[Views of assistant professors on digital transformation in otorhinolaryngology education : Current status and perspectives in undergraduate and advanced training]

BACKGROUND

Digital transformation in curricular teaching in medicine comprises the use of digital teaching and learning formats as well as the transfer of digital skills for medical staff. Concepts of knowledge transfer and competency profiles also have to be adapted and transferred in advanced training due to necessary changes.

OBJECTIVE

The aim of this study was an evaluation of the current state of digital transformation in otorhinolaryngology teaching in undergraduate and advanced training at otorhinolaryngology departments of university medical centers in Germany.

MATERIALS AND METHODS

A questionnaire with nine questions on digital transformation was sent to the assistant professors of 37 national university ENT departments. The anonymous survey was conducted online via the online platform SurveyMonkey®.

RESULTS

Of the contacted assistant professors, 86.5% participated in the survey. Teaching sessions on digital skills for medical students are part of the curriculum in only 25% of ENT departments. Digital teaching formats are used by half of the departments in undergraduate training. Only 56.25% of the assistant professors receive support to realize the changes required by digital transformation. In 40.62% of departments, the issue of digital transformation is broached during advanced training, but only 28.12% use digital teaching methods to train junior doctors.

CONCLUSION

Aspects of digital transformation are implemented mainly in undergraduate education, partly driven by the COVID 19 pandemic. Overall, there is still considerable backlog in undergraduate and advanced training in ENT.

Influence of depressive disorders, stress, and personality traits on quality of life after cochlear implantation

PURPOSE

This study aimed to determine whether preoperative depressiveness, stress, and personality influence quality of life (QOL) after cochlear implant (CI) surgery.

METHODS

In this prospective study, 79 patients undergoing CI surgery were evaluated preoperatively and 12 months postoperatively. Disease-specific QOL was assessed with the Nijmegen Cochlear Implant Questionnaire (NCIQ) and general QOL with the WHOQOL-BREF. Depressiveness and stress were assessed with the Patient Health Questionnaire (PHQ-D). The Charlson Comorbidity Index (CCI) was used to classify comorbidities. The Big Five Personality Test (B5T) was used to assess the basic personality dimensions. Speech comprehension was evaluated in quiet with the Freiburg monosyllable test and in noise with the Oldenburg sentence test.

RESULTS

After CI surgery, the total NCIQ score improved significantly (Δ 17.1 ± 14.7, p < 0.001). General QOL (WHOQOL-BREF, Δ 0.4 ± 9.9, p = 0.357), stress (Δ 0.25 ± 3.21, p = 0.486), and depressiveness (Δ 0.52 ± 3.21, p = 0.121) were unaffected by CI surgery. Patients without elevated depressiveness (p < 0.01) or stress (p < 0.001) had significantly better total NCIQ scores. The results of the multiple regression analyses show that, after adjusting for the CCI, personality, age, and mental health stress (ß = - 0.495, p < 0.001) was significantly associated with postoperative NCIQ outcome scores. Depressiveness and neuroticism had the strongest influence on the generic QOL (ß = - 0.286 and ß = - 0.277, p < 0.05).

CONCLUSION

Stress symptoms and personality traits are significant predictive factors for disease-specific QOL, as well as hearing status. This should be considered in the preoperative consultation and in optimizing the rehabilitation process.

Influence of inner ear impedance on middle ear sound transfer functions

Introduction

For experimental studies on sound transfer in the middle ear, it may be advantageous to perform the measurements without the inner ear. In this case, it is important to know the influence of inner ear impedance on the middle ear transfer function (METF). Previous studies provide contradictory results in this regard. With the current study, we investigate the influence of inner ear impedance in more detail and find possible reasons for deviations in the previous studies.

Methods

11 fresh frozen temporal bones were prepared in our study. The factors related to inner ear impedance, including round window membrane stiffness, cochleostomy, cochlea fluid and cochlea destruction were involved in the experimental design. After measuring in the intact specimen as a reference (step 1), the round window membrane was punctured (step 2), then completely removed (step 3). The cochleostomy was performed (step 4) before the cochlear fluid was carefully suctioned through scala tympani (step 5) and scala vestibuli (step 6). Finally, cochlea was destroyed by drilling (step 7). Translational and rotational movement of the stapes footplate were measured and calculated at each step. The results of the steps were compared to quantify the effect of inner ear impedance changing related to the process of cochlear drainage.

Results

As the inner ear impedance decreases from step 1 to 7, the amplitudes of the METF curves at each frequency gradually increase in general. From step 6 on, the measured METF are significantly different with respect to the intact group at high frequencies above 3 kHz. The differences are frequency dependent. However, the significant decrement of rotational motion appears at the frequencies above 4.5 kHz from the step 5.

Conclusion

This study confirms the influence of inner ear impedance on METF only at higher frequencies (≥3 kHz). The rotational motions are more sensitive to the drainage of fluid at the higher frequency. Study results that found no influence of cochlea impedance may be due to incomplete drainage of the cochlea.

Influence of cochlear implantation on the working ability of hearing-impaired patients: A prospective study on potential influencing factors

PURPOSE

This study evaluates the effect of cochlear implantation (CI) on work ability. The influences of quality of life (QOL), age, mental health, and hearing were analyzed.

METHODS

Seventy-nine patients undergoing CI surgery were evaluated preoperatively and 12 months postoperatively. Work ability was evaluated using the Work Ability Index (WAI). QOL was assessed with the Nijmegen Cochlear Implant Questionnaire (NCIQ) and the WHOQOL-BREF. Mental health was assessed with the Patient Health Questionnaire.

RESULTS

The WAI was unaffected by CI (Δ 0.8 ± 6.8, p = 0.42). No significant changes in WAI were observed for employees (Δ - 1.1 ± 5.7, p = 0.25) and pensioners (Δ -0.4 ± 7.8, p = 0.73). Patients without elevated depressiveness, stress, or somatoform symptoms had significantly better WAI.The multiple regression analyses show that WHOQOL-BREF (ß = 0.49, p ≤ 0.001), age (ß = -0.34, p ≤ 0.001), and depressiveness (ß = 0.33, p = 0.04) were significantly associated with WAI. In the employee group, the NCIQ (ß = 0.58, p = 0.008) had the strongest association with the WAI.

CONCLUSION

Age, mental health, and QOL are predictive factors for work ability. This should be considered in the consultation and the rehabilitation process.

Visualization of bone formation in sheep's middle ear by using fluorochrome sequential labelling (FSL)

One factor for the lacking integration of the middle ear stapes footplate prosthesis or the missing healing of stapes footplate fractures could be the known osteogenic inactivity. In contrast, it was recently demonstrated that titanium prostheses with an applied collagen matrix and immobilised growth factors stimulate osteoblastic activation and differentiation on the stapes footplate. Regarding those findings, the aim of this study was to evaluate the potential of bone regeneration including bone remodeling in the middle ear. Ten one-year-old female merino sheep underwent a middle ear surgery without implantation of middle ear prostheses or any other component for activating bone formation. Post-operatively, four fluorochromes (tetracycline, alizarin complexion, calcein green and xylenol orange) were administered by subcutaneous injection at different time points after surgery (1 day: tetracycline, 7 days: alizarin, 14 days: calcein, 28 days: xylenol). After 12 weeks, the temporal bones including the lateral skull base were extracted and histologically analyzed. Fluorescence microscopy analysis of the entire stapes with the oval niche, but in particular stapes footplate and the Crura stapedis revealed evidence of new bone formation. Calcein was detected in all and xylenol in 60% of the animals. In contrast, tetracycline and alizarin could only be verified in two animals. The authors were able to demonstrate the osseoregenerative potential of the middle ear, in particular of the stapes footplate, using fluorescence sequence labelling.

In Vivo Thickness of the Healthy Tympanic Membrane Determined by Optical Coherence Tomography

OBJECTIVE

Tympanic membrane (TM) thickness is an important parameter for differentiation between a healthy and a pathologic TM. Furthermore, it is needed for modeling the middle ear function. Endoscopic optical coherence tomography (eOCT) provides the opportunity to measure the TM thickness of the entire TM in vivo.

MATERIALS AND METHODS

A total of 27 healthy ears were examined by eOCT. The system uses a light source with a central wavelength of 1,300 nm. The endoscope with an outer diameter of 3.5 mm provides a field of view of 10 mm and a working distance of 10 mm. Thickness measurements were carried out at 8 points on the TM. Additionally, the existing literature was analyzed, and a mean TM thickness value was determined.

RESULTS

The mean thickness of the TM over all measurement points of the pars tensa was 120.2 μm, and the pars flaccida was significantly thicker with a mean thickness of 177.9 μm. Beyond that, there were no significant differences between the single quadrants. The mean TM thickness in the literature was 88.8 μm.

DISCUSSION

EOCT provides the possibility for in vivo thickness determination of the TM. The mean thickness seems to be higher than in the previous studies, which were mostly carried out ex vivo. Our study takes the three-dimensional refraction into account and provides a method for the refraction correction.

The Dresden in vivo OCT dataset for automatic middle ear segmentation

Endoscopic optical coherence tomography (OCT) offers a non-invasive approach to perform the morphological and functional assessment of the middle ear in vivo. However, interpreting such OCT images is challenging and time-consuming due to the shadowing of preceding structures. Deep neural networks have emerged as a promising tool to enhance this process in multiple aspects, including segmentation, classification, and registration. Nevertheless, the scarcity of annotated datasets of OCT middle ear images poses a significant hurdle to the performance of neural networks. We introduce the Dresden in vivo OCT Dataset of the Middle Ear (DIOME) featuring 43 OCT volumes from both healthy and pathological middle ears of 29 subjects. DIOME provides semantic segmentations of five crucial anatomical structures (tympanic membrane, malleus, incus, stapes and promontory), and sparse landmarks delineating the salient features of the structures. The availability of these data facilitates the training and evaluation of algorithms regarding various analysis tasks with middle ear OCT images, e.g. diagnostics.

[Interprofessional evaluation of "soft skills" of students in the practical year]

OBJECTIVE

The present study deals with the implementation of a questionnaire with 360° evaluation to assess the performance of students in the practical year (PJ). A special focus is put on the "soft skills" (self-competence, methodological competence, social competence), whose evaluation in medical studies has not yet taken place comprehensively.

MATERIAL & METHODS

The study was conducted prospectively with 21 PJ students of the Medical Faculty of the TU Dresden. The assessment was performed by means of a self-designed questionnaire, which was divided into 4 sub-competencies (self-competence, methodological competence, social competence, clinical skills and abilities), which could be assessed by means of a 6-point Likert scale. Four professions were involved in the assessment: Medical Service, Nursing Service, Functional Service, and Administration.

RESULTS

On average, the strongest deficits in terms of self-confidence, willingness to perform, and ability to deal with conflict were revealed by students in the PJ. Students showed a very good performance in performing a medical history and basic skills of clinical examination.

CONCLUSION

The implementation of 360° feedback is possible and useful for students in the internship year across disciplines and professions. Such personal and interprofessional feedback has not been widely available. The questionnaire represents the first comprehensive measurement tool of soft skills for medical students and provides a good basis for comprehensive feedback.

Value of patient-reported outcome measures for evaluating the benefit of speech processor upgrading in patients with cochlear implants

BACKGROUND

Patients with a cochlear implant (CI) should be evaluated for a new speech processor every 6 years. The aim of this analysis was to assess the subjective and audiological benefit of upgrades.

METHODS

Speech understanding and subjective benefit were analyzed in 99 patients with the old and the new speech processor after 4 weeks of wearing. Speech understanding was assessed using the Freiburg monosyllabic test in quiet (FBE) at 65 dB and 80 dB, and the Oldenburg Sentence Test (OLSA) at 65 dB noise with adaptive speech sound level. The Abbreviated Profile of Hearing Aid Benefit (APHAB) was used to assess subjective hearing impairment, and the Audio Processor Satisfaction Questionnaire (APSQ) was used to assess subjective satisfaction.

RESULTS

The speech processor upgrade resulted in a significant improvement of speech understanding in quiet at 65 dB (mean difference 8.9 ± 25.9 percentage points, p < 0.001) and 80 dB (mean difference 8.1 ± 29.7 percentage points, p < 0.001) and in noise (mean difference 3.2 ± 10.7 dB signal-to-noise ratio [S/N], p = 0.006). Using the APHAB, a significant improvement (mean difference 0.07 ± 0.16, p < 0.001) in hearing impairment was demonstrated in all listening situations. The APSQ showed significantly higher patient satisfaction with the new speech processor (mean difference 0.42 ± 1.26, p = 0.006). A comparative assessment of the benefit based on subjective and speech audiometric results identified a proportion of patients (35-42%) who subjectively benefited from the upgrade but had no measurable benefit based on speech audiometry.

CONCLUSION

There was a significant improvement in audiologically measurable and subjectively reflected speech understanding and patient satisfaction after the upgrade. In patients with only a small improvement in audiologically measurable speech understanding, the subjective benefit should also be assessed with validated measurement instruments in order to justify an upgrade to the payers in the health sector.

High-Dose Glucocorticoids for the Treatment of Sudden Hearing Loss

High-Dose Glucocorticoids for Sudden Hearing LossThis trial compared courses of high-dose intravenous prednisolone or high-dose oral dexamethasone versus standard-dose oral prednisone in adults with idiopathic sudden sensorineural hearing loss. At 30 days, systemic high-dose glucocorticoid therapy was not superior to a lower-dose regimen with respect to change in hearing threshold, and it was associated with a higher risk of side effects.

Non-rigid point cloud registration for middle ear diagnostics with endoscopic optical coherence tomography

PURPOSE

Middle ear infection is the most prevalent inflammatory disease, especially among the pediatric population. Current diagnostic methods are subjective and depend on visual cues from an otoscope, which is limited for otologists to identify pathology. To address this shortcoming, endoscopic optical coherence tomography (OCT) provides both morphological and functional in vivo measurements of the middle ear. However, due to the shadow of prior structures, interpretation of OCT images is challenging and time-consuming. To facilitate fast diagnosis and measurement, improvement in the readability of OCT data is achieved by merging morphological knowledge from ex vivo middle ear models with OCT volumetric data, so that OCT applications can be further promoted in daily clinical settings.

METHODS

We propose C2P-Net: a two-staged non-rigid registration pipeline for complete to partial point clouds, which are sampled from ex vivo and in vivo OCT models, respectively. To overcome the lack of labeled training data, a fast and effective generation pipeline in Blender3D is designed to simulate middle ear shapes and extract in vivo noisy and partial point clouds.

RESULTS

We evaluate the performance of C2P-Net through experiments on both synthetic and real OCT datasets. The results demonstrate that C2P-Net is generalized to unseen middle ear point clouds and capable of handling realistic noise and incompleteness in synthetic and real OCT data.

CONCLUSIONS

In this work, we aim to enable diagnosis of middle ear structures with the assistance of OCT images. We propose C2P-Net: a two-staged non-rigid registration pipeline for point clouds to support the interpretation of in vivo noisy and partial OCT images for the first time. Code is available at: https://gitlab.com/nct_tso_public/c2p-net.

Validation of the German language version of the Chronic Ear Survey and its psychometric comparison with an established German measurement instrument

BACKGROUND

With the Chronic Ear Survey (CES), a validated measurement instrument for the assessment of disease-specific health-related quality of life (HRQoL) has been available internationally since 2000. The aim of this study was to provide a validated German version of this international instrument and to compare it with the German Chronic Otitis Media Outcome Test 15 (COMOT-15).

METHODOLOGY

The CES was translated into German via a forward-backward translation process. For validation, 79 patients with COM undergoing middle ear surgery were prospectively included. HRQoL was determined preoperatively and 6 months postoperatively using the CES and the COMOT-15. Pure tone audiometry was also performed at both measurement time points. In the control examination, an additional retrospective assessment of the preoperative situation was additionally performed using the CES and the COMOT-15 to assess the response shift. The determined psychometric characteristics were internal consistency, test-retest reliability, discrimination validity, agreement validity, responsiveness, and response shift for both measurement instruments. Convergent validity of both measurement instruments was assessed using linear regression.

RESULTS

On the basis of the CES, patients with COM could be reliably distinguished from patients with healthy ears. The CES showed satisfactory reliability with high internal consistency (Cronbach α 0.65-0.85) and high retest reliability (r > 0.8). The global assessment of HRQoL impairment correlated very well with the scores of the CES (r = 0.51). In addition, it showed a high sensitivity to change (standardized response mean -0.86). Compared to the COMOT-15, it showed a lower response shift (effect size -0.17 vs. 0.44). Both measurement instruments correlated only slightly with air conduction hearing threshold (r = 0.29 and r = 0.24, respectively). The concordant validity of both measurement instruments was high (r = 0.68).

CONCLUSION

The German version of the CES shows satisfactory psychometric characteristics, so that its use can be recommended. The CES focuses on the influence of ear symptoms on HRQoL, whereas the COMOT-15 also includes functional and psychological aspects. Due to only minor response shift effects, the CES is particularly suitable for studies with multiple repeat measurements.

Word Recognition with a Cochlear Implant in Relation to Prediction and Electrode Position

BACKGROUND

the word recognition score (WRS) achieved with cochlear implants (CIs) varies widely. To account for this, a predictive model was developed based on patients' age and their pre-operative WRS. This retrospective study aimed to find out whether the insertion depth of the nucleus lateral-wall electrode arrays contributes to the deviation of the CI-achieved WRS from the predicted WRS.

MATERIALS AND METHODS

patients with a pre-operative maximum WRS > 0 or a pure-tone audiogram ≥80 dB were included. The insertion depth was determined via digital volume tomography.

RESULTS

fifty-three patients met the inclusion criteria. The median WRS achieved with the CI was 70%. The comparison of pre- and post-operative scores achieved with a hearing aid and a CI respectively in the aided condition showed a median improvement of 65 percentage points (pp). A total of 90% of the patients improved by at least 20 pp. The majority of patients reached or exceeded the prediction, with a median absolute error of 11 pp. No significant correlation was found between the deviation from the predicted WRS and the insertion depth.

CONCLUSIONS

our data support a previously published model for the prediction of the WRS after cochlear implantation. For the lateral-wall electrode arrays evaluated, the insertion depth did not influence the WRS with a CI.

Effect of Cochlear Implant Electrode Insertion Depth on Speech Perception Outcomes: A Systematic Review

Objective

The suitable electrode array choice is broadly discussed in cochlear implantation surgery. Whether to use a shorter electrode length under the aim of structure preservation versus choosing a longer array to achieve a greater cochlear coverage is a matter of debate. The aim of this review is to identify the impact of the insertion depth of a cochlear implant (CI) electrode array on CI users' speech perception outcomes.

Databases Reviewed

PubMed was searched for English-language articles that were published in a peer-reviewed journal from 1997 to 2022.

Methods

A systematic electronic search of the literature was carried out using PubMed to find relevant literature on the impact of insertion depth on speech perception. The review was conducted according to the preferred reporting items for systematic reviews and meta-analyses guidelines of reporting. Studies in both, children and adults with pre- or postlingual hearing loss, implanted with a CI were included in this study. Articles written in languages other than English, literature reviews, meta-analyses, animal studies, histopathological studies, or studies pertaining exclusively to imaging modalities without reporting correlations between insertion depth and speech outcomes were excluded. The risk of bias was determined using the "Risk of Bias in Nonrandomized Studies of Interventions" tool. Articles were extracted by 2 authors independently using predefined search terms. The titles and abstracts were screened manually to identify studies that potentially meet the inclusion criteria. The extracted information included: the study population, type of hearing loss, outcomes reported, devices used, speech perception outcomes, insertion depth (linear insertion depth and/or the angular insertion depth), and correlation between insertion depth and the speech perception outcomes.

Results

A total of 215 relevant studies were assessed for eligibility. Twenty-three studies met the inclusion criteria and were analyzed further. Seven studies found no significant correlation between insertion depth and speech perception outcomes. Fifteen found either a significant positive correlation or a positive effect between insertion depth and speech perception. Only 1 study found a significant negative correlation between insertion depth and speech perception outcomes.

Conclusion

Although most studies reported a positive effect of insertion depth on speech perception outcomes, one-third of the identified studies reported no correlation. Thus, the insertion depth must be considered as a contributing factor to speech perception rather than as a major decisive criterion.

Registration

This review has been registered in PROSPERO, the international prospective register of systematic reviews (CRD42021257547), available at https://www.crd.york.ac.uk/PROSPERO/.

In vivo microstructural investigation of the human tympanic membrane by endoscopic polarization-sensitive optical coherence tomography

SIGNIFICANCE

Endoscopic optical coherence tomography (OCT) is of growing interest for in vivo diagnostics of the tympanic membrane (TM) and the middle ear but generally lacks a tissue-specific contrast.

AIM

To assess the collagen fiber layer within the in vivo TM, an endoscopic imaging method utilizing the polarization changes induced by the birefringent connective tissue was developed.

APPROACH

An endoscopic swept-source OCT setup was redesigned and extended by a polarization-diverse balanced detection unit. Polarization-sensitive OCT (PS-OCT) data were visualized by a differential Stokes-based processing and the derived local retardation. The left and right ears of a healthy volunteer were examined.

RESULTS

Distinct retardation signals in the annulus region of the TM and near the umbo revealed the layered structure of the TM. Due to the TM's conical shape and orientation in the ear canal, high incident angles onto the TM's surface, and low thicknesses compared to the axial resolution limit of the system, other regions of the TM were more difficult to evaluate.

CONCLUSIONS

The use of endoscopic PS-OCT is feasible to differentiate birefringent and nonbirefringent tissue of the human TM in vivo. Further investigations on healthy as well as pathologically altered TMs are required to validate the diagnostic potential of this technique.

Auditory thresholds compatible with optimal speech reception likely evolved before the human-chimpanzee split

The anatomy of the auditory region of fossil hominins may shed light on the emergence of human spoken language. Humans differ from other great apes in several features of the external, middle and inner ear (e.g., short external ear canal, small tympanic membrane, large oval window). However, the functional implications of these differences remain poorly understood as comparative audiometric data from great apes are scarce and conflicting. Here, we measure the sound transfer function of the external and middle ears of humans, chimpanzees and bonobos, using laser-Doppler vibrometry and finite element analysis. This sound transfer function affects auditory thresholds, which relate to speech reception thresholds in humans. Unexpectedly we find that external and middle ears of chimpanzees and bonobos transfer sound better than human ones in the frequency range of spoken language. Our results suggest that auditory thresholds of the last common ancestor of Homo and Pan were already compatible with speech reception as observed in humans. Therefore, it seems unlikely that the morphological evolution observed in the bony auditory region of fossil hominins was driven by the emergence of spoken language. Instead, the peculiar human configuration may be a by-product of morpho-functional constraints linked to brain expansion.

Digital teaching and assessment of psychomotor skills of the clinical head and neck examination during COVID-19 pandemic

PURPOSE

During COVID-19, a fully digital course was established for teaching and assessing the psychomotor skills of clinical head and neck examination. Influence of different digital teaching formats was investigated.

METHODS

The students (n = 286) received disposable instruments, a manual, and instructional videos for the examination. 221 students additionally received 45 min of interactive teleteaching. After 5 days of practice, all students were required to submit a video of their examination and report their spent practice time. The assessment was carried out using a checklist which was already established in presence teaching.

RESULTS

The average score achieved by digital teaching was 86%. Previously published data show that presence teaching achieved 94%. With a teleteaching unit the total score was significantly better than without (87% vs 83%). Teleteaching leads to a significant positive correlation between practice time and total score. Without teleteaching there is a negative correlation. After the same practice time, presence teaching leads to better total scores than digital teaching.

CONCLUSION

Digital teaching and assessing of a complex psychomotor skill is possible. Interactive teaching methods increase learning success. Nevertheless, presence teaching seems to be better at teaching these skills. The results can provide a basis for developing hybrid teaching models.

Multimodal additive manufacturing of biomimetic tympanic membrane replacements with near tissue-like acousto-mechanical and biological properties

The three additive manufacturing techniques fused deposition modeling, gel plotting and melt electrowriting were combined to develop a mimicry of the tympanic membrane (TM) to tackle large TM perforations caused by chronic otitis media. The mimicry of the collagen fiber orientation of the TM was accompanied by a study of multiple funnel-shaped mimics of the TM morphology, resulting in mechanical and acoustic properties similar to those of the eardrum. For the different 3D printing techniques used, the process parameters were optimized to allow reasonable microfiber arrangements within the melt electrowriting setup. Interestingly, the fiber pattern was less important for the acousto-mechanical properties than the overall morphology. Furthermore, the behavior of keratinocytes and fibroblasts is crucial for the repair of the TM, and an in vitro study showed a high biocompatibility of both primary cell types while mimicking the respective cell layers of the TM. A simulation of the in vivo ingrowth of both cell types resulted in a cell growth orientation similar to the original collagen fiber orientation of the TM. Overall, the combined approach showed all the necessary parameters to support the growth of a neo-epithelial layer with a similar structure and morphology to the original membrane. It therefore offers a suitable alternative to autologous materials for the treatment of chronic otitis media. STATEMENT OF SIGNIFICANCE: Millions of people worldwide suffer from chronic middle ear infections. Although the tympanic membrane (TM) can be reconstructed with autologous materials, the grafts used for this purpose require extensive manual preparation during surgery. This affects not only the hearing ability but also the stability of the reconstructed TM, especially in the case of full TM reconstruction. The synthetic alternative presented here mimicked not only the fibrous structure of the TM but also its morphology, resulting in similar acousto-mechanical properties. Furthermore, its high biocompatibility supported the migration of keratinocytes and fibroblasts to form a neo-epithelial layer. Overall, this completely new TM replacement was achieved by combining three different additive manufacturing processes.

[Health-related quality of life in chronic otitis media-measurement methods and their application in surgical therapy]

BACKGROUND

Chronic otitis media (COM) can lead to significant impairment of health-related quality of life (HRQoL) due to symptoms such as otorrhea, pain, hearing loss, tinnitus, or dizziness. A systematic assessment of HRQoL in COM is becoming increasingly important as it complements (semi-)objective outcome parameters in clinical practice and research. HRQoL is measured by means of patient-reported outcome measures (PROMs). There are two disease-specific validated PROMs available for COM in German-the Chronic Otitis Media Outcome Test (COMOT-15) and the Zurich Chronic Middle Ear Inventory (ZCMEI-21)-which have become increasingly popular in recent years.

OBJECTIVE

The purpose of this narrative review is to present the current state of research on measuring HRQoL in COM before and after surgical procedures.

RESULTS AND CONCLUSION

Hearing is the most important factor influencing HRQoL in COM. Surgical procedures usually result in a clinically relevant improvement in HRQoL in COM with or without cholesteatoma. However, if cholesteatoma is present, its extent does not correlate with HRQoL. While HRQoL plays a secondary role in establishment of the indication for surgical therapy in COM with cholesteatoma, it plays an important role in terms of relative surgical indications, e.g., a symptomatic open mastoid cavity after resection of the posterior canal wall. We encourage the regular use of disease-specific PROMs preoperatively as well as during follow-up to assess HRQoL in COM in individual patients, in research, and in the context of quality monitoring.

[Value of patient-reported outcome measures for evaluating the benefit of speech processor upgrading in patients with cochlear implants. German version]

BACKGROUND

Patients with a cochlear implant (CI) should be evaluated for a new speech processor every 6 years. The aim of this analysis was to assess the subjective and audiological benefit of upgrades.

METHODS

Speech understanding and subjective benefit were analyzed in 99 patients with the old and the new speech processor after 4 weeks of wearing. Speech understanding was assessed using the Freiburg monosyllabic test in quiet (FBE) at 65 dB and 80 dB, and the Oldenburg Sentence Test (OLSA) at 65 dB noise with adaptive speech sound level. The Abbreviated Profile of Hearing Aid Benefit (APHAB) was used to assess subjective hearing impairment, and the Audio Processor Satisfaction Questionnaire (APSQ) was used to assess subjective satisfaction.

RESULTS

The speech processor upgrade resulted in a significant improvement of speech understanding in quiet at 65 dB (mean difference 8.9 ± 25.9 percentage points, p < 0.001) and 80 dB (mean difference 8.1 ± 29.7 percentage points, p < 0.001) and in noise (mean difference 3.2 ± 10.7 dB signal-to-noise ratio [S/N], p = 0.006). Using the APHAB, a significant improvement (mean difference 0.07 ± 0.16, p < 0.001) in hearing impairment was demonstrated in all listening situations. The APSQ showed significantly higher patient satisfaction with the new speech processor (mean difference 0.42 ± 1.26, p = 0.006). A comparative assessment of the benefit based on subjective and speech audiometric results identified a proportion of patients (35-42%) who subjectively benefited from the upgrade but had no measurable benefit based on speech audiometry.

CONCLUSION

There was a significant improvement in audiologically measurable and subjectively reflected speech understanding and patient satisfaction after the upgrade. In patients with only a small improvement in audiologically measurable speech understanding, the subjective benefit should also be assessed with validated measurement instruments in order to justify an upgrade to the payers in the health sector.

Stapedius reflex thresholds obtained in a free sound field as an indicator for over- and understimulation in cochlear implant listeners

OBJECTIVE

The goal of this study was to determine open field stapedius reflex thresholds (oSRTs) in CI patients with fittings based on subjective loudness ratings. A further objective was to compare these oSRTs and those of eSRT-based fittings that are similar to the oSRTs of normal hearing.

DESIGN

Impedance measurements of the ear drum were taken while subjects were wearing their audio processors. The stapedius reflex was elicited by electrical stimulation transmitted through the activated CI system in response to an acoustic stimulus presented in the free sound field.

STUDY SAMPLE

Subjects were 50 experienced CI users (n = 57 ears) with CI fittings based on subjective loudness scaling.

RESULTS

A reference range for the oSRTs was defined that was identified in CI patients with eSRT-based fittings. Sound levels for stapedius reflex detection were inside the reference target range in 70% of the cases, below the reference range (i.e. down to 40 dB HL) in 20% of the cases, and above the reference range in 10% of the cases.

CONCLUSION

Stapedius reflex detection in a free sound field may help detect fittings with too high or too low stimulation levels that might reduce audiological performance.

[Validation of the German language version of the Chronic Ear Survey and its psychometric comparison with an established German language measurement instrument. German version]

BACKGROUND

With the Chronic Ear Survey (CES), a validated measurement instrument for the assessment of disease-specific health-related quality of life (HRQoL) has been available internationally since 2000. The aim of this study was to provide a validated German version of this international instrument and to compare it with the German Chronic Otitis Media Outcome Test 15 (COMOT-15).

METHODOLOGY

The CES was translated into German via a forward-backward translation process. For validation, 79 patients with COM undergoing middle ear surgery were prospectively included. HRQoL was determined preoperatively and 6 months postoperatively using the CES and the COMOT-15. Pure tone audiometry was also performed at both measurement time points. In the control examination, an additional retrospective assessment of the preoperative situation was additionally performed using the CES and the COMOT-15 to assess the response shift. The determined psychometric characteristics were internal consistency, test-retest reliability, discrimination validity, agreement validity, responsiveness, and response shift for both measurement instruments. Convergent validity of both measurement instruments was assessed using linear regression.

RESULTS

On the basis of the CES, patients with COM could be reliably distinguished from patients with healthy ears. The CES showed satisfactory reliability with high internal consistency (Cronbach α 0.65-0.85) and high retest reliability (r > 0.8). The global assessment of HRQoL impairment correlated very well with the scores of the CES (r = 0.51). In addition, it showed a high sensitivity to change (standardized response mean -0.86). Compared to the COMOT-15, it showed a lower response shift (effect size -0.17 vs. 0.44). Both measurement instruments correlated only slightly with air conduction hearing threshold (r = 0.29 and r = 0.24, respectively). The concordant validity of both measurement instruments was high (r = 0.68).

CONCLUSION

The German version of the CES shows satisfactory psychometric characteristics, so that its use can be recommended. The CES focuses on the influence of ear symptoms on HRQoL, whereas the COMOT-15 also includes functional and psychological aspects. Due to only minor response shift effects, the CES is particularly suitable for studies with multiple repeat measurements.

A bone conduction implant using self-drilling screws : Self-drilling screws as a new fixation method of an active transcutaneous bone conduction hearing implant

BACKGROUND

The active transcutaneous bone conduction implant (tBCI; BONEBRIDGE™ BCI 601; MED-EL, Innsbruck, Austria) is fixed to the skull with two self-tapping screws in predrilled screw channels. The aim of this prospective study was to evaluate the safety and effectiveness of fixation with self-drilling screws instead of the self-tapping screws, in order to simplify the surgical procedure.

MATERIALS AND METHODS

Nine patients (mean age 37 ± 16 years, range 14-57 years) were examined pre- and 12 months postoperatively for word recognition scores (WRS) at 65 dB SPL, sound-field (SF) thresholds, bone conduction thresholds (BC), health-related quality of life (Assessment of Quality of Life, AQOL-8D questionnaire), and adverse events (AE).

RESULTS

Due to avoidance of one surgical step, the surgical technique was simplified. Mean WRS in SF was 11.1 ± 22.2% (range 0-55%) pre- and 77.2 ± 19.9% (range 30-95%) postoperatively; mean SF threshold (pure tone audiometry, PTA4) improved from 61.2 ± 14.3 dB HL (range 37.0-75.3 dB HL) to 31.9 ± 7.2 dB HL (range 22.8-45.0 dB HL); mean BC thresholds were constant at 16.7 ± 6.8 dB HL (range 6.3-27.5 dB HL) pre- and 14.2 ± 6.2 dB HL (range 5.8-23.8 dB HL) postoperatively. AQOL-8D mean utility score increased from 0.65 ± 0.18 preoperatively to 0.82 ± 0.17 postoperatively. No device-related adverse events occurred.

CONCLUSION

Implant fixation by means of self-drilling screws was safe and effective in all nine patients. There was significant audiological benefit 12 months after implantation.

Real-time monitoring of middle ear prosthesis coupling

INTRODUCTION

In reconstructive middle ear surgery, acoustic quality has received a high level of attention in recent years. Careful intraoperative selection and positioning of passive middle ear prostheses during tympanoplasty with ossiculoplasty is essential to ensure satisfactory sound transmission and postoperative hearing outcome. The reconstruction quality of the ossicular chain (OC) can be evaluated intraoperatively using a surgical assistance system which is based on a real-time monitoring system (RTM system) that acquires the transmission (middle ear transfer function (METF)) with electromagnetic excitation of the OC. In this experimental study, the METF with electromagnetic excitation of the (reconstructed) OC was compared to usual acoustic excitation and the benefit of the RTM system was investigated for the implantation of partial (PORP) and total (TORP) prostheses.

METHODS

Laser Doppler vibrometry (LDV) was used to measure the middle ear transfer function (METF) in 18 human temporal bones (TB). The RTM system uses electromagnetic excitation of the OC with a magnet placed on the umbo. Comparatively, measurements with the usual acoustical excitation, using an earphone in the external auditory canal, were performed. The measurements began with the intact OC, followed by real-time monitoring guided OC reconstruction with PORP and TORP. In addition, during the simulation of an intraoperative setting, the influence of the influence of opening (tympanomeatal flap lifted and pushed anteriorly) and closing (tympanomeatal flap folded back) the tympanic membrane on the measurements with the RTM system was determined.

RESULTS

Electromagnetic and acoustic excitation of the intact and the reconstructed OC provided comparable METF. The application of the RTM system significantly improved the quality of the OC reconstruction. The METF increased by up to 10 dB over the entire frequency range during implantation of the PORP with positioning control by the RTM system. When using the TORP, the METF could be improved by up to 15 dB. The opening of the tympanomeatal flap did not affect the measurements with the RTM system at the reconstructed OC.

CONCLUSION

In this TB study, we demonstrated that the quality of OC reconstruction (improved METF as a benchmark for improved transmission) could be significantly increased by means of a RTM system. Intraoperative studies should now be conducted to investigate to which quantitative extent the intraoperative reconstruction quality can be improved and whether or not this improvement also manifests in an increased (long-term) hearing outcome. This will enable conclusions to be drawn about the contribution of the intraoperative reconstruction quality to the (long-term) hearing outcome in the context of the conglomerate of various factors influencing the postoperative hearing outcome.

[Transcutaneous bone conduction implant with self-drilling screws : A new method for fixation of an active transcutaneous bone conduction implant. German version]

BACKGROUND

The active transcutaneous bone conduction implant (tBCI; BONEBRIDGE™ BCI 601; MED-EL, Innsbruck, Austria) is fixed to the skull with two self-tapping screws in predrilled screw channels. The aim of this prospective study was to evaluate the safety and effectiveness of fixation with self-drilling screws instead of the self-tapping screws, in order to simplify the surgical procedure.

MATERIALS AND METHODS

Nine patients (mean age 37 ± 16 years, range 14-57 years) were examined pre- and 12 months postoperatively for word recognition scores (WRS) at 65 dB SPL, sound-field (SF) thresholds, bone conduction thresholds (BC), health-related quality of life (Assessment of Quality of Life, AQOL-8D questionnaire), and adverse events (AE).

RESULTS

Due to avoidance of one surgical step, the surgical technique was simplified. Mean WRS in SF was 11.1 ± 22.2% (range 0-55%) pre- and 77.2 ± 19.9% (range 30-95%) postoperatively; mean SF threshold (pure tone audiometry, PTA₄) improved from 61.2 ± 14.3 dB HL (range 37.0-75.3 dB HL) to 31.9 ± 7.2 dB HL (range 22.8-45.0 dB HL); mean BC thresholds were constant at 16.7 ± 6.8 dB HL (range 6.3-27.5 dB HL) pre- and 14.2 ± 6.2 dB HL (range 5.8-23.8 dB HL) postoperatively. AQOL-8D mean utility score increased from 0.65 ± 0.18 preoperatively to 0.82 ± 0.17 postoperatively. No device-related adverse events occurred.

CONCLUSION

Implant fixation by means of self-drilling screws was safe and effective in all nine patients. There was significant audiological benefit 12 months after implantation.

[From Learning Objective to Examination: Constructive Alignment in Education and Training]

An examination that is as transparent, performance-based, and fair as possible is something that teachers and learners both desire. This article is intended to help sharpen the basic understanding of examination designs and to shed light on the variable interplay of teaching and examination formats. This article is intended to help sharpen the basic understanding of examination designs and to shed light on the variable interplay of teaching and examination formats.

Methods and reference data for middle ear transfer functions

Human temporal bone specimens are used in experiments measuring the sound transfer of the middle ear, which is the standard method used in the development of active and passive middle ear implants. Statistical analyses of these experiments usually require that the TB samples are representative of the population of non-pathological middle ears. Specifically, this means that the specimens must be mechanically well-characterized. We present an in-depth statistical analysis of 478 data sets of middle ear transfer functions (METFs) from different laboratories. The data sets are preprocessed and various contributions to the variance of the data are evaluated. We then derive a statistical range as a reference against which individual METF measurements may be validated. The range is calculated as the two-sided 95% tolerance interval at audiological frequencies. In addition, the mean and 95% confidence interval of the mean are given as references for assessing the validity of a sample group. Finally, we provide a suggested procedure for measuring METFs using the methods described herein.

Development of electrospun, biomimetic tympanic membrane implants with tunable mechanical and oscillatory properties for myringoplasty

Most commonly, autologous grafts are used in tympanic membrane (TM) reconstruction. However, apart from the limited availability and the increased surgical risk, they cannot replicate the full functionality of the human TM properly. Hence, biomimetic synthetic TM implants have been developed in our project to overcome these drawbacks. These innovative TM implants are made from synthetic biopolymer polycaprolactone (PCL) and silk fibroin (SF) by electrospinning technology. Static and dynamic experiments have shown that the mechanical and oscillatory behavior of the TM implants can be tuned by adjusting the solution concentration, the SF and PCL mixing ratio and the electrospinning parameters. In addition, candidates for TM implants could have comparable acousto-mechanical properties to human TMs. Finally, these candidates were further validated in in vitro experiments by performing TM reconstruction in human cadaver temporal bones. The reconstructed TM with SF-PCL blend membranes fully recovered the acoustic vibration when the perforation was smaller than 50%. Furthermore, the handling, medium adhesion and transparency of the developed TM implants were similar to those of human TMs.

Accessing the Stapedius Muscle Via Novel Surgical Retrofacial Approach: A Cadaveric Feasibility Study

HYPOTHESIS

Despite the complete embodiment of the stapedius muscle (SM) into the pyramidal eminence, it is possible to safely gain access to the SM belly via a retrofacial approach. This presents a novel approach to directly measure the electrically evoked stapedius reflex threshold (eSRT).

BACKGROUND

Objective fitting of maximum comfortable loudness levels for cochlear implant users can improve the benefit introduced by the device. Sensing SM activity via direct surgical access represents a potential tool for objective eSRT fitting.

METHODS

Eighteen human temporal bones (TBs) were used. Micro-computed tomography was performed for six TBs. Standard computed tomography for six TBs. Manual 3D-segmentation of the relevant middle and inner ear anatomy was performed on 12 TBs. Mastoidectomy and posterior tympanotomy allowed the access to middle ear of all 18 the TBs. Once identified the mastoidal segment of the facial nerve (FN), the retrofacial access to the SM was drilled.

RESULTS

The total access rate was 72.2%. Only in the first three cases the posterior semi-circular canal was hit. The SM access was identified posterior to the FN at a 4 ± 0.78 mm distance from the stapes' head, almost halfway to the chorda tympani's branching point along the FN direction. The drilling depth to access the SM posterior to the external surface of FN on average was 2 ± 0.30 mm. The exposure took on average of 5 to 8 minutes.

CONCLUSIONS

The retrofacial approach seems to offer a feasible and reproducible access to the SM belly opening an avenue to electromyographic sensing of eSRT.

Bio-Compatible Sensor for Middle Ear Pressure Monitoring on a Bio-Degradable Substrate

Hypotension in the middle ear can cause serious diseases and hearing disorders. Until now, pressure in the middle ear is measured indirectly by using the impedance of the tympanic membrane (tympanometry). Direct methods are just described in scientific studies and would be harmful in clinical routine. Here, we demonstrate a bio-compatible pressure sensor, which can resolve pressure changes in the range of −7.5 kPa up to +7.5 kPa, and due to its compact design (area of 2 × 4 mm2), can be directly implanted in the human middle ear. Furthermore, the read-out of the pressure sensor can be conveniently done using wireless data communication technologies employing a plate capacitor with an elastic dielectric for pressure monitoring and a planar coil. Thus, our sensor allows for direct pressure measurements in the middle ear, avoiding additional surgeries after device implantation.

[Update cochlear-implantation: indications and surgical aspects]

In childhood, inadequately rehabilitated hearing loss leads to impaired language acquisition and social, mental and emotional development. In adults, social withdrawal due to limited communication skills is often a consequence of unsatisfactory hearing rehabilitation. Therefore, in patients with profound hearing loss, the indication for cochlear implantation should be considered. Technical advances in cochlear implant development, as well as in microsurgical techniques and the rehabilitation process, have led to an expansion of indications in recent years. Adequate hearing rehabilitation is associated not only with an improvement in hearing function and speech understanding, but also with an increase in quality of life at all ages. In patients with unilateral profound hearing loss, cochlear implantation leads to an improvement of speech understanding and localization ability as well as to a reduction of the head shadow effect and tinnitus. The indication process, surgical treatment and the subsequent rehabilitation process require interprofessional cooperation in specialized centers.

[The situation of education in ENT-residency-training in Germany]

Hintergrund

Als Ansatzpunkt zur Entwicklung konkreter Optimierungsvorschläge für das HNO-ärztliche Weiterbildungssystem wurde zunächst die Ausbildungssituation an deutschen HNO-Kliniken analysiert, um existierende Schwachstellen der Weiterbildung identifizieren zu können.

Methodik

HNO-Weiterbildungsassistenten an deutschen HNO-Kliniken wurden eingeladen, an einer Online-Befragung teilzunehmen. Der Fragebogen bestand dabei aus 78 Einzelfragen.

Ergebnisse

An der Umfrage nahmen 223 Weiterbildungsassistenten der HNO-Heilkunde teil. Defizite der Ausbildung wie ein fehlendes regelmäßiges Feedback zwischen Weiterbildungsberechtigten und Weiterbildungsassistenten/-innen, eine nur mittelmäßig bewertete Vermittlung von Fachkompetenz sowie eine in den Freitextkommentaren genannte „Willkür“ der Weiterbildungsbeauftragten hinsichtlich der Gestaltung des Weiterbildungsverlaufs sowie Zeit- und Personalmangel treten in den Fokus unserer Auswertung. Einige der verbindlich aufgeführten Empfehlungen der Weiterbildungsordnung wie die Festlegung von konkreten Weiterbildungszielen im Rahmen eines regelmäßigen Gesprächs oder der Einsatz eines Log-Buchs werden bislang nur vereinzelt umgesetzt. Forderungen zum Ausbau von externen Fortbildungsmöglichkeiten (Hospitation/Rotation) und einer externen objektiven Überprüfung der klinikinternen Durchführung der Weiterbildung im Sinne einer Qualitätssicherung beispielsweise durch Fachvertreter der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC) werden diskutiert.

Schlussfolgerung

Die Umsetzung einer strukturierten und standardisierten Weiterbildung in Deutschland, welche im Sinne einer freiwilligen Eigeninitiative auch durch die DGHNOKHC in ihrer Umsetzung überprüft wird, kann eine Basis für eine effektivere verbindliche Weiterbildung schaffen.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00106-020-00838-9) enthält eine Tabelle, die Ergebnisse einer Fragenauswahl gegliedert nach Themenkomplexen darstellt. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

Erratum zu: Die Weiterbildungssituation in der HNO-Heilkunde in Deutschland

Ein Erratum zu dieser Publikation wurde veröffentlicht: 10.1007/s00106-020-00838-9

Mimicking the Human Tympanic Membrane: The Significance of Scaffold Geometry

The human tympanic membrane (TM) captures sound waves from the environment and transforms them into mechanical motion. The successful transmission of these acoustic vibrations is attributed to the unique architecture of the TM. However, a limited knowledge is available on the contribution of its discrete anatomical features, which is important for fabricating functional TM replacements. This work synergizes theoretical and experimental approaches toward understanding the significance of geometry in tissue-engineered TM scaffolds. Three test designs along with a plain control are chosen to decouple some of the dominant structural elements, such as the radial and circumferential alignment of the collagen fibrils. In silico models suggest a geometrical dependency of their mechanical and acoustical responses, where the presence of radially aligned fibers is observed to have a more prominent effect compared to their circumferential counterparts. Following which, a hybrid fabrication strategy combining electrospinning and additive manufacturing has been optimized to manufacture biomimetic scaffolds within the dimensions of the native TM. The experimental characterizations conducted using macroindentation and laser Doppler vibrometry corroborate the computational findings. Finally, biological studies with human dermal fibroblasts and human mesenchymal stromal cells reveal a favorable influence of scaffold hierarchy on cellular alignment and subsequent collagen deposition.

Biomimetic Tympanic Membrane Replacement Made by Melt Electrowriting

The tympanic membrane (TM) transfers sound waves from the air into mechanical motion for the ossicular chain. This requires a high sensitivity to small dynamic pressure changes and resistance to large quasi-static pressure differences. The TM achieves this by providing a layered structure of about 100µm in thickness, a low flexural stiffness, and a high tensile strength. Chronically infected middle ears require reconstruction of a large area of the TM. However, current clinical treatment can cause a reduction in hearing. With the novel additive manufacturing technique of melt electrowriting (MEW), it is for the first time possible to fabricate highly organized and biodegradable membranes within the dimensions of the TM. Scaffold designs of various fiber composition are analyzed mechanically and acoustically. It can be demonstrated that by customizing fiber orientation, fiber diameter, and number of layers the desired properties of the TM can be met. An applied thin collagen layer seals the micropores of the MEW-printed membrane while keeping the favorable mechanical and acoustical characteristics. The determined properties are beneficial for implantation, closely match those of the human TM, and support the growth of a neo-epithelial layer. This proves the possibilities to create a biomimimetic TM replacement using MEW.

Measurement of middle ear transfer function in temporal bones using electromagnetic excitation: Comparison to sound excitation and evaluation of influencing factors

Hearing a sound produces vibrations of the ossicles in the middle ear, which can be measured in the micrometer to nanometer range. Destruction of middle ear structures results most commonly from chronic inflammatory diseases. In these cases, passive and active middle ear implants are used for reconstruction of the ossicular chain. The positioning of the implants depends primarily on the surgeon's experience. So far, no objective assessment has been conducted to affirm if the chosen positioning is the best in each specific case. We have established a new method, allowing us to measure the middle ear transfer function (METF) intraoperatively. Using the new method, a magnet is placed on the umbo of the malleus handle and is stimulated by a coil positioned underneath the head. The resulting vibration is measured on the stapes footplate using Laser Doppler vibrometry (LDV). Acoustic and electromagnetic excitation show comparable METF in lower frequencies, which differ up to 10 dB in frequencies over 1 kHz. The position of the coil does not play a relevant part in the METF, whereas the location of the magnet on the tympanic membrane highly impacts the METF. This technique demonstrates reproducible results. Electromagnetic excitation is comparable to sound excitation and is suited for measuring the METF. A stable positioning of the magnet on the umbo is essential in order to acquire valid data.

Stapedius reflex evoked in free sound field in cochlear implant users compared to normal-hearing listeners

OBJECTIVE

To determine the relation between stapedius reflex thresholds in cochlear implant users evoked once through direct electric stimulation on single channels (ESRT) and once through acoustic stimulation in free sound field. For comparison, stapedius reflex thresholds were obtained in free sound field in a normal-hearing control group.

DESIGN

For each participant a new ESRT-based fitting was created. Stapedius reflex thresholds were obtained for this new fitting in free sound field for different loudness adjustments. Acoustic stimuli for eliciting the stapedius reflex were narrow band noise signals covering the audiometric frequency range.

STUDY SAMPLE

N = 29 experienced CI users (34 ears) and N = 10 normal hearing listeners.

RESULTS

ESRT-based fitting resulted in different stapedius reflex behaviour compared to normal-hearing listeners. A frequency dependence was observed. Stapedius reflex thresholds decreased with increasing centre frequencies of acoustic narrow band noise stimuli. A linear relation between upper stimulation levels on the implant channels and corresponding stapedius reflex thresholds evoked in free sound field was found.

CONCLUSION

The found correlation may be a guideline for adjusting the electrical dynamic range during cochlear implant fitting. This allows the implant system to mimic the natural reflex behaviour in the best possible way and potentially avoid overstimulation.

[Spectroscopic investigation of the middle ear mucosa]

BACKGROUND

The middle ear mucosa (MEM) plays a central role in the middle ear due to its function of providing regular ventilation. To date, assessment of the state of the MEM is only possible subjectively by the surgeon. An objective characterization of the state of the MEM is desirable.

OBJECTIVE

The aim of this study was to enable objective characterization of the MEM and test infrared (IR) spectroscopy as a possible diagnostic tool for clinical use.

MATERIALS AND METHODS

During middle ear surgery, 48 MEM samples were collected and divided into four groups according to clinical appearance: group I: normal MEM; group II: sclerotic MEM; group III: inflammatory thickened MEM; group IV: granulated MEM. After collection, samples were analyzed by IR spectroscopy to identify characteristic IR spectra.

RESULTS

In the supervised analysis of the selected images, the biochemical differences representing the decisive factors for classification into groups I to IV were characterized. The differences in amide bands, carbohydrates, lipids, and proteins permit reliable separation of the clinical categories.

CONCLUSION

Spectroscopic investigations enable objective characterization of the MEM. Conclusions regarding biochemical differences make it possible to weigh up treatment options. Routine use of IR spectroscopy in the operating theater requires histopathological comparison and an extended dataset with reference values of the individual groups.

["Online from tomorrow on please": comparison of digital framework conditions of curricular teaching at national university ENT clinics in times of COVID-19 : Digital teaching at national university ENT clinics]

Hintergrund

Die Corona-Krise beeinflusst nicht nur das professionelle Handeln, sondern auch die Lehre an den Universitäten. Schlagworte wie „E-Learning“ und „Digitalisierung“ suggerieren die Möglichkeit innovativer, ad hoc verfügbarer Lösungsansätze für die Lehre in der aktuellen COVID-19-Situation. Die aktuelle Umstellung auf digitale Lehre ist aber nicht primär durch eine didaktische Sinnhaftigkeit oder institutionelle Strategie, sondern durch äußere Notwendigkeit geprägt.

Ziel der Arbeit

Ziel der Arbeit war die Erfassung der Lehrsituation an nationalen Universitäts-HNO-Kliniken und akademischen Lehrkrankenhäusern zu Beginn des virtuellen Corona-Sommersemesters 2020.

Material und Methode

Ein eigens erstellter Fragebogen zur jeweiligen lokalen Situation, den örtlichen Rahmenbedingungen sowie zu bundesweiten Szenarien wurde an alle 39 nationalen Universitäts-HNO-Kliniken und 20 akademischen Lehrkrankenhäuser mit HNO-Hauptabteilung versandt.

Ergebnisse

Die ausgefüllten Fragebögen von 31 Universitätskliniken (UK) und 10 akademische Lehrkrankenhäuser (ALK) gingen in die Auswertung ein. Es zeigten sich offensichtliche Diskrepanzen zwischen verfügbaren Ressourcen und tatsächlich verfügbaren digitalisierten Lehrinhalten. Weitere Kritikpunkte offenbarten sich in Bezug auf die Kommunikation mit der Medizinischen Fakultät, die digitale Infrastruktur und insbesondere in der oftmals mangelnden Kollaboration mit den zentralen Supportstrukturen, wie Medien‑, Didaktik- und Rechenzentren.

Schlussfolgerung

Es gibt durchaus positive Beispiele für eine gelungene Überführung der Präsenzlehre in das ausschließlich virtuelle Sommersemester 2020 innerhalb der Universitäts-HNO-Kliniken. Mehrheitlich aber überwiegen kritische Einschätzungen der Lehrbeauftragten bzw. Ärztlichen Direktoren gegenüber der aktuellen Lehrsituation. Eine zeitkritische strategische Weiterentwicklung ist dringend erforderlich.

[From reconstruction to function : Hands-on training in tympanoplasty using real-time feedback]

Hintergrund

In der Mittelohrchirurgie bedarf es ausgezeichneter feinmotorischer Fertigkeiten. Aufgrund des hohen Komplikationspotenzials im Mittelohr ist die Ausbildung dieser Fertigkeiten am Modell anzustreben.

Fragestellung

Wie gut ist die Ausbildungsmöglichkeit an geeigneten Modellen? Können die am Modell erlernten Fertigkeiten in die intraoperative Situation übertragen werden? Beeinflusst das Modell und die Ausbildung daran die zukünftige Ohrchirurgie?

Material und Methode

Vorliegende Publikationen und eigene Erfahrungen am Dresdener Tympanoplastikmodell (DTM) wurden analysiert und diskutiert.

Ergebnisse

Obwohl die Mittelohrchirurgie hohe Anforderungen an den Ausführenden stellt und am Sinnesorgan Ohr schwerwiegende Komplikationen drohen, gibt es bisher nur wenige Trainingsmöglichkeiten dafür. Das DTM ist ein validiertes Übungsmodell, das diese Lücke schließen kann. Durch eine Real-Time-Feedback-Variante des Modells kann auch das Verständnis für Rekonstruktionsqualität und intraoperative akustische Noxen verbessert werden. Die Übertragung des Real-Time-Feedback-Gedankens in die reale Mittelohrchirurgie kann die Rekonstruktionsqualität zukünftig verbessern.

Schlussfolgerungen

Das Training an geeigneten Modellen ist speziell beim Erlernen der Mittelohrchirurgie anzustreben. Mit dem Real-Time-Feedback kann beim Lernen und Operieren eine weitere Sinneswahrnehmung in die eigene und fremde Qualitätskontrolle der Tympanoplastik sehr wirksam einbezogen werden.

Quality in middle ear surgery - a critical position determination

When evaluating the outcome of reconstructive middle ear surgery, it is insufficient to use only the achieved improvement of audiometric measurement results. Although, as functional parameters, they occupy a central position in the therapeutic assessment of the ear as a sensory organ, they must be supplemented by a number of modern quality control factors. Different perspectives for assessment of quality must be taken into account. What is important from the patient's point of view may not be the same factors as to the physician, while the physician places a high value on factors that are less significant for the medical insurance company. The international otological community, who would like to draw conclusions from middle ear surgery data, might set different criteria altogether for assessing quality of surgery.Hence, we propose to adapt the general concept of quality to middle ear surgery. This must be implemented on different levels and surgical therapy of middle ear diseases must be understood as a process.This means that quality assessment must comprise additional aspects, which include a structured description and recording of disease-specific symptoms, findings, and outcome of treatment. Furthermore, in today's world the use of internationally recognized classification systems must be regarded as a quality feature, in order to make results not only publishable but also capable of meta-analysis. Internationally developed and recognized reporting systems are available for this purpose. Their use in routine care not only makes the collected data internationally comparable, but also enables systematic evaluation within the institution for quality description and control.In addition to audiological measurement results, surgical quality indicators are considered. We also focus on emerging complications and the value of systematic and structured evaluation and documentation systems. Validated measuring instruments are already available for patient benefit assessment, the use of which should no longer be limited to scientific studies. In summary, quality assessment of surgery should be extended to include not only the "patient as a whole", but also to the "therapy process as a whole", incorporating features of structural and process quality.

Imaging birefringent tissue in the human tympanic membrane by polarization-sensitive optical coherence tomography

Acousto-mechanical properties of the human tympanic membrane mainly depend on the connective tissue in its layered structure. Using polarization-sensitive optical coherence tomography, a depth-resolved imaging technique which provides additional tissue specific contrast, polarization changes of the birefringent layers in the human tympanic membrane were detected. By depicting estimated local retardances, distinguishing different tissue types was possible. This suggests the ability to image pathological alterations of the connective tissue with PSOCT, which extends the conventional diagnostic methods in middle ear surgery.