Doris-Maria Denk-Linnert

Tinnitus and mobile phone use

Objectives The mechanisms that produce tinnitus are not fully understood. While tinnitus can be associated with diseases and disorders of the ear, retrocochlear diseases and vascular pathologies, there are few known risk factors for tinnitus apart from these conditions. There is anecdotal evidence of an link between mobile phone use and tinnitus, but so far there have been no systematic investigations into this possible association. Methods 100 consecutive patients presenting with tinnitus were enrolled in an individually matched case–control study. For each case a control subject was randomly selected from visiting outpatients matched for sex and age. The patients history was obtained and clinical examinations were conducted to exclude patients with known underlying causes of tinnitus. Mobile phone use was assessed based on the Interphone Study protocol. ORs were computed by conditional logistic regression with years of education and living in an urban area as covariates. Results Mobile phone use up to the index date (onset of tinnitus) on the same side as the tinnitus did not have significantly elevated ORs for regular use and intensity or for cumulative hours of use. The risk estimate was significantly elevated for prolonged use (≥4 years) of a mobile phone (OR 1.95; CI 1.00 to 3.80). Conclusions Mobile phone use should be included in future investigations as a potential risk factor for developing tinnitus.

Towards Objective Voice Assessment: The Diplophonia Diagram.

OBJECTIVES Diplophonia is an often misinterpreted symptom of disordered voice, and needs objectification. An audio signal processing algorithm for the detection of diplophonia is proposed. Diplophonia is produced by two distinct oscillators, which yield a profound physiological interpretation. The algorithms performance is compared with the clinical standard parameter degree of subharmonics (DSH). STUDY DESIGN This is a prospective study. METHODS A total of 50 dysphonic subjects with (28 with diplophonia and 22 without diplophonia) and 30 subjects with euphonia were included in the study. From each subject, up to five sustained phonations were recorded during rigid telescopic high-speed video laryngoscopy. A total of 185 phonations were split up into 285 analysis segments of homogeneous voice qualities. In accordance to the clinical group allocation, the considered segmental voice qualities were (1) diplophonic, (2) dysphonic without diplophonia, and (3) euphonic. The Diplophonia Diagram is a scatter plot that relates the one-oscillator synthesis quality (SQ1) to the two-oscillator synthesis quality (SQ2). Multinomial logistic regression is used to distinguish between diplophonic and nondiplophonic segments. RESULTS Diplophonic segments can be well distinguished from nondiplophonic segments in the Diplophonia Diagram because two-oscillator synthesis is more appropriate for imitating diplophonic signals than one-oscillator synthesis. The detection of diplophonia using the Diplophonia Diagram clearly outperforms the DSH by means of positive likelihood ratios (56.8 versus 3.6). CONCLUSIONS The diagnostic accuracy of the newly proposed method for detecting diplophonia is superior to the DSH approach, which should be taken into account for future clinical and scientific work.

Summarized institutional experience of paediatric airway surgery

OBJECTIVES The management of paediatric airway stenosis is complex, and requires a dedicated team, consisting of thoracic surgeons, phoniatricians, logopaedics, paediatricians and anaesthetists. The majority of paediatric laryngotracheal stenosis is a sequela of prematurity and prolonged post-partal intubation/tracheostomy. Surgical correction is often difficult due to a frequent combination of glottic and subglottic defects. METHODS In 2012, the Laryngotracheal Program Vienna was launched. Since then, 18 paediatric patients were surgically treated for (laryngo-)tracheal problems. RESULTS The median age of our patients was 26 months (range 2-180 months). Laryngotracheal stenosis extending up to the level of the vocal cords was evident in 9 patients. Three children were diagnosed with an isolated subglottic, and four with a short-segment tracheal stenosis or malacia. Two patients had a long-segment congenital malformation together with vascular ring anomalies. Five children were pretreated by rigid endoscopy before surgical correction, 12 of our 18 patients had a tracheostomy, 3 children were intubated at the time of operation. Different techniques of corrections were applied: laryngotracheal reconstruction (n = 4), extended partial cricotracheal resection (n = 4), cricotracheal resection with or without anterior split or dorsal mucosal flap (n = 4), slide tracheoplasty (n = 2), tracheal resection (n = 4). In 8 patients, a rib cartilage interposition was necessary in order to obtain a sufficient lumen enlargement and in 7 of these patients, an LT-Mold was placed to stabilize the reconstruction. We lost 2 patients, who were referred to our institution after failure of multiple preceding interventions, 2 and 3 months after the operation. Twelve patients are currently in an excellent condition, one is in an acceptable condition without a need for an intervention. Two patients required an endoscopic reintervention 18 and 33 months after the operation, 1 child is currently still cannulated. CONCLUSIONS Paediatric airway surgery is complex, and requires a dedicated interdisciplinary team. An armamentarium of different resection and reconstruction techniques is necessary in order to achieve good long-term results.

Comparison of an audio-based and a video-based approach for detecting diplophonia

Abstract Background and objectives Diplophonia is a common symptom in voice disorders. Depending on the underlying aetiology, diplophonic patients typically need treatment such as phonosurgery or speech therapy. In current clinical practice, the presence of diplophonia is assessed by auditive rating. To avoid subjectivity in voice assessment and to follow principles of evidence based medicine, objective instrumental assessment methods are needed. In order to gain insight into instrumental assessment of diplophonic voice, comparisons between different assessment approaches are necessary. The aim of the study is to compare the performance of two independent objective approaches on their ability to detect diplophonia. The compared approaches are the formerly published degree of subharmonics (DSH), and a newly proposed measure for spatial bimodality of the vocal fold vibration. Material and methods From a clinical database of 352 laryngeal high-speed videos with synchronous audio recordings, 60 phonation segments (20 euphonic, twenty diplophonic and twenty non-diplophonic dysphonic) were auditively selected. For all phonation segments, the DSH and the newly proposed measure for spatial bimodality were determined. The DSH is the occurrence rate of audio analysis blocks with ambiguous fundamental frequency in percent. The bimodality measure quantifies the spatial occurrence of secondary oscillation frequencies along the vocal folds’ edges. Both the DSH and the bimodality measure are evaluated on their ability to detect diplophonia by means of cut off threshold classification. Results and conclusions The DSH showed excellent classification rates for separating diplophonic from euphonic phonation (sensitivity: 98.4%, specificity: 100%). In separating diplophonic from non-diplophonic dysphonic phonation, the bimodality measure slightly outperforms the DSH approach (sensitivity: 54.6%, specificity: 92.7%). The separation of diplophonia from other kinds of dysphonia is challenging, and more sophisticated methods are needed. It is concluded that auditive and glottal diplophonia must be distinguished. As the clinical assessment of diplophonia primarily aims at determining glottal conditions, the video-based approach might deliver clinically more relevant data than the auditive approach.

Evaluation of Symptoms

Symptoms of pharyngeal/esophageal diseases are mainly related to swallowing function, e.g., dysphagia, aspiration, globus sensation or heartburn. Dysphagia and aspiration may lead to malnutrition, potentially life-threatening pulmonary complications (e.g., aspiration pneumonia) and impairment of life-quality. The most important dysphagia related symptom is aspiration. Other components of dysphagia are drooling, leaking, delayed triggering of the swallowing reflex, retentions, nasal penetration or pharyngeal regurgitation. The etiologies of oropharyngeal dysphagia may be divided into three groups: diseases of the upper aerodigestive tract, neurological diseases and psychogenic disorders. Possible hints to suspect dysphagia and aspiration are indirect and direct symptoms. They necessitate an interdisciplinary diagnostic work-up for revealing etiology and pathophysiology. For the proof or exclusion of aspiration it´s direct visualization by videoendoscopy and videofluoroscopy remains indispensable and cannot be replaced by screening procedures.

Pre-emptive glottic enlargement before laryngotracheal surgery in patients at high risk for postoperative bilateral vocal fold paralysis†

OBJECTIVES Bilateral vocal fold paralysis (VFP) is a severe complication after laryngotracheal (LT) surgery. The reduced glottic opening leads to significant respiratory distress immediately after the operation and requires the placement of a tracheostomy in most cases. Patients with a pre-existing unilateral VFP or expected recurrent nerve resection are at the highest risk for glottic failure. These patients might benefit from a pre-emptive glottic enlargement before LT surgery. METHODS We performed a retrospective review of patients who received a pre-emptive glottis enlargement before LT surgery at the Medical University of Vienna from October 2011 to December 2016. Peri- and postoperative outcomes of this strategy were analysed. RESULTS Six patients underwent preparatory glottic enlargement prior to LT resection. Four patients had recurrent thyroid cancer, and 1 patient had thymic cancer invading the cervical airway. The remaining patient had a complex benign glotto/subglottic stricture complicated by a pre-existing bilateral VFP. All patients received oblique cricotracheal resections extending into the larynx [resection length 39 ± 7 mm (mean ± SD)]. Extubation within 24 h after surgery was achieved in 5 of 6 cases, although all patients had postoperative unilateral (n = 5) or bilateral (n = 1) VFP as anticipated. In 5 of the 6 patients, oral intake could be started immediately after the operation. The remaining patient regained full swallowing function after intensive swallowing rehabilitation. Postoperative voice quality was subjectively perceived as satisfactory by all patients. CONCLUSIONS Pre-emptive glottic enlargement is a valuable treatment strategy in patients at highest risk for postoperative bilateral VFP. It facilitates immediate postoperative extubation, despite at least unilateral VFP and extensive LT surgical procedures.

Assessment of nasalance and nasality in patients with a repaired cleft palate

In patients with a repaired cleft palate, nasality is typically diagnosed by speech language pathologists. In addition, there are various instruments to objectively diagnose nasalance. To explore the potential of nasalance measurements after cleft palate repair by NasalView®, we correlated perceptual nasality and instrumentally measured nasalance of eight speech items and determined the relationship between sensitivity and specificity of the nasalance measures by receiver-operating characteristics (ROC) analyses and AUC (area under the curve) computation for each single test item and specific item groups. We recruited patients with a primarily repaired cleft palate receiving speech therapy during follow-up. During a single day visit, perceptive and instrumental assessments were obtained in 36 patients and analyzed. The individual perceptual nasality was assigned to one of four categories; the corresponding instrumental nasalance measures for the eight specific speech items were expressed on a metric scale (1–100). With reference to the perceptual diagnoses, we observed 3 nasal and one oral test item with high sensitivity. However, the specificity of the nasality indicating measures was rather low. The four best speech items with the highest sensitivity provided scores ranging from 96.43 to 100%, while the averaged sensitivity of all eight items was below 90%. We conclude that perceptive evaluation of nasality remains state of the art. For clinical follow-up, instrumental nasalance assessment can objectively document subtle changes by analysis of four speech items only. Further studies are warranted to determine the applicability of instrumental nasalance measures in the clinical routine, using discriminative items only.