examined with the LiSe-DaZ in addition to the clinical established diagnostic during their in-patient stay in the hospital.

RESULTS

The children, on average, showed in the receptive language abilities (LiSe-DaZ vs. TROG-D), the expressive vocabulary (LiSe-DaZ vs. AWST-R or WWT) and in the use of prepositions (LiSe-DaZ vs. Ravensburger Dysgrammatical clinical trial) significantly (p<0,0005) better results in the LiSe-DaZ. Thus, the majority of children were diagnosed as language impaired by clinically established tests whereas the LiSe-DaZ considered the children's language development to be normal. This difference was consistently more prominent for children with German as a second language.

CONCLUSIONS

Compared with the clinically established tests, the informative value of the LiSe-DaZ turned out to be insufficient. The LiSe-DaZ does not detect children with the need of language therapy. Nevertheless, a norming of the established speech tests for bi- or multilingual children would be desirable to avoid unfounded judgements.

Disruption of the ATE1 and SLC12A1 Genes by Balanced Translocation in a Boy with Non-Syndromic Hearing Loss

We report on a boy with non-syndromic hearing loss and an apparently balanced translocation t(10;15)(q26.13;q21.1). The same translocation was found in the normally hearing brother, father and paternal grandfather; however, this does not exclude its involvement in disease pathogenesis, for example, by unmasking a second mutation. Breakpoint analysis via FISH with BAC clones and long-range PCR products revealed a disruption of the arginyltransferase 1 (ATE1) gene on translocation chromosome 10 and the solute carrier family 12, member 1 gene (SLC12A1) on translocation chromosome 15. SNP array analysis revealed neither loss nor gain of chromosomal regions in the affected child, and a targeted gene enrichment panel consisting of 130 known deafness genes was negative for pathogenic mutations. The expression patterns in zebrafish and humans did not provide evidence for ear-specific functions of the ATE1 and SLC12A1 genes. Sanger sequencing of the 2 genes in the boy and 180 GJB2 mutation-negative hearing-impaired individuals did not detect homozygous or compound heterozygous pathogenic mutations. Our study demonstrates the many difficulties in unraveling the molecular causes of a heterogeneous phenotype. We cannot directly implicate disruption of ATE1 and/or SLC12A1 to the abnormal hearing phenotype; however, mutations in these genes may have a role in polygenic or multifactorial forms of hearing impairment. On the other hand, it is conceivable that our patient carries a disease-causing mutation in a so far unidentified deafness gene. Evidently, disruption of ATE1 and/or SLC12A1 gene function alone does not have adverse effects.

[Vohwinkel syndrome. Hearing loss and keratoderma on the hands and feet]

The combination of sensorineural hearing loss and keratoderma on the hands and feet is rare. We report the case of a child that failed newborn hearing screening and also showed keratoderma on both hands and feet. The child's father exhibited the same constellation of symptoms, which is typical for mutilating keratoderma with deafness (Vohwinkel syndrome). This hereditary autosomal dominant disease is caused by mutation of the GJB2 gene that encodes the protein connexin 26. In our case it was highly likely that the GJB2 gene in the father carried a spontaneous mutation that was inherited by the daughter.

[Stroboscopy findings: a comparison of flexible CCD-videostroboscopy and rigid stroboscopy]

OBJECTIVE

After exclusion of morphologic laryngeal alterations by laryngoscopy the prospective study compared stroboscopy findings using a flexible distal charge-coupled device chip-optic (CCD-optic) and a rigid 70° - or 90° -laryngoscope.

MATERIAL AND METHODS

52 patients with functional dysphonia and 47 candidates for speech therapy education were checked with both examination methods. The stroboscopy results were rated randomized and pseudonymized by 3 experts assessed by a study protocol according to the European laryngological society basic protocol 2001.

RESULTS

The interrater-reliability was moderate to good. Using the flexible videolaryngoscopy less gaging, less supraglottic contraction during phonation, more often a complete glottal closure and more often a normal mucosal wave movement were found.

CONCLUSION

To get an optimal endoscopy result the combination of rigid laryngoscopy and flexible videolaryngoscopy and -stroboscopy will be recommended. Because of the variety of stroboscopic findings for the diagnosis of functional dysphonia additional the case history and functional voice examinations are necessary.

Ear symptoms in children with Fabry disease: data from the Fabry Outcome Survey

BACKGROUND

Hearing loss and tinnitus are common symptoms in Fabry disease and increase in prevalence with age. This study aimed to provide an epidemiological description of hearing impairment and tinnitus in children with Fabry disease in the Fabry Outcome Survey (FOS), an international database to assess the natural history of Fabry disease and the efficacy of enzyme replacement therapy with agalsidase alpha.

METHODS

Signs and symptoms questionnaires were completed for 543 children with Fabry disease. Pure-tone audiograms were obtained from 101 children (53 girls, 48 boys).

RESULTS

On questioning, 33% of the children (n = 179) reported subjective hearing impairment. However, when assessed by age-appropriate audiometry, only 19 of 101 patients (19%) had a persistent hearing loss at least one frequency. Of these, 14 had a high-frequency hearing loss, 4 a pan-frequency hearing loss, and 1 a pattern typical of noise-induced loss. Of the 101 children with audiometry, 44 complained of tinnitus. Only 2 children reported sudden hearing loss, which was not verified by audiometry. Children with tinnitus had greater disease severity scores.

CONCLUSIONS

Hearing loss is a well-known clinical manifestation in patients with Fabry disease. It was reported in significant numbers of children in the FOS signs and symptoms questionnaire, but confirmed in only 19% by formal audiometry. The subjective hearing impairment may have been due to middle-ear effusions in many cases. Tinnitus is a well-recognized symptom in Fabry disease and can present in childhood. The presence of tinnitus correlated with overall disease severity.

Haploinsufficiency of 16.4 Mb from chromosome 22pter-q11.21 in a girl with unilateral conductive hearing loss

We present the postnatal diagnosis of a de novo der(18)t(18;22)(p11.32;q11.21)pat, resulting in an unbalanced 45,XX,der (18)t(18;22) karyotype in a girl with conductive hearing loss on the left and ptosis of the right upper eye-lid. Unilateral ptosis was also observed in the patient's 2 years and 8 months younger sister, who grows noticeably faster and appears to be a much quicker learner. After speech therapy the patient was eventually placed in normal school. The haploinsufficient 16.4-Mb region on chromosome 22pter-->q11.21 contains 10 genes as well as many predicted genes, pseudogenes, and retrotransposed sequences with unknown functions. This observation may prove useful for prenatal diagnosis and genetic counselling of chromosome 22q11.1 gains and losses.

Validierte Diagnostik des Dysgrammatismus

BACKGROUND

Non-standardized procedures are used to evaluate, in particular, grammatical performance in most German institutions performing diagnostic procedures on children with impaired speech and language development. This makes a comparison of results difficult.

METHODS

We studied 181 boys and 72 girls aged between 5 and 6 years using four subtests of IDIS additionally to the routine procedure. Results were compared to the "degree of dysgrammatism" determined from the traditional evaluation based on expert rating.

RESULTS

The new procedure is able to divide the children into groups with normal speech and language ability, with deficits accessible to a traditional logopedic treatment, and with severe speech and language impairment that necessitates intensive treatment.

DISCUSSION

The proposed tests allow an accurate evaluation of grammatical performance instead of subjective estimates.

Hörstörungen bei Morbus Fabry

BACKGROUND

Fabry disease is an X-linked lysosomal storage disease involving deficient activity of alpha-galactosidase A, which leads initially to pain, and later to renal insufficiency, cardiomyopathy and stroke. Until now few details are available on hearing impairment in patients with Fabry disease, and especially few relating to female patients.

PATIENTS AND METHODS

We examined 43 female and 29 male patients. In this study we looked into the question of whether and to what extent patients of both genders are affected by hearing impairment.

RESULTS

Hearing loss is characteristic being more severe at high frequencies frequencies. Overall, 22 female and 15 male patients were found to have suffered a hearing loss. Patients with severe symptoms of Fabry disease usually demonstrate more prominent hearing losses.

CONCLUSIONS

Both men and women with Fabry disease are affected by hearing impairment. It seems that the hearing loss is less marked in female than in male patients. Children with Fabry disease complain of tinnitus more frequently than other children and quite early in the course of the disease.

Deficient membrane integration of the novel p.N14D-GJB2 mutant associated with non-syndromic hearing impairment

Mutations in GJB2, the gene encoding for the Gap Junction protein Connexin 26 (Cx26), have been established as the major cause of hereditary, non-syndromic hearing impairment (HI). We report here the identification of a novel point mutation in GJB2, c.40A>G [p.N14D], detected in compound heterozygosity with the c.35delG mutation in two brothers with moderate non-syndromic sensorineural HI. The mother who carried one wildtype and a p.N14D allele displayed normal hearing. The mutation leads to substitution of the neutral amino acid asparagine (N) by the negatively charged aspartic acid (D) at amino acid number 14, a position that is conserved among Cx26 of different organisms and among many other connexin isoforms. To investigate the impact of this mutation on protein function, Cx26 activity was measured by depolarization activated hemichannel conductance in non-coupled Xenopus laevis oocytes. Oocytes injected with the p.N14D mutant cRNA showed strongly reduced currents compared to wildtype. Coinjection of wildtype and mutant cRNA at equimolar levels restored the conductive properties supporting the recessive character of this mutation. Total Cx26 protein expression and cell surface abundance examined by western blotting and by quantitative immunoassays revealed that the hemichannel was properly synthesized but not integrated into the plasma membrane. In this study we have shown that the GJB2 mutation p.N14D is associated with recessively inherited HI and exhibits a defective phenotype due to diminished expression at the cell surface.

Diagnostik und Therapie der auditorischen Synaptopathie/Neuropathie

Pathological auditory brainstem responses (lack of responses, elevated thresholds and perturbed waveforms) in combination with present otoacoustic emissions are typical audiometric findings in patients with a hearing impairment that particularly affects speech comprehension or complete deafness. This heterogenous group of disorders first described as "auditory neuropathy" includes dysfunction of peripheral synaptic coding of sound by inner hair cells (synaptopathy) and/or of the generation and propagation of action potentials in the auditory nerve (neuropathy). This joint statement provides prevailing background information as well as recommendations on diagnosis and treatment. The statement focuses on the handling in the german language area but also refers to current international statements.

Hearing loss in Fabry disease: data from the Fabry Outcome Survey

Hearing loss is a common symptom in Fabry disease, but neither its natural course nor its aetiology has been defined precisely. The aim of this study was to provide a detailed epidemiological description of hearing impairment in patients in the Fabry Outcome Survey (FOS), which is the largest available database of Fabry patients. Questionnaires were completed by 566 Fabry patients, of whom 316 reported ear-related symptoms. Pure-tone audiograms from 86 patients, performed before starting enzyme replacement therapy, were analysed and compared with age- and sex-specific normal values (International Organization for Standardization, ISO 7029). When compared to an age-matched population (ISO 7029), 74% of patients had a threshold elevated above the 95th centile in at least one tested frequency. All frequencies were affected to a similar degree. However, only 14 patients (16%) were clinically affected by hearing impairment according to the age-independent World Health Organization (WHO) classification (mean threshold at 0.5, 1 and 2 kHz worse than 25 dB). Hearing loss was sensorineural in 63 patients (73%) of whom 7 patients (8%) had also a conductive component. One patient had a purely conductive hearing loss. Episodes of sudden hearing loss seemed to occur more frequently than in the general population. Men were affected earlier and more severely than women. Hearing in Fabry disease is significantly worse than in an age-matched general population but leads to clinically relevant hearing impairment in only 16% of cases. It resembles accelerated presbycusis with an additional Fabry-specific strial-type hearing loss.

Agalsidase alpha and hearing in Fabry disease: data from the Fabry Outcome Survey

Fabry disease is an X-linked lysosomal storage disorder characterized by multi-organ dysfunction, including hearing loss - mainly sensorineural. The recent introduction of enzyme replacement therapy (ERT) has resulted in improvements in renal and cardiac function, pain and quality of life. One study has also suggested small improvements in high-frequency hearing. In this paper, we study the effect of ERT on hearing in patients in the Europe-wide database - the Fabry Outcome Survey (FOS). Twenty-six patients in FOS had pure-tone audiometry performed up to 6 months before starting ERT with agalsidase alpha and after a median of 12 months of treatment. We assessed changes in hearing thresholds, expressed as deviations from the 50th centile of the normal population (International Organization for Standardization ISO 7029) to correct for age-related non-specific hearing deterioration. Hearing did not change significantly in ears with normal hearing (less than 10 dB deviation from the 50th centile of ISO 7029) or those with severe hearing loss (more than 40 dB deviation from the 50th centile of ISO 7029) at baseline. In ears with a mild or moderate hearing loss at baseline, hearing thresholds, expressed as deviations from the normal 50th centile, improved significantly by 4-7 dB at most frequencies (P < 0.05). Agalsidase alpha stabilizes, and possibly improves, hearing in Fabry patients who have not already progressed to severe hearing loss. Further follow-up of these patients will determine the longer-term effects of ERT.

Left-hemispheric dominance for articulation: a prospective study on acute ischaemic dysarthria at different localizations

Dysarthria is a frequent symptom in cerebral ischaemia. However, speech characteristics of these patients have not previously been investigated in relation to lesion site in a prospective study. We investigated the auditory perceptual features in 62 consecutive patients with dysarthria due to a single, non-space-occupying cerebral infarction confirmed by MRI. Standardized speech samples of all patients were stored within 72 h after stroke onset using a digital tape recorder. Speech samples were assessed independently by two experienced speech therapists, who were unaware of the clinical and neuroradiological findings, using an interval scale ranging from 0 to 6. Separately assessed were features of articulation, phonation, prosody, and the global severity for a total of 31 items. Extracerebellar infarctions (85.5%) were located in the lower motor cortex (14.5%), striatocapsular region (46.8%) and base of the pons (24.2%). Isolated cerebellar infarctions were present in 14.5% of patients. There was a strong correlation between the findings of both examiners, showing identical scores, or only minor differences (<1 on the assessment scale) for 80% of all items. The average severity of dysarthria was 2.9 +/- 1.3. Articulatory abnormalities were the predominant deviation characteristics, affecting in particular the production of consonants. However, phonatory and prosodic abnormalities were also frequently observed speech characteristics. As revealed by factor analysis of speech characteristics the total severity of dysarthria was mainly influenced by the impairment of articulation. Speech parameters describing characteristics of articulation and prosody showed significant side-to-side and area differences, while this effect was lacking for any voice parameter. Left cerebral lesions showed a more severe overall impairment of speech and articulation, independent of lesion topography. Thirty-eight of 62 patients were available for follow-up. Speech evaluation showed normal speech within weeks in 15 out of 38 patients (39.5%). In the other 23 patients overall severity of dysarthria was mild. This is the first prospective study which describes speech characteristics of dysarthria due to acute unilateral cerebral infarctions. We could demonstrate that dysarthria in extracerebellar infarctions was more frequently caused by left-sided lesions and that the severity of dysarthria was more pronounced in left-sided lesions independent from lesion topography. All extracerebellar lesions were located along the course of the cortico-bulbar tract fibres. Compatible with a common pathophysiological basis of dysarthria in these patients, none of the 31 speech items differed significantly between subcortical and brainstem lesions.

Recurrent laryngeal nerve paralysis (RLNP) following esophagectomy for carcinoma

BACKGROUND

The aim of this study was to report the frequency of post-operative recurrent laryngeal nerve paralysis (RLNP) following resection for esophageal carcinoma.

PATIENTS AND METHODS

Four hundred and four patients were studied. Diagnosis of post-operative RLNP was performed by indirect laryngoscopy. Tumour characteristics, surgical approach and perioperative morbidity and mortality following esophageal resection were recorded.

RESULTS

Sixty patients were diagnosed with post-operative RLNP, of whom 47 had a unilateral and 16 a bilateral lesion. RLNP was more frequently diagnosed after transhiatal resection with cervical esophagogastrostomy as compared to abdomino-thoracic resection (p=0.06). A higher rate of post-operative pneumonia was evident in patients with RLNP (33 of 63 as opposed to 90 of 341; p=0.027).

CONCLUSION

RLNP is associated with a significant morbidity, especially pulmonary complications after resection of esophageal cancer.

[Delay in the development of the auditory pathways. A differential diagnosis in hearing impairment in young infants]

BACKGROUND

Due to the increased frequency of screening tests in new-born infants, the number of subsequent examinations of very young children has increased in the Departments of Phoniatrics and Pediatric Audiology. To exclude hearing loss in young children, click stimulated brainstem evoked response audiometry (BERA) and otoacoustic emission tests are, in general, considered to be reliable methods. However, pathologic BERA thresholds and pathologic hearing reactions have been observed occasionally in young infants who show improved and even normal hearing reactions in subjective and objective hearing tests after some months.

PATIENTS AND RESULTS

Our group of 14 children (ten female, four male) was initially examined by BERA at the ages of 1-7 months. Twelve children had an elevated risk of hearing loss due to complications in the pre-, peri- and postnatal period. In the BERA, no deafness was diagnosed, but in all children at least monaural pathologic BERA thresholds were observed. Subjective hearing tests confirmed hearing loss. Objective and even subjective hearing reactions improved and normalised within a few months at least monaurally.

CONCLUSION

In very young infants, the possibility of a delayed maturation of the auditory pathways must be considered when a hearing loss is diagnosed. Our examples prove that young children with sensorineural hearing loss need more than one objective hearing examination during the first year of life.

Diagnostik und Differenzierung sprachentwicklungsgest�rter Kinder?

BACKGROUND

Specific language impairment (SLI) is defined as a developmental disorder in which language comprehension and the child's ability to use expressive spoken language is markedly below the appropriate level for his or her mental age. The intelligence of SLI children is in the normal range, while their language abilities are impaired. "Normal intelligence", the defining feature of SLI is questioned in this study.

PATIENTS AND METHODS

Using IDIS (an inventory of diagnostic information in language impairment), we examined 138 children aged 5 and 6 years with severe language impairment; 108 SLI and 30 LI children. Various indicators of speech and language such as articulation, the ability to discriminate sounds, lexicon, grammar and pragmatic abilities but also auditory and visual perception, auditory and visual memory, fine and gross motor function were assessed.

RESULTS

The performance of the SLI children was significantly higher in most of the tests than that of the LI children. Factor analysis showed that the two groups also differed in the structure of performance. Auditory short-term memory was reduced in most children irrespective of intelligence.

CONCLUSIONS

We propose the retention of the differentiation of subgroups of developmental speech and language disorders depending on the level of intelligence.

Inner ear function in children with Fabry disease

AIM

The prevalence of hearing loss in patients with Fabry disease is still uncertain. This paper examines hearing loss in a group of young patients with Fabry disease.

METHODS

A clinical ear nose and throat examination, pure-tone air and bone conduction audiometry, speech audiometry and middle ear testing (tympanometry and acoustic reflex testing) were carried out in four girls and two boys with Fabry disease (age, 7-17 years), receiving enzyme replacement therapy (ERT).

RESULTS

None of the patients complained of a hearing disorder or suffered from hearing loss. Three female patients reported tinnitus; however, this was not reported as being a problem. One boy reported tinnitus for the first time during 6 months of ERT.

CONCLUSION

Based on this small sample of patients, it appears that the hearing disorders associated with Fabry disease develop mainly in adulthood. Tinnitus may be an earlier symptom than previously thought in Fabry disease.

[Acoustic schwannoma with progressive hearing loss in children. A case report]

BACKGROUND

Neurinomas of the vestibulocochlear nerve unrelated to neurofibromatosis in children are extremely rare. Only 20 cases in children under the age of 16 are reported in the literature. Progressive unilateral hearing loss, tinnitus, vertigo and neurological deficits due to cranial nerve or brainstem compression are clinical signs.

PATIENT AND RESULTS

We report on the case of a 12-years-old girl with an unilateral hearing loss, progressing to total deafness. Otoacoustic emissions were normal. In the MRI a large cerebellopontine angle tumor was found, identified as schwannoma of the vestibulocochlear nerve.

CONCLUSIONS

The importance of MR Imaging in children with progressive unilateral hearing loss is demonstrated in this case.

[Cogan-I-syndrome. A rare differential diagnosis in progressive sensorineural hearing loss]

We report on two patients affected by Cogan's syndrome since infancy.Cogan's syndrome is described as the association of abrupt or intermittent worsening of vestibulo-auditory function and non-syphilic interstitial keratitis or, in patients with "atypical" Cogan's syndrome, various severe, inflammatory eye diseases. The first patient was affected with different inflammatory eye diseases from her fifth year and became blind in one eye when she was 7 years old. At that time, a deterioration of her hearing ability was also diagnosed. The hearing loss progressed to a severe hearing disorder. The second patient suffered from different inflammatory eye diseases from his second year. When he was 3 years old,he was diagnosed with a severe hearing disorder that progressed.Cogan's syndrome was diagnosed when he was 13 years old. The recognition of Cogan's syndrome is particularly complex in young patients. The difficulty of the diagnosis requires a search for ophthalmic diseases in young children with acute and progressive vestibulo-auditory symptoms.

[Expert assessment of oropharyngeal dysphagia]

The number of patients with chronic dysphagia is increasing as more patients with neurologic diseases and carcinomas of the head and neck can be successfully treated and survive. The expert assessment of a dysphagia should be based not only on anamnestic data, as proposed by the German guidelines "Anhaltspunkte für die ärztliche Gutachtertätigkeit im sozialen Entschädigungsrecht und nach dem Schwerbehindertengesetz," but also on clinical, endoscopic, and radiologic examinations. Modern procedures of treatment enable us to prevent aspiration or insufficient nutrition; nevertheless, dysphagia causes severe limitations for the patients.

Sensory neuropathy of the trigeminal, glossopharyngeal, and vagal nerves in Sjögren's syndrome

Isolated cranial nerve involvement in primary Sjögren's syndrome (primary SS) has rarely been described. We report the case of a patient with sensory neuropathy of the trigeminal and also the glossopharyngeal and vagal nerves, which has not been identified previously. The electrophysiological findings in our patient with primary SS confirmed trigeminal sensory neuropathy with abnormal blink reflexes and abnormal cutaneous masseter inhibitory reflexes.

Functional results after CO2 laser surgery compared with conventional phonosurgery

Treatment of benign vocal fold lesions by the use of the CO2 laser is discussed critically. The aim of the present prospective randomized study was to examine the post-operative functional results after laser phonosurgery in comparison to those after cold phonosurgery. In total, 44 patients with benign vocal fold lesions underwent surgery. Conventional cold phonosurgery was performed in 23 patients, and 21 patients were treated by laser phonosurgery. To determine vocal function, examinations were performed pre-operatively, on the second post-operative day, and one and four months post-operatively. The examinations included direct videolaryngoscopy, determination of maximal phonation, speech voice field as well as singing voice field. The results four months after surgery showed an improvement of vocal function in both treatment groups in comparison to the pre-operative findings. The improvement is only statistically significant after cold surgery.

[CO2 laser versus conventional microlaryngoscopy in benign changes of the vocal cords]

BACKGROUND

Microsurgical treatment of benign vocal fold lesions as nodules, polyps, and Reinke's edema is a routine intervention in phonosurgery. After laser treatment of malignant neoplasms of the larynx has been accepted as a technical advance by most laryngologists, use of the laser has been also proposed for benign lesions.

PATIENTS

Forty-four patients with a benign lesion of the vocal fold were randomized and operated conventionally or with the CO2-laser. Preoperatively, two days, one month, and four months postoperatively, the patients were queried about vocal problems and their subjective rating of their voice quality. Videolaryngostroboscopy was performed, the maximal phonation time was determined, and a phonetogram of the speaking and of the singing voice was registered. A phonetically balanced text and sustained vowels were registered on a DAT recorder and used for subjective rating by experienced listeners and electroacoustic analysis.

RESULTS

All parameters showed worsening immediately postoperatively and an improvement later compared to the preoperative value. There was no statistical difference between conventional treatment and CO2 laser treatment.

CONCLUSIONS

Microsurgical treatment of benign lesions of the glottis either by CO2 laser or by conventional surgery leeds to comparable results as seen in the final result.

The c-Fos transcription factor in the auditory pathway of the juvenile rat: effects of acoustic deprivation and repetitive stimulation

The expression of the inducible transcription factors (ITF) c-Fos and JunB was investigated in the dorsal cochlear nucleus (DCN), ventral cochlear nucleus (VCN) and inferior colliculus (IC) of juvenile and adult rats following deprivation and repetitive stimulation paradigms using 8 kHz tone bursts at 5 min duration and 70 dB, 90 dB or 120 dB sound pressure level (SPL). (1) During postnatal development without stimulation, c-Fos is absent in DCN and VCN from postnatal day (P) 12 to adulthood, but shows a strong expression in the IC which declines during maturation. A similar decrease was also seen in the pons. (2) Between P15 and P35 stimulation of rats with 8 kHz for 5 min at 70 dB SPL evoked expression of c-Fos in a moderate number of cells of DCN, VCN and IC. Higher sound pressure levels increased the number of c-Fos immunoreactive neurons as studied at P21. (3) Deprivation of acoustic stimulation up to P21 reduced the expression of c-Fos when rats were stimulated with 90 dB immediately after the restoration of acoustic input. In contrast to 90 dB SPL, c-Fos immunoreactivity (IR) did not significantly differ between deprived and normal rats following application of 120 dB SPL at P21. Stimulation at P28, i.e., 7 days after the end of the deprivation, evoked an increase of c-Fos only in the IC compared to otherwise normally stimulated rats. At P35, effects of the former deprivation on the c-Fos expression were not longer detectable. (4) In a repetitive stimulation paradigm, 8 kHz tone bursts 5 min in duration were applied each second day between P23 and P35 or each day between P29 and P35. When compared with acutely stimulated rats at P35, both repetitive acoustic stimulation protocols reduced the c-Fos immunoreactivity by 50%-75% in the DCN, VCN and IC. In adult 4-month-old rats, repetitive stimulation did not reduce the c-Fos immunoreactivity from its moderate levels as compared with acute stimulation. (5) In some experiments, we studied also the expression of the JunB protein. JunB paralleled the expression of c-Fos following single acoustic stimulation, but was expressed in a substantially lower number of cells. In contrast to c-Fos, however, repetitive stimulation as described in section 4 did not evoke a decrease of JunB in the lower acoustic pathway.

Vocal function following laser and conventional surgery of small malignant vocal fold tumours

In the described study, 26 patients after conventional cordectomy, and 27 patients after laser cordectomy were examined six months or more after the operation. Videolaryngostroboscopy revealed that patients after laser cordectomy more often phonate on purely glottic level (81 per cent) in comparison to patients after conventional cordectomy (19 per cent). Webs were more frequent and more extended after conventional cordectomy compared to endoscopic laser surgery. The maximal phonation time showed a very wide range with a mean value of 9 to 10 sec; there was no statistical difference between the groups of patients. Using Yanagihara's classification of sonograms, a better voice quality was measured after laser cordectomy than conventional cordectomy. The patients' estimation of their voice quality did not correlate with objective parameters.

Decreased expression of the c-Fos, but not Jun B, transcription factor in the auditory pathway of the rat after repetitive acoustic stimulation

Between the 21st and 34th postnatal days, male rats received an acoustic stimulus every second day, and the expression of c-Fos and Jun B proteins was compared with rats that received only a single acoustic stimulus at postnatal day 34. For acoustic stimulation, 8-kHz pure-tone bursts (100 ms duration at a rate of 6.3 Hz) were applied for 5 min. The numbers of neurons immunoreactive to c-Fos and Jun B were studied 2 h after the last or acute stimulus, respectively, in the ventral cochlear nucleus (VCN), dorsal cochlear nucleus (DCN) and inferior colliculus (IC). Compared with the single stimulus, repetitive stimulation significantly reduced the number of c-Fos labeled neurons in the VCN by 51%, in the DCN by 75% and in the IC by 48%. In contrast to c-Fos, repetitive stimulation did not significantly lower the number of Jun-B-expressing neurons. These findings indicate that independent intraneuronal pathways terminate on the induction of c-Fos- and Jun-B-expressing genes during the juvenile maturation of the acoustic pathway and that chronic exposure of acoustic events alters the program of intraneuronal gene expression by reducing transcriptional activities with subsequent stabilization at the genetic level.

[Effects of surgical therapy of obstructive snoring on swallowing and voice quality]

The efficacy of uvulopharyngopalatoplasty (UPPP) in treating obstructive snoring has been reported from many centers. The reduction of uvula and soft palate may result in palatal incompetence. We examined 23 patients undergoing UPPP pre- and postoperatively and found a slight preoperative hypernasality in three patients. None of our patients had problems with swallowing. During the first week postoperatively, most of the patient had hypernasality and noted a nasal escape of liquids. Three to four months after surgery, three patients still had problems swallowing. All 21 patients seen during the last follow-up examination had a nasal escape of air detected by auscultation in at least one of the tests. Two patients had an audible hypernasality. Two patients could not pronounce the letters any more. More than one year after surgery, palatal incompetence was no longer detectable.

Expression of the c-fos transcription factor in the rat auditory pathway following postnatal auditory deprivation

As an animal model for inborn hearing loss rat pups were reared in a sound-proof chamber from birth until age 21 days. In addition, pinnae were bilaterally sutured closed to reduce any influence of ambient sound. At the end of the sound deprivation, outer ear channels were reopened. Since previous studies failed to show any difference in the number or morphology of neurons in the auditory pathway in bilaterally sound-deprived animals, expression of c-fos protein was used as a functional marker to map trans-synaptic information transfer in the auditory pathway with cellular resolution. At day 21 sound-deprived rats and untreated controls were stimulated with pure tones of 8kHz for 5min at different sound pressure levels. Acoustic stimulation induced c-fos in both parts of the cochlear nucleus, superior olivary complex and inferior colliculus. Compared to untreated rats, deprivation reduced the number of c-fos labeled neurons in the dorsal and ventral part of the cochlear nucleus and inferior colliculus by 58% and 30%, respectively, following low sound pressure levels (90dB). In contrast, high sound pressure levels (120dB) increased the number of c-fos labeled neurons in these areas and evoked only minor differences in the number of labeled neurons in both untreated and sound deprived rats.

The influence of an insecticide on the function of the eustachian tube

Organophosphorus compounds in the form of insecticides are in widespread use and have recently attracted considerable interest as environmentally toxic agents. As little is known about the effect of environmental toxins on the tubal function in the ear, we studied the middle ear pressure necessary to force the eustachian tube to open (POL = pressure opening level) under physiological conditions in laboratory mini pigs and under the influence of an i.v. organophosphorus compound (Paraoxon). The median POL in the untreated animals was 6.4 kPa (n = 8). After intoxication with Paraoxon the median POL increased to 12.0 kPa (n = 8). Tubal instillation of surfactant in intoxicated pigs reduced the POL to a median of 7.3 kPa (n = 8), while in non-intoxicated animals (n = 4) it also lowered the POL, though not significantly. These results suggest that organophosphorus compound interferes with the surfactant-dependent tubal patency.

Development of aerodynamic aspects in children's voice

To determine the changes with increasing age in children this study measured the air flow and the acoustic signal in children aged 4-15 years. The subglottal pressure was estimated from the intraoral pressure during the phonation of the word 'ipipi'. From these parameters the glottal resistance and the glottal efficiency were calculated. Since these parameters depend on the sound pressure level, a linear regression of the parameters versus the sound pressure level was done, and the values for 75 dB SPL were taken for statistical analysis. The study found a subglottal pressure in younger children between 6 and 10 cm water column, which seemed to diminish with age. The phonatory flow rate was between 50 and 150 ml/s in younger children, which seemed to increase with age. The glottal resistance did not depend on age, values of 20-250 Ns/m5 at a sound pressure level of 75 dB exceed those for adults given in the literature. The measurements for the glottal efficiency showed a broad variability between 20 ppm and 400 ppm.

[Effect of auditory deprivation on maturation of auditory pathways in the rat]

To examine the influence of an auditory deprivation on the maturation of the central auditory pathways we reared newborn rats until the age of 21 days in a sound-proof chamber and additionally sutured their pinnae. At the age of 21 days we reopened the outer ear channels and placed the young rats into a normal environment. Every three days we recorded brain stem auditory evoked potentials with clicks, 1-, 8- and 16 kHz tone pulses until the age of 45 days, at the age of 60 days for the last time. Additionally all animals underwent middle latency response audiometry. Only directly after reopening the ear channels the thresholds for 8 and 16 kHz were worse in the deprived animals than in the normal ones. For clicks and 1 kHz and all testings on the other days the mean threshold response of the deprived rats did not differ from that of the normal animals. Testing with clicks, the interpeak latencies (I-IV), that is the brain stem transmission time, were prolonged significantly between the 24th and the 36th day of life. Measuring with 1 kHz tone pulses we found a difference from the 30th to the 36th day. Testing with 8 and 16 kHz tone pulses the brainstem transmission time was significantly prolonged between the 21st and 33rd day of life. The middle latency responses showed large variances, there was no significant difference. After the 36th day of life all latencies had normalised.

[Hearing ability after dissection of the vertebral nerve. A long-term study]

To prove the influence of the vertebral nerve on hearing in rabbits, the vertebral artery, together with its sympathetic plexus (n. vertebralis Frank), was unilaterally cut at the height of the first vertebral body, the atlas. Both preoperatively and several times after dissection, auditory and vestibular functions were investigated using BERA and electronystagmography. The hearing threshold was not influenced, neither in the first days after the operation nor as much as six months later. The latencies between wave I and V did not change. Similar results were to be found for the vestibular system. There was no imbalance clinically and it was not possible to detect any electronystagmographic difference between the two vestibular organs. These results indicate, that there is still no experimental proof of hearing loss, as a result of disturbance of the sympathetic vertebral nerve.

[Reduction of reactivity to allergic rhinitis with intravenous administration of calcium. Clinical-experimental study on the effect of changes of local airway resistance after nasal allergen provocation]

The antiallergic activity of calcium was investigated in 25 patients with allergic rhinitis by nasal provocation with increasing doses of phleum pratense during a symptom free interval. Prior to that provocation, the patients received 9 mmol calcium (Calcium-Sandoz) i.v. or placebo respectively (double blind cross-over design). The concentration of serum calcium increased after calcium injection by 0.45 +/- 0.055 mmol/l. Calcium exerted a significant protective effect as compared to placebo: higher allergen doses, (p = 0.021) i.e. 20433 biological units/ml vs. 7494 biological units/ml, were required in order to induce a defined allergic reaction (50% decrease of nasal air flow). The data thus furnish evidence that intravenous calcium reduces the allergic response in type I allergy.

[Middle ear effusion and allergy in childhood]

Besides mechanical or infectious factors in the genesis of secretory otitis media IgE-mediated hypersensitivity has often been discussed. In order to estimate the importance of an allergic reaction in the development of middle ear disease, we examined 27 children having adenoids and a secretory otitis media. We documented the patients' history of allergy and determined the IgE-levels in the serum, the middle ear effusions and the adenoid tissue. 5 out of 27 children suffered from an allergy of the upper respiratory tract, but only in one child we found an elevated level of IgE in middle ear effusion. On the basis of our investigations and recent literature, we suggest that an allergic rhinitis might cause an Eustachian tube dysfunction in a few patients. There is no evidence of a local allergic reaction of the middle ear mucosa.

[Treatment of zoster oticus]

On the basis of aetiology and pathophysiology a rational concept for the treatment of zoster oticus is attempted. The current literature and own experiences favour the simultaneous application of the virostatic acyclovir and glucocorticosteroids.