Position paper on olfactory dysfunction

Background

Olfactory dysfunction is an increasingly recognised condition, associated with reduced quality of life and major health outcomes such as neurodegeneration and death. However, translational research in this field is limited by heterogeneity in methodological approach, including definitions of impairment, improvement and appropriate assessment techniques. Accordingly, effective treatments for smell loss are limited. In an effort to encourage high quality and comparable work in this field, among others, we propose the following ideas and recommendations. Whilst the full set of recommendations are outlined in the main document, points include the following: • Patients with suspected olfactory loss should undergo a full examination of the head and neck, including rigid nasal endoscopy with small diameter endoscopes. • Subjective olfactory assessment should not be undertaken in isolation, given its poor reliability. • Psychophysical assessment tools used in clinical and research settings should include reliable and validated tests of odour threshold, and/or one of odour identification or discrimination. • Comprehensive chemosensory assessment should include gustatory screening. • Smell training can be helpful in patients with olfactory loss of several aetiologies.

Conclusions

We hope the current manuscript will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency and generalisability of work in this field.

Surgical anatomy of the round window-Implications for cochlear implantation

BACKGROUND

The round window is an important portal for the application of active hearing aids and cochlear implants. The anatomical and topographical knowledge about the round window region is a prerequisite for successful insertion for a cochlear implant electrode.

OBJECTIVE OF REVIEW

To sum up current knowledge about the round window anatomy and to give advice to the cochlear implant surgeon for optimal placement of an electrode.

TYPE OF REVIEW

Systematic Medline search.

SEARCH STRATEGY

Search term "round window[Title]" with no date restriction. Only publications in the English Language were included. All abstracts were screened for relevance, that is a focus on surgical anatomy of the round window. The search results were supplemented with hand searching of selected reviews and reference lists from included studies.

EVALUATION METHOD

Subjective assessment.

RESULTS

There is substantial variability in size and shape of the round window. The round window is regarded as the most reliable surgical landmark to safely locate the scala tympani. Factors affecting the optimal trajectory line for atraumatic electrode insertion are anatomy of the round window, the anatomy of the intracochlear hook region and the variable orientation and size of the cochlea's basal turn.

CONCLUSIONS

The very close relation to the sensitive inner ear structures necessitates a thorough anatomic knowledge and careful insertion technique, especially when implanting patients with residual hearing. In order to avoid electrode migration between the scalae and to achieve protect the modiolus and the basilar membrane, it is recommended to aim for an electrode insertion vector from postero-superior to antero-inferior.

Influence of backside loading on the floating mass transducer: An in vitro experimental study

HYPOTHESIS

The vibration of the floating mass transducer (FMT) of a single active middle-ear implant (AMEI) is distinctly influenced by the properties of the material coupled to its back side.

BACKGROUND

In round window vibroplasty, the FMT needs to be padded against the surrounding bone opposite from the round window membrane. This represents one factor influencing its performance as a round window driver. Therefore, we examined the effects of different materials linked to the back side of an FMT on its vibration range.

METHODS

The back side of an FMT was glued to a silicone cylinder 1.0 mm in diameter and 1.0 mm - 1.5 mm in length and of 40A, 50A or 70A Shore hardness; to cartilage of equivalent size; or to a round window soft coupler (RWSC), all firmly fixed on a steel plate. The vibrations were determined by a laser Doppler vibrometer (LDV) measuring the velocity of the centre point on the front side of the FMT.

RESULTS

The materials on the back side of the FMT significantly influenced the vibration range of the FMT. The RWSC and silicone of 40A Shore hardness allowed for the highest detected velocities, while cartilage led to a distinct reduction similarly to 70A silicone.

CONCLUSION

The coupling on the back side of an FMT distinctly affects its vibration range. In this regard, the RWSC and silicone of 40A Shore hardness yield the least impairment of vibration. Thus, the RWSC may be a feasible option in round window vibroplasty when additionally connected to the FMT opposite from the round window membrane.

Position paper on olfactory dysfunction

BACKGROUND

Olfactory dysfunction is an increasingly recognised condition, associated with reduced quality of life and major health outcomes such as neurodegeneration and death. However, translational research in this field is limited by heterogeneity in methodological approach, including definitions of impairment, improvement and appropriate assessment techniques. Accordingly, effective treatments for smell loss are limited. In an effort to encourage high quality and comparable work in this field, among others, we propose the following ideas and recommendations. Whilst the full set of recommendations are outlined in the main document, points include the following: - Patients with suspected olfactory loss should undergo a full examination of the head and neck, including rigid nasal endoscopy with small diameter endoscopes. - Subjective olfactory assessment should not be undertaken in isolation, given its poor reliability. - Psychophysical assessment tools used in clinical and research settings should include reliable and validated tests of odour threshold, and/or one of odour identification or discrimination. - Comprehensive chemosensory assessment should include gustatory screening. - Smell training can be helpful in patients with olfactory loss of several aetiologies.

CONCLUSIONS

We hope the current manuscript will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency and generalisability of work in this field.

Endoscopic laser-assisted diverticulotomy without versus with wound closure in the treatment of Zenker's diverticulum

The aim of the present study was to compare the modifications of endoscopic laser-assisted diverticulotomy regarding closure of mucosal wound at the cricopharyngeal bridge. The results of 62 cases after endoscopic laser-assisted diverticulotomy without and with wound closure were retrospectively compared. After laser-assisted transection of the cricopharyngeal bridge, the mucosa wound was left open (OW) in 35 cases (56%), whereas a closure of the mucosa wound (CW) with sutures and fibrin glue was performed in 27 patients (44%). Duration of hospitalization, residual diverticular sac rate and occurrence of complications did not differ significantly between the two groups. Mean surgical time was significantly less in the OW cases. According to these results, it can be assumed that readapting and sealing the wound after transecting the cricopharyngeal bridge does not significantly reduce the complication rate. It does, however, extend the length of surgery and increases the cost of the procedure.

[Generation Y in ENT: leading a young generation of doctors]

BACKGROUND

The shortage of qualified doctors and nurses has led to a competition between hospitals. Analyzing the circumstances of the competition, nurses and doctors of so-called generation Y are important. These employees are mainly female and have different requirements compared to previous generations. Therefore, knowledge of these requirements will become a critical success factor for hospitals in the future.

METHOD

We interviewed medical students in Kiel and Hannover from 2005 to 2011 about the clinical department chosen, the criteria for choosing a specific clinic, and the importance of MD and PhD programs. In addition, we conducted an internet and Medline search for scientific studies on labor shortage, generation Y, and demographics. The data were sorted by main categories and relevance for hospitals. Statistical analyses were performed using descriptive measures.

RESULTS

We received 1,097 answers which represents approx. 75% of all students. Sixty-seven percent of the students were female, 33% male. Preferences for departments revealed internal medicine, pediatrics, and anesthesiology as the top three. ENT followed at rank 10. The main criteria for choosing a clinic were working climate, structure and broadness of education, family friendliness, and respect. MD programs were rated 2.6, while PhD programs were rated 3.6. Staff members of Generation Y "live while working" and disagree with hierarchies. Internet and computers are part of their daily routine.

CONCLUSION

Employees of Generation Y challenge leadership in hospitals by increasing demands. However, Generation Y can increase professionalization and competitiveness for hospitals significantly.

[The shortage of qualified staff in Germany: a survey on head physicians' expectations of young doctors]

BACKGROUND

The shortage of medical specialists in Germany has led to increased competition between hospitals, particularly in the recruitment of young skilled doctors. The quality of training appears to be the critical factor in a clinic's recruiting process. At the same time, the suitability of candidates is decreasing. There is currently no data on the suitability of candidates for otorhinolaryngology, nor are there any forecasts about the labor shortage in this speciality.

METHODS

We compiled a questionnaire according to accepted guidelines, which was then sent to 160 ENT departments by email. We asked about the size and location of the department and the number of applicants that were suitable or unsuitable. Finally, we asked about the current availability of staff as well as the requirements set by the head physician.

RESULTS

The response rate was 34% (54 questionnaires). Departments received an average of 20 applications per year, of which 36% were unsuitable. Departments received more applications in the new German states than in the old; however, no difference in the quality of candidates was seen. University hospitals receive almost three times more applications than other hospitals. The size of the department correlates with the number of applications and quality of the candidates. Almost 60% of chief physicians expected the lack of qualified staff to worsen in the future. However, 40% of chief physicians of large departments (> 50 beds) expected the situation to improve or remain unchanged. Chief physicians' main expectations of candidates included commitment, independent learning and team spirit.

CONCLUSIONS

A broad and structured residency program for new employees is the most important factor in the recruitment of new physicians. Large departments and university hospitals have advantages here. The expectations of head physicians differ from those of young staff in terms of commitment and autonomous learning.

Experiments on the coupling of an active middle ear implant to the stapes footplate

BACKGROUND

Although the function of active middle ear implants in cases of intact ossicular chains and ventilated middle ears is well known, information about sound transfer function to the inner ear in cases of chronic middle ear effusion and defective middle ear structures is needed. A temporal bone model was developed to measure (1) the coupling of the active middle ear implant Vibrant Soundbridge in cases of nonventilated radical cavities, and (2) the effect of effusion and cartilage shielding.

METHODS

Three fresh human temporal bone specimens were studied. After preparation of a radical cavity, the floating mass transducer was coupled to the stapes footplate. The transducer was stimulated with 50 mV multisinus signals and inner ear fluid vibration was measured using a microphone in the round window niche. Several coupling conditions were simulated with mass and stiffness variations and cartilage shielding.

RESULTS

Coupling modality and prestress have the most influence on the sound transfer function to the inner ear. Cartilage shielding may ensure better coupling of the FMT to the footplate. The effect of middle ear effusion is negligible.

CONCLUSION

The Vibrant Soundbridge provides good sound transfer to the inner ear not only in cases of coupling onto an intact ossicular chain in a ventilated middle ear but also in cases of coupling to the stapes footplate in non-ventilated radical cavities.

Clinical results with an active middle ear implant in the oval window

BACKGROUND

Some patients with chronic middle ear disease and multiple failed revisions, who also need a hearing aid, may benefit from an active middle ear implant. An advantage of an active middle ear implant is that the ear canal is unoccluded.

METHODS

Following extensive experimental development in temporal bones and investigations of various locations and attachments of a Vibrant Soundbridge transducer, a new titanium clip holder for the vibrant floating mass transducer was developed. This assembly is a total ossicular replacement prosthesis (TORP) that is placed on the stapes footplate. Six patients were implanted with this device.

RESULTS

Acoustic results demonstrate significantly improved gain, especially in the high frequencies, which is typically unobtainable by conventional hearing aids.

CONCLUSION

The simple procedure of placing an active TORP assembly on the stapes footplate, similar to the implantation of a passive TORP prosthesis during tympanoplasty, offers promising treatment for cases of incurable middle ear disease.

[Impact of TORP diameter on fracture of the footplate]

BACKGROUND

A columella-prosthesis is the typical reconstruction procedure of the ossicular chain in cases with a destroyed stapedial arch. Lightweight titanium prostheses are commonly used for this type of surgery. The smaller the prosthesis foot the lower the risk of dislocation and friction of the prosthesis with the bony rim of the oval niche. However, using a smaller prosthesis foot, fracture of the footplate and penetration of the prosthesis into the inner ear are conceivable.

METHODS

Using fresh temporal bone preparations, lacking the stapedial arch, in conjunction with a load cell, the force needed to fracture the footplate was measured. Different prostheses with different foot diameters (0.2 - 0.8 mm) were used in these experiments. Furthermore, a human stapes was evaluated morphologically by scanning electron microscopy.

RESULTS

The forces leading to fracture of the footplate were measured to be between 250 mN and 980 mN. Statistical analysis showed no significant difference between 0.2 mm and 0.8 mm prosthesis foots. Moreover, different forces were attributed to varying thickness of the stapes footplate. In scanning electron microscopy the rough and uneven bony surface of the footplate could be demonstrated.

CONCLUSION

Due to the uneven footplate, only punctual contact of the prosthesis foot can be achieved. Hence, the risk of footplate fracture is not considerably higher by using smaller diameters. However, the use of smaller feet in upcoming generations of TORPs seems to be appropriate.

[Vallecular cyst as a rare cause of progressive inspiratory stridor]

BACKGROUND

Vallecular cysts are frequently observed, benign masses of the upper aerodigestiv tract. Usually they appear as harmless and asymptomatic and go unnoticed by the patient. In rare cases, obstructions of the upper airway due to monstrous vallecular cysts may become life threatening.

CASE

We report on a 69-year-old otherwise healthy woman with a rapidly progressive history of dyspnea caused by a pedicled vallecular cyst. Increasing stridor prompted emergency surgical resection.

CONCLUSION

Vallecular cysts that increase in size can cause dyspnea due to obstruction of the aditus of the larynx. This case demonstrates the need for surgical treatment at an early stage of pedicled vallecular cysts.

[Olfactory dysfunction due to nasal sinus disease. Causes, consequences, epidemiology, and therapy]

Olfaction not only contributes to our quality of life but, among other functions, it is also necessary for identifying potential dangers, e.g., fire or spoilt food. In general the value of olfaction is only recognized when the sense of smell is impaired or lost. Olfactory dysfunction is diagnosed according to its cause (e.g., sinonasal, post-traumatic, post-upper respiratory tract infection, neurodegenerative, and idiopathic). At present little is known about prognostic factors for predicting resolution of olfactory loss on an individual basis. In cases of impaired olfaction due to sinonasal disease, both conservative and operative treatments have been established. Corticoids are used both topically and systemically. In cases of severe mechanical obstructions or advanced stages of nasal polyposis, FESS (functional endoscopic sinus surgery) seems to be the state of the art.

Gustatory function in chronic inflammatory middle ear diseases

HYPOTHESIS

Changes of gustatory function after ear surgery have been studied extensively. However, little is known on the influence of repeated/chronic inflammation within the middle ear on taste.

STUDY DESIGN

Prospective study.

MATERIALS AND METHODS

Forty-six patients suffering from either cholesteatoma (n = 25) or chronic otitis media mesotympanalis (n = 21) received quantitative gustatory tests. None of these patients had been operated on before these investigations.

RESULTS

Side by side comparison showed a significantly lower taste function on the anterior two thirds of the tongue ipsilateral to the site of inflammation, regardless of the diagnosis. Further analyses exhibited a trend toward greater impairment in relation to the severity of the inflammatory process.

CONCLUSION

These data are proof that taste function changes in relation to chronic middle ear diseases. It further shows that many of these alterations go unnoticed by the patients.

Assessment of olfactory function after septoplasty: a longitudinal study

AIM

Aim of the study was to evaluate septoplasty-related changes of lateralised olfactory function during both early and late postoperative periods in comparison to the preoperative situation.

MATERIAL/METHODS

Lateralised olfactory function was assessed in 30 patients using the "Sniffin' Sticks" test battery. Measurements were performed preoperatively, and 4 and 9 months postoperatively.

RESULTS

Prior to septal surgery measurements revealed significantly higher odor thresholds for the obstructed nostril compared to contralateral thresholds. No such observations were made for suprathreshold measures. Postoperatively, a significant decline of odor discrimination was found in comparison to the preoperative situation. However, there was no significant change of odor thresholds and odor identification function during the 9-month postoperative follow up. On an individual basis, one of the initially normosmic patients became hyposmic following surgery.

CONCLUSIONS

The present data indicate that odor thresholds, but not suprathreshold olfactory function, are related to nasal obstruction resulting from septal deviation. In contrast, postoperative changes were only seen for odor discrimination. Apart from psychological explanations of this finding, it may be hypothesized that these observations result from changes in intranasal airflow following surgery.

Optical measurement of nasal swellings

We introduce a new optical method to noninvasively and continuously measure the swelling process of the nasal mucosa whereby we use light of different wavelengths in the red and near-infrared range which is transilluminated through the nasal tissue and whose extinction is recorded as a function of time. From the temporal and spectral extinction data, we are able to extract characteristic parameters that describe the swelling process quantitatively by means of a regression-type parameter estimation algorithm. The method has been applied to the nasal allergen provocation test and verified on a limited number of volunteers.

[The human vomeronasal organ]

Odors influence human behavior. The perception of so-called pheromones is frequently mentioned in the context of a functional vomeronasal organ. Vomeronasal ducts can be detected in approximately half of the population. Its functionality, still a matter of debate, seems to be unlikely, at least after birth. It is easily conceivable that pheromone-induced changes in behavior are mediated through receptors in the human olfactory epithelium.

Clinical presentation of qualitative olfactory dysfunction

Many patients with olfactory dysfunction not only experience quantitative reduction of olfactory function, but also suffer from distorted olfactory sensations. This qualitative dysfunction is referred to as parosmia (also called "troposmia") or phantosmia, with the major difference that distorted olfactory sensations are experienced in the presence or absence of an odor, respectively. Our clinical observations corroborate the literature in terms of a general underestimation of the incidence of olfactory distortions. Based on selected cases we try to show that olfactory distortions exhibit a large variance in their clinical appearance. Further, emphasis is placed on the fact that only a detailed and directed history of the patient can provide cues to the correct diagnosis.

[Modeling light distribution in nasal tissue structures]

There are different applications in the field of optical diagnostics in which the theories explaining the light transport in tissue do not lead to simple solutions for complicate geometric conditions. In these cases the Monte Carlo method provides a powerful tool to solve this problem statistically. In order to simulate the light transport in the nasal region a model was created which includes the structure depending on the swelling of the mucous membrane as well as the Monte Carlo model. Using this model it is possible to evaluate the measured values qualitatively. However, due to the long distance between light source and detector the statistical error becomes a major problem for reliable statements.

Tremor in otosurgery: influence of physical strain on hand steadiness

BACKGROUND

The microscopically small middle ear structures require the otosurgeon to have a steady hand because instrument stability is a critical factor for a successful microsurgical procedure. Hand steadiness is mainly influenced by the tremor movements of the hand. The aim of this study was to measure hand tremor under simulated microsurgical conditions and to estimate the influence of different kinds of physical strain (e.g., physical exertion and hand exercise), as well as food abstinence and coffee consumption. Further, the effect of one-or two-handed manipulation and microsurgical experience was investigated.

METHODS

The hand movements of 16 adult subjects were assessed during a defined manual manipulation using a stapes model to simulate microsurgical procedures. A laserinterferometric-based displacement technique was developed to measure tremor amplitude and frequency, as well as maximum displacement, to evaluate the subjects' fine motor skills.

RESULTS

The mean tremor frequency across all measurements was 8.1 Hz and did not show any dependence on different kinds of physical strain. Two-handed manipulations showed significantly lower tremor amplitudes than one-handed performances. Tremor amplitude and maximum displacement did not change after hand exercise, food abstinence, and coffee consumption. However, after physical exertion, a significant increase in the tremor amplitude was found. Subjects with advanced microsurgical experience showed smaller tremor amplitudes for one-handed runs.

CONCLUSION

The tremor data are interpreted as a recommendation to avoid physical exertion before microsurgery. In cases of absolute necessity for hand steadiness, two-handed manipulations are preferable. Further, hand steadiness might be improved by microsurgical training and experience.

A threshold-like measure for the assessment of olfactory sensitivity: the "random" procedure

Many tests of olfactory dysfunction are either too complex, too expensive, or too time-consuming to be of use in routine clinical testing. Thus, the present multicenter study was undertaken to investigate a new approach, the so-called "random" test. In this test different concentrations of citronellal and phenyl ethyl alcohol are applied according to a pre-established order; patients are asked to identify the odor if possible. The test score is the sum of correctly identified odors. Test administration takes about 10 min. Two studies were performed. Basic characteristics of the test were explored in experiment 1 in 176 healthy subjects (76 male, 100 female; age 12-85 years, mean age 30 years), namely test-retest reliability, correlation with other measures of olfactory sensitivity, and sensitivity of the test to differences in age and gender. In the second experiment the test was tried in 97 patients (45 male, 52 female; age 19-78 years, mean age 47 years) in a clinical environment to investigate its usefulness in diagnosing olfactory loss. The "random"-test was found (1) to exhibit a test-retest reliability similar to that reported for established measures of olfactory function (r = 0.71; P < 0.001), (2) to correlate with other measures of olfactory sensitivity (0.82 > r > 0.60; P < 0.001), (3) to differentiate between expected differences in olfactory sensitivity in relation to gender (t > 2.602, P < 0.011), and (4) to discriminate between different degrees of olfactory loss (F > 36.6, P < 0.001). Based on these data, and the fact that the new test requires little time and is easy to use, this approach can be expected to suit clinical needs.

Middle ear mechanics and their interface with respect to implantable electronic otologic devices

The understanding of construction principles of the middle ear and its mechanical behavior is valuable in the development of implantable hearing aids, as these devices have to adapt to the mechanics of the normal middle ear for optimal function. The input of the vibrational energy of a transducer into the ossicular chain follows the same mechanical fundamentals as in passive prostheses. Many aspects of middle ear mechanics, which are relevant for the acoustic quality of ossicular prostheses thus are also applicable for implantable transducers: the direction of vibrational mode, the stability of the contact zone between driver and ossicles, the increase of mass and impedance of the vibratory elements in the middle ear, the performance at changes of ambient air pressure, the potential feed back effects, and so forth.

Frequency and localization of the putative vomeronasal organ in humans in relation to age and gender

OBJECTIVES/HYPOTHESES

In many species the vomeronasal organ (VNO) serves as a chemosensory organ in addition to the olfactory system. The present investigation was undertaken to study 1) the frequency of monolateral or bilateral detection of the putative VNO (pVNO) in humans, 2) its localization in humans, and 3) whether detectability of the pVNO varies with age or gender.

STUDY DESIGN

Prospective.

METHODS

A total of 173 subjects participated in this study (88 women and 85 men; age range, 2-91 y). Inspection of the nose was performed with a speculum and a 30 degrees endoscope. The exact localization of the VNO was measured with custom-built rulers.

RESULTS

The study revealed the following major results: 1) A pVNO is detectable in approximately two-thirds of the population and bilateral pVNOs are present in approximately 40% of investigated subjects, 2) its localization on the left and right nasal septum is almost symmetrical, and 3) and detectability of the pVNO is not related to age or gender.

CONCLUSIONS

The present data indicated that the pVNO is present in approximately two-thirds of the population. This value may be biased by methodological or biological factors; nevertheless, it indicates that the pVNO is not observed in all humans regardless of age and gender. Thus, considering its variability in shape and immunohistochemical characteristics and the missing nerval connections between the peripheral "organ" and the central nervous system, the present results are not suited to argue for a functional significance of the pVNO in humans.

[Visualization of cochlear implant electrode movements in the cochlea by using x-ray microscopy]

BACKGROUND

The movements of the electrode cable of a cochlear implant inside the cochlea during the insertion procedure generally are invisible, even in temporal bone experiments. Yet, the development of new designs of electrodes, their positioning near to the modiolus etc. requires an exact knowledge on the dynamic behaviour of the electrodes inside the cochlea. The exclusive method for looking through the undamaged cochlea walls is by x-ray technique.

METHODS

A specific x-ray tube with a focal spot size of barely 5 microns allows useful direct magnifications of more than 20-30 times. We performed temporal bone experiments with this tube and studied the behaviour of conventional and perimodiolar electrode cables of a MedEl-Cl during the insertion procedure under fluoroscopic viewing.

RESULTS

The high resolution imaging revealed the influence of stiffness of the electrode cable on the insertion depth of a conventional electrode. If the angle of the direction of insertion was too steep, the resulting kinking of the cable at the medial wall of the basal turn was instantly visible. The direct visualisation of the movements of the cable was useful in optimizing the design and stiffness of various prototypes of perimodiolar electrodes for a deep insertion.

CONCLUSIONS

The dynamic examination technique disclosed that the stiffness of actual electrode cables is not optimally adapted to the form of the cochlear cavity for deep insertion. The non-destructive visualisation technique will facilitate the development of advanced electrode design, especially for various concepts of perimodiolar electrodes.

[Intraoperative measurement of stapes mobility using a hand-guided electromagnetic probe]

BACKGROUND

The hearing results of otosurgery are still unsatisfactory. Even after successful implantation of middle ear prostheses there often remains an air bone gap of 30 dB or more. As possible reasons dislocation of the prostheses due to scar growth, changes in prostheses' attachment or ventilation disorders are being discussed. Decreased stapes mobility, which has been judged only manually up to now, is supposed to be a further reason.

METHOD

We are introducing a new electromagnetic probe. The output signal of this device is proportional to the impedance of the stapes-annular ligament cochlear fluid system at the sensor's resonance frequency (2.4 kHz). The advantage of this system is characterised by its hand-guidance. Injury of the sensitive stapes-annular ligament due to tremor movements of the surgeon can be excluded using a special construction of the sensor head. The maximum force of the sensor's tip onto the stapes during measurement is limited to below 5 mN.

RESULTS

Preliminary measurement results of 20 patients are presented with normal and abnormal stapes mobility. These results are compared to the subjective impression of the surgeon, who usually tested the stapes mobility by hand. As a result of our investigations probe measurements can detect more exactly decreased mobility of the stapes than the surgeon.

CONCLUSIONS

Our device may help to detect latent stapes fixation caused by chronic inflammation of the middle ear. The intraoperative measurement of stapes mobility may influence the strategy of the surgeon. Furthermore it would be helpful in patient consulting prior to a revision-tympanoplasty with predicting the potential hearing improvement.

[Normal sense of smell in Kallmann syndrome. A case report]

BACKGROUND

Kallmann's syndrome (KS) was first mentioned in 1944 as an association of anosmia and hypogonadotropic hypogonadism. Causes are multiple genetic defects the most common of which is the x-linked KS appearing mostly in men. However, autosomal dominant and autosomal recessive forms have also been described.

PATIENT

We present a case of KS with normosmia (male, 39 years of age). All symptoms of hypogonadotropic hypogonadism were present.

RESULTS

Psychophysical olfactory testing revealed left-sided anosmia with right-sided normosmia which was confirmed by electrophysiological measures of olfactory function. Magnetic resonance imaging indicated aplasia of the left olfactory tract and bulb, whereas the right-sided structures appeared to be normal.

CONCLUSIONS

As indicated in this case with lateralized anosmia and contralateral normosmia, overall olfactory function strongly depends on the "best" nostril. Therefore, in many clinical situations, lateralized olfactory testing appears to be extremely important.