Armin Steffen

Application of the Vibrant Soundbridge to unilateral osseous atresia cases.

Patients with high‐grade atresia‐microtia suffer from a combined malformation of the outer and middle ears, typically leading to a severe hearing impairment. Long‐term results of middle ear reconstruction with tympanoplasty are often insufficient due to persistent air‐bone gaps, and new techniques in hearing rehabilitation are required. The objective of this research is to evaluate the active middle ear implant, the Vibrant Soundbridge® (VSB), for hearing rehabilitation of patients with unilateral osseous aural atresia.

A prospective evaluation of psychosocial outcomes following ear reconstruction with rib cartilage in microtia

Little is known about the psychosocial improvement of microtic patients following reconstruction with rib cartilage. Furthermore, no data exist on detailed follow-ups of patients who refused ear repair. To the best of our knowledge, this is the first report of a prospective evaluation of psychosocial outcomes with a validated instrument in ear reconstruction with rib cartilage. Twenty-one patients, who had undergone rib-cartilage reconstruction to treat a congenital auricular defect, were evaluated prospectively for psychosocial changes using a clinically validated questionnaire. In addition, patients were asked to judge the new auricle and thoracic scar. Twenty-three patients, who decided against an ear reconstruction following consultation, were analysed for the reasons behind their refusal. Almost 66% of the treated patients were able to integrate the new ear into their body concept. If faced with the same surgery decision again, 88% would still choose to undergo ear reconstruction with rib cartilage. There were strong postoperative improvements in psychosocial attitude (p=0.02). In our sample, patients who declined ear repair showed higher values of psychosocial attitude (p=0.006) compared with the preoperative results in treated patients. Our study shows that the clinically known improvement of psychosocial aspects can be documented by a validated psychological test. The patients expectations and surgical limits of the reconstruction with rib cartilage need detailed discussion prior to surgery to prevent dissatisfaction despite surgical success. Our data help to accept a childs denial as these patients have a good psychosocial standing even with an unrepaired microtia.

The Psychosocial Consequences of Reconstruction of Severe Ear Defects or Third-Degree Microtia With Rib Cartilage

BACKGROUND There are few data focusing on the improvement of psychosocial functioning and self-esteem in patients with congenital or acquired severe auricular defects. OBJECTIVE We investigated the satisfaction of patients following auricular reconstruction with rib cartilage. METHODS One hundred patients treated for reconstruction with rib cartilage for congenital or traumatic auricular defects have been evaluated retrospectively for changes in self-esteem, performance ability, and psychosocial attitude using a clinically established questionnaire, Frankfurter Selbstkonzeptskalen (FSKN). In addition, patients were asked to judge the new auricle and the thoracic scar using a new questionnaire. RESULTS Of 68 patients who took part in this study, almost 90% could integrate the new ear into their body concept. If faced with the same decision for surgery again, 75% would again choose a reconstruction with rib cartilage. More than three-quarters rated the thoracic scar as acceptable in relation to the benefits of the new ear, although one-third felt uncomfortable with the pain and cosmetic appearance of the thoracic scar. According to the results of the FSKN questionnaire, values in psychosocial abilities improved postoperatively. There was no clear change in either self-esteem or performance ability. CONCLUSIONS Ear reconstruction with rib cartilage remains, under most circumstances, the procedure of choice for repairing auricular defects. There is a high acceptance of this method among patients, although the impact of the thoracic scar needs to be discussed extensively before surgery. The importance of the surgeons experience cannot be underestimated, because it determines the aesthetic results and the patients satisfaction in this challenging area of plastic surgery.

Outcomes of Upper Airway Stimulation for Obstructive Sleep Apnea in a Multicenter German Postmarket Study.

Objective Selective stimulation of the hypoglossal nerve is a new surgical therapy for obstructive sleep apnea, with proven efficacy in well-designed clinical trials. The aim of the study is to obtain additional safety and efficacy data on the use of selective upper airway stimulation during daily clinical routine. Study Design Prospective single-arm study. Setting Three tertiary hospitals in Germany (Munich, Mannheim, Lübeck). Subjects and Methods A multicenter prospective single-arm study under a common implant and follow-up protocol took place in 3 German centers (Mannheim, Munich, Lübeck). Every patient who received an implant of selective upper airway stimulation was included in this trial (apnea-hypopnea index ≥15/h and ≤65/h and body mass index <35 kg/m2). Before and 6 months after surgery, a 2-night home sleep test was performed. Data regarding the safety and efficacy were collected. Results From July 2014 through October 2015, 60 patients were included. Every subject reported improvement in sleep and daytime symptoms. The average usage time of the system was 42.9 ± 11.9 h/wk. The median apnea-hypopnea index was significantly reduced at 6 months from 28.6/h to 8.3/h. No patient required surgical revision of the implanted system. Conclusion Selective upper airway stimulation is a safe and effective therapy for patients with obstructive sleep apnea and represents a powerful option for its surgical treatment.

The Lübeck flowchart for functional and aesthetic rehabilitation of aural atresia and microtia.

Objective Current strategies for functional rehabilitation of microtia-atresia patients with bone-anchored implants or surgical atresia repair have been extended by the feasibility of active middle ear implants. The aim of the present research is to evaluate a new flowchart of the treatment of these patients that considers active middle ear implants. Patients Congenital aural atresia and microtia. Intervention(s) Bilateral cases are provided with a conductive hearing aid after birth and implanted with an active middle ear implant within the second year. Unilateral cases are provided with a conductive hearing aid and implanted with a middle ear or bone-conduction device in early childhood. Unilateral cases without amplification in the vulnerable time after birth are carefully selected for late implantation. At age 8 to 10, the auricular reconstruction is completed. Main Outcome Measure(s) Feasibility of implantation irrespective of age, functional gain in audiometry. Results The results of early implantation are as good as those previously published for adolescents. Mean reaction threshold with the Vibrant Soundbridge was 21 dB. Mean functional gain was 48 dB. The local tissues are unaltered and ready for auricular reconstruction. Conclusion Active middle ear implants allow early and selective stimulation of the auditory pathway in children with congenital conductive hearing loss and are expected to lead to the normal development of the binaural hearing functions. To date, it is the only option if the stimulation is to be started at the age of 12 to 18 months. This was implemented into a new flowchart for aural atresia-microtia.

Outcome after one year of upper airway stimulation for obstructive sleep apnea in a multicenter German post‐market study

Upper airway stimulation (UAS) of the hypoglossal nerve has been implemented in the routine clinical practice for patients with moderate‐to‐severe obstructive sleep apnea (OSA) who could not adhere to continuous positive airway pressure. This study reports objective and patient‐reported outcome after 12 months of implantation.

[Sk2 guidelines"diagnosis and therapy of snoring in adults" : compiled by the sleep medicine working group of the German Society of Otorhinolaryngology, Head and Neck Surgery].

These guidelines aim to facilitate high quality medical care of adults with snoring problems. The guidelines were devised for application in both in- and outpatient environments and are directed primarily at all those concerned with the diagnosis and therapy of snoring. According to the AWMF three-level concept, these represent S2k guidelines.A satisfactory definition of snoring does not currently exist. Snoring is the result of vibration of soft tissue structures in narrow regions of the upper airway during breathing while asleep. Ultimately, these vibrations are caused by the sleep-associated decrease in muscle tone in the area of the upper airway dilator muscles. A multitude of risk factors for snoring have been described and its occurrence is multifactorial. Data relating to the frequency of snoring vary widely, depending on the way in which the data are collected. Snoring is usually observed in middle-aged individuals and affected males predominate. Clinical diagnosis of snoring should comprise a free evaluation of the patients medical history. Where possible this should also involve their bed partner and the case history can be complimented by questionnaires. To determine the airflow relevant structures, a clinical examination of the nose should be performed. This examination may also include nasal endoscopy. Examination of the oropharynx is particularly important and should be performed. The larynx and the hypopharynx should be examined. The size of the tongue and the condition of the mucous membranes should be recorded as part of the oral cavity examination, as should the results of a dental assessment. Facial skeleton morphology should be assessed for orientation purposes. Technical examinations may be advisable in individual cases. In the instance of suspected sleep-related breathing disorders, relevant comorbidities or where treatment for snoring has been requested, an objective sleep medicine examination should be performed. Snoring is not-at least as we currently understand it-a disease associated with a medical threat; therefore there is currently no medical necessity to treat the condition. All overweight patients with snoring problems should strive to lose weight. If snoring is associated with the supine position, positional therapy can be considered. Some cases of snoring can be appropriately treated using an intraoral device. Selected minimally invasive surgical procedures on the soft palate can be recommended to treat snoring, provided that examinations have revealed a suitable anatomy. The choice of technique is determined primarily by the individual anatomy. At an appropriate interval after the commencement or completion a therapeutic measure, a follow-up examination should be conducted to assess the success of the therapy and to aid in the planning of any further treatments.ZusammenfassungZiel dieser Leitlinie ist die Förderung einer qualitativ hochwertigen ärztlichen Versorgung von Erwachsenen mit Schnarchen. Die Leitlinie wurde für die Anwendung im Rahmen der ambulanten und stationären Versorgung konzipiert und richtet sich primär an alle, die mit der Diagnostik und Therapie des Schnarchens befasst sind. Sie entspricht nach dem 3-Stufen-Konzept der AWMF einer S2k-Leitlinie.Eine befriedigende Definition des Schnarchens existiert derzeit nicht. Das Schnarchen entsteht durch eine Vibration von Weichteilstrukturen an Engstellen des oberen Atemwegs während der Atmungstätigkeit im Schlaf. Auslöser ist letztlich die Abnahme des Muskeltonus im Bereich der Dilatatoren des oberen Atemwegs während des Schlafs. Es wurde eine Vielzahl von Risikofaktoren für das Schnarchen beschrieben. Die Entstehung ist multifaktoriell. Die Angaben zur Häufigkeit des Schnarchens variieren erheblich in Abhängigkeit von der Art der Erhebung. Das Schnarchen tritt am häufigsten im mittleren Lebensalter auf und zeigt eine Dominanz des männlichen Geschlechts. Zur klinischen Diagnostik soll bei Schnarchern die freie Anamnese, wenn möglich unter Einbeziehung des Bettpartners, durchgeführt werden; sie kann durch Fragebögen ergänzt werden. Zur Beurteilung der strömungsrelevanten Strukturen sollte eine klinische Untersuchung der Nase erfolgen. Diese kann auch eine endoskopische Beurteilung beinhalten. Die Untersuchung des Oropharynx ist von großer Bedeutung und soll durchgeführt werden. Eine Untersuchung des Larynx und des Hypopharynx sollte erfolgen. Bei der Untersuchung der Mundhöhle sollen die Größe der Zunge, der Zustand der Schleimhäute und der Zahnbefund beurteilt werden. Eine orientierende Beurteilung der skelettalen Morphologie des Gesichtsschädels sollte erfolgen. Im Einzelfall können technische Untersuchungsverfahren sinnvoll sein. Eine objektivierende schlafmedizinische Untersuchung soll erfolgen, wenn der Verdacht auf eine schlafbezogene Atmungsstörung besteht, relevante Komorbiditäten vorliegen, oder wenn ein Therapiewunsch bezüglich des Schnarchens besteht. Beim Schnarchen handelt es sich, zumindest nach derzeitigem Kenntnisstand, nicht um eine Erkrankung mit einer medizinischen Gefährdung und es besteht daher derzeit keine medizinische Notwendigkeit zur Behandlung. Eine Reduktion des Körpergewichts bei allen übergewichtigen Betroffenen sollte angestrebt werden. Wenn ein rein rückenlagebezogenes Schnarchen besteht, kann die Therapie mit einer Rückenlageverhinderung erwogen werden. In geeigneten Fällen kann die Therapie des Schnarchens mit einer Unterkieferprotrusionsschiene (UKPS) erfolgen. Ausgewählte minimal-invasive chirurgische Verfahren am Weichgaumen können zur Therapie des Schnarchens empfohlen werden, sofern ein geeigneter anatomischer Befund vorliegt. Die Auswahl des Verfahrens hängt in entscheidender Weise vom individuellen anatomischen Befund ab. Nach Einleitung bzw. Durchführung einer therapeutischen Maßnahme sollte nach einem angemessenen Zeitraum zur Überprüfung des Therapieerfolgs und ggf. zur Planung weiterer Maßnahmen eine Nachuntersuchung erfolgen.AbstractThese guidelines aim to facilitate high quality medical care of adults with snoring problems. The guidelines were devised for application in both in- and outpatient environments and are directed primarily at all those concerned with the diagnosis and therapy of snoring. According to the AWMF three-level concept, these represent S2k guidelines.A satisfactory definition of snoring does not currently exist. Snoring is the result of vibration of soft tissue structures in narrow regions of the upper airway during breathing while asleep. Ultimately, these vibrations are caused by the sleep-associated decrease in muscle tone in the area of the upper airway dilator muscles. A multitude of risk factors for snoring have been described and its occurrence is multifactorial. Data relating to the frequency of snoring vary widely, depending on the way in which the data are collected. Snoring is usually observed in middle-aged individuals and affected males predominate. Clinical diagnosis of snoring should comprise a free evaluation of the patient’s medical history. Where possible this should also involve their bed partner and the case history can be complimented by questionnaires. To determine the airflow relevant structures, a clinical examination of the nose should be performed. This examination may also include nasal endoscopy. Examination of the oropharynx is particularly important and should be performed. The larynx and the hypopharynx should be examined. The size of the tongue and the condition of the mucous membranes should be recorded as part of the oral cavity examination, as should the results of a dental assessment. Facial skeleton morphology should be assessed for orientation purposes. Technical examinations may be advisable in individual cases. In the instance of suspected sleep-related breathing disorders, relevant comorbidities or where treatment for snoring has been requested, an objective sleep medicine examination should be performed. Snoring is not—at least as we currently understand it—a disease associated with a medical threat; therefore there is currently no medical necessity to treat the condition. All overweight patients with snoring problems should strive to lose weight. If snoring is associated with the supine position, positional therapy can be considered. Some cases of snoring can be appropriately treated using an intraoral device. Selected minimally invasive surgical procedures on the soft palate can be recommended to treat snoring, provided that examinations have revealed a suitable anatomy. The choice of technique is determined primarily by the individual anatomy. At an appropriate interval after the commencement or completion a therapeutic measure, a follow-up examination should be conducted to assess the success of the therapy and to aid in the planning of any further treatments.

Diagnosis and treatment of snoring in adults–S2k Guideline of the German Society of Otorhinolaryngology, Head and Neck Surgery

Snoring is an obscure phenomenon, and many authors have tried to highlight the numerous facets in the past. Remarkable knowledge has been elaborated about obstructive snoring but not about primary snoring with its many epithets such as harmless, simple, habitual, benign, non-apnoeic, continuous, rhythmic etc. In 2010, the German Society of Otorhinolaryngology, Head and Neck Surgery published the S1 guideline: Diagnosis and Treatment of Snoring in Adults in ‘Sleep and Breathing’ 14: 317–321. The guideline has been revised and updated by the group of 10 German authors under the leadership of Boris Stuck in the present S2k guideline. It was initially published in the German journal ‘HNO’ 2013; 61: 944–57. The review of the literature was performed in June 2012 usingMedLine with the following search criteria: {‘snoring’ NOT ‘apnea’ NOT ‘apnoea’}, limited to the terms ‘English’, ‘German’, ‘adults’ and ‘humans’. I think it is very worthy of merit that the author group continued to follow the new developments of the difficult to explain phenomenon of snoring which is not a disease with a medical hazard. The authors wisely interpreted snoring in the sense of this guideline as a diagnosis of exclusion. To date, there is no satisfactory definition of snoring available and no validated questionnaire that aims to differentiate the snoring addressed by this guideline from snoring associated with obstructive sleep apnea. The numerous aspects of snoring are described in detail as to definition, nosology, aetiology, pathophysiology, epidemiology, health effects, clinical presentation, diagnostic measures (very widely discussed), therapeutic principles (conservative approaches—surgical treatments), and inclusive recommendations if possible. As studies about objectively assessing snoring and wellcontrolled clinical trials concerning the treatments and their outcome are lacking, it is not surprising that the words ‘may be’ and ‘could be’ are often to be found in the statements and recommendations. The guideline ends with a list of 93 references and a report of how this guideline was created. The process of compiling it is meticulously described including how all the German Societies were addressed which are engaged in sleep medicine. A detailed description of the commercial interests of the author group completes the guideline. This guideline has not only clarified the understanding of primary snoring but also left open questions. Snoring reminds me of the Lernean Hydra, the fearsome dragon-like monster with nine serpents’ heads. Hercules undertook to slay the beast by clubbing it on its multiple heads. But as soon as one head was crushed, two new ones sprang up in its place. Help came by his faithful companion Iolaus who burnt the wound of the cutoff heads. Thus, Hercules and Iolaus step by step overcame the monster. For the moment, there is no Hercules amongst us and only many companions like Iolaus who may perhaps be able to tame the monster ‘snoring’ in the long run.

Sleep apnoea in patients after treatment of head neck cancer

Conclusions: The prevalence of sleep apnoea among patients following treatment of head and neck carcinomas seems to be slightly higher than in the normal population. The possible importance of tumour treatment features, especially transient tracheostoma, needs further assessment. Objectives: The epidemiology of sleep apnoea in patients following the treatment of head and neck cancer remains unclear. This study was undertaken to assess the prevalence of sleep apnoea in head and neck cancer patients by characterizing their clinical, anatomical and tumour treatment features. Patients and methods: Our study examined 31 patients in a prospective non-controlled study using a standardized questionnaire that included the Epworth Sleepiness Scale (ESS) and a polygraph. Results: Six of the 31 patients showed a pathologic AHI ≥ 20/h. Subjects positive for sleep apnoea more often had a tumour of the hypopharynx or larynx and more often had a transient tracheostoma during cancer therapy. Radiotherapy had no clear impact on the prevalence of sleep apnoea.

Psychometric validation of the youth quality of life-facial differences questionnaire in patients following ear reconstruction with rib cartilage in microtia.

1. Cho BC, Lee SH. Surgical results of two-stage reconstruction of the auricle in congenital microtia using an autogenous costal cartilage alone or combined with canaloplasty. Plast Reconstr Surg. 2006;117:936–947. 2. Moore KL, Dalley AF. Clinically Oriented Anatomy. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. 3. Briscoe C. The interchondral joints of the human thorax. J Anat. 1925;59:432–437. 4. Chin W, Zhang R, Zhang Q, Xu Z, Li D, Wu J. Modifications of three-dimensional costal cartilage framework grafting in auricular reconstruction for microtia. Plast Reconstr Surg. 2009; 124:1940–1946. Psychometric Validation of the Youth Quality of Life-Facial Differences Questionnaire in Patients following Ear Reconstruction with Rib Cartilage in Microtia Sir: M icrotia repair with rib cartilage leads to superior aesthetic results.1 Several surgeons have reported increased quality of life using polyethylene implants.2 More attention has been paid to the psychosocial situations of patients with microtia using validated psychometric instruments.2,3 In particular, disease-related quality-of-life tools offer the opportunity to recognize specific everyday problems of patients with facial deformities in a standardized manner. Because adolescents represent the most relevant age group and because age dependency is well known in the psychosocial context,4 the age aspect requires consideration. The Youth Quality of Life-Facial Differences questionnaire is a validated instrument that focuses on head and neck deformities and concentrates on adolescents,5 and is available in English and Spanish. Our study aimed to establish a linguistic German translation according to the Youth Quality of Life-Facial Differences questionnaire guidelines and to assess psychometric test criteria. A forward translation was established by two German native speakers. After clarifying different interpretations, a backward translation was performed by a bilingual English native speaker who had not read the original version. In a third step, six German adolescents with different congenital conditions in the head and neck area filled out the quesFig. 1. The operative technique is shown. (Left) The helix from the eighth costal cartilage and the antihelix from the lateral