Marcus M. Maassen

Quality of life after unilateral acoustic neuroma surgery via middle cranial fossa approach

Conclusions Patients with acoustic neuroma experienced reduced quality of life (QOL) after surgery. Individual factors did not have a significant effect on QOL. In the future, QOL should be a basic factor in the outcome evaluation of different therapeutic regimens in the treatment of acoustic neuroma. Objective To measure the QOL of patients who underwent unilateral acoustic neuroma surgery via the middle cranial fossa approach. Material and methods The Short Form-36 (SF-36) Health Survey and a self-designed disease-specific questionnaire were used during follow-up examinations to assess health-related QOL. The pure-tone average was used to specify hearing ability. Facial nerve function was described using the House–Brackmann grading system. A total of 28 male and 14 female patients who underwent surgery between 1997 and 2001 were included in the study. Results Patients’ QOL scores revealed significant reductions in QOL in comparison to normative German QOL data. Gender, age, tumor size or location and clinical symptoms such as hearing loss and restricted facial nerve function did not have an effect on QOL. The SF-36 scales physical functioning, role functioning—physical, bodily pain, general health, social functioning and role functioning—emotional demonstrated significant QOL reductions.

Ossifying fibroma of the ethmoid involving the orbit and the skull base.

c p u w ssifying fibroma is a rare, benign fibroosseus tumor. The average age at diagnosis is 31 years, with a range f 3 to 63 years, and a female-to-male ratio of 1.6:1. It is sually found in the craniofacial bones, with the mandible eing the most common site, accounting for 75% to 89% of ases. Less commonly, the orbit, paranasal sinuses, or axilla have also been involved. Total removal must be erformed to avoid recurrences. We report a case of an ssifying fibroma of the ethmoid with involvement of the rbit, the frontal bone, and the skull base.

How safe is percutaneous ethanol injection for treatment of thyroid nodule? Report of a case of severe toxic necrosis of the larynx and adjacent skin.

Objective—Since 1990, percutaneous ethanol injection therapy (PEIT) has been clinically applied as a treatment for autonomous functioning nodules of the thyroid as well as for cystic lesions. Some additional indications are currently under consideration, e.g. inoperable advanced cancer of the thyroid. Since its inception, PEIT has generally been regarded as an effective, low-risk, inexpensive procedure which can be performed on an ambulatory basis. Material and Methods—We report the first case of severe ethyl toxic necrosis of the larynx combined with necrotic dermatitis in a patient treated with PEIT by a radiologist. Results—The patient was admitted to hospital, where the necrosis and dermatitis were treated conservatively. A cyst which developed in the right false vocal fold was removed by microsurgery 10 months later. Voice was restored almost to normal but a significant reduction in nodular volume was not seen, probably due to the inexperience of the operator. Conclusion—PEIT for functional thyroid gland autonomy is an inexpensive method of treating hyperthyroidism with focal autonomy on an ambulatory basis if surgical intervention and radioiodine therapy are not feasible either for medical reasons or because of refusal by the patient. Severe complications must be taken into consideration and discussed with the patient. To avoid complications, substantial experience and a precise ultrasound-guided injection are required. In the case of complications the opinion of a specialist should be sought at an early stage.

Erste Implantationen eines vollständig implantierbaren elektronischen Hörsystems bei Patienten mit Innenohrschwerhörigkeit

Zusammenfassung:Für die Mehrzahl der Innenohrschwerhörigen kann selbst mit modernster Hörgerätetechnik keine die Patienten zufriedenstellende Hörrehabilitation erzielt werden. Für diese große Zahl von Betroffenen ohne adäquate Versorgung sind teilimplantierbare Hörgeräte entwickelt worden, die konventionellen Hörgeräten besonders bei Klangtreue und Sprachverständlichkeit deutlich überlegen sein können. Allerdings können sie den Kranken durch außen an Kopf oder Körper zu tragende Teile stigmatisieren. Auch nutzen sie die Störschallunterdrückung als auch die auditorische Raumorientierung mittels des äußeren Gehörgangs noch nicht aus. Hier berichten wir über die ersten Implantationen eines neuartigen, vollständig implantierbaren Hörsystems (TICA® LZ 3001) bei Innenohrschwerhörigen. Es nimmt den Schall über ein trommelfellnahes Mikrophon durch die intakte Gehörgangshaut auf. Ein retroaurikulär subkutan implantierter, mehrkanaliger digital programmierbarer Audioprozessor verarbeitet das Signal und gibt es über einen piezoelektronischen Wandler im Mastoid an den Amboßkörper weiter. Energie wird durch eine implantierbare Batterie bereitgestellt. Implantierte Patienten empfinden das Gehörte als verzerrungsfrei und transparent. Sie verstehen Sprache und empfinden Musik besser als ohne Implantat. Insbesondere im Störlärm kann z.T. ein erheblich verbessertes Sprachverständnis erreicht werden. Die bisherigen Ergebnisse ermutigen, weitere Implantationserfahrungen mit dem vollständig implantierbaren Hörsystem zu sammeln.SummaryFor the majority of patients with sensorineural hearing loss (SNHL) many available hearing aids often do not achieve satisfactory results. For these patients partially implantable hearing devices have been developed, allowing distortion-free hearing and speech intelligibility that may be superior to conventional hearing aids. The external parts of partial implants, however, may result in a patient’s stigmatization. Furthermore, they do not use the acoustic properties of the external auditory canal. Recently, we published the successful development of the first totally implantable hearing device for the treatment of SNHL (HNO 46 [1998] 853–863). Here we report the first implantations of this unique, totally implantable electronic hearing system in patients with SNHL: Implex TICA LZ 3001. The implant microphone is implanted subcutaneously in the outer ear canal near the ear drum. The signal is processed by a digitally programmable multichannel audioprocessor located subcutaneously on the bony skull behind the ear. A piezoelectric transducer is coupled to the body of the incus and drives the ossicular chain by vibratory actions. Energy is provided by an implantable battery. Implanted patients describe hearing as being distortion-free and transparent. Speech intelligibility and the hearing of music are improved. Patients may achieve better speech discrimination, especially in the presence of background noise. The aid can be used during sports, including swimming. To our knowledge, this is the first report of the implantation of a totally implantable electronic hearing system in patients. These results encourage further implantations of the totally implantable hearing system in the course of an ongoing clinical study.

Phase III results with a totally implantable piezoelectric middle ear implant: Speech audiometry, spatial hearing and psychosocial adjustment

Objective To evaluate the treatment efficacy of an electromechanical middle ear amplifier implant (AI) in patients with chronic moderate-to-severe sensorineural hearing loss (SNHL). The AI is a piezoelectric system with a sound processor and a rechargeable battery within a hermetically sealed titanium canister. Its titanium-sealed microphone is placed in the bony region of the ear canal. The incus-coupled transducer (actuator), which is also inside a titanium casing, is fastened to the adjacent bone. Material and Methods This was a phase III study comprising 20 intention-to-treat patients. Telemetrical adjustments followed electromechanical amplifier implantations. We used a word recognition test as our primary efficacy measure (Freiburg Speech Recognition Test; DIN 45621). Secondary efficacy measures were the sentence comprehension test (Goettinger Satztest, 1996) for auditory orientation within noisy and quiet environments and a psychosocial adjustment test (Gothenburg Profile Test, 1998). The 6-month follow-up comprised a complete medical examination. Nineteen patients completed the study (per-protocol patients; 100% reference). Results Seventeen patients (89%) demonstrated improved binaural recognition of phonetically balanced monosyllables. Fourteen postoperative patients (74%) attained a perfect score (100%) on this test, compared to only 3 preoperative patients (16%). Thirteen patients (68%) reached the sentence recognition threshold at a 2:1 dB signal-to-noise ratio during noisy trials. Correct identification of the noise source direction in the horizontal plane occurred in 89% of the trials. The Gothenburg Profile Test scores showed that the subjective evaluation of hearing, orientation, social behavior and self-confidence increased from 48% to 88%. Three patients did not benefit from the implant. Conclusion Treatment of SNHL with a totally implantable hearing system can be an efficient method for those patients unable to wear hearing aids. However, in order to avoid implantation in non-responders, there is a need for more specific audiological indication criteria.

Dynamics of Middle Ear Prostheses – Simulations and Measurements

The efficient and systematic development of a middle ear prosthesis necessitates the use of computer models for the prosthesis itself and the reconstructed middle ear. The structure and parameters of the computer model have to be verified by specific measurements of the implant and the reconstructed ear. To obtain a realistic model of a reconstructed ear, three steps of modeling and measurements have been carried out. To get a first approach of the coupling elements a mechanical test rig representing a simplified reconstructed middle ear was built. The velocity of the stapedial footplate was measured with a laser Doppler vibrometer. The corresponding computer model was formulated, and the respective parameters were determined using the measured dynamical transfer functions. In the second step, a prosthesis was implanted into a human temporal bone without inner ear. Exciting this system with noise, the velocity of the stapes footplate was measured with the laser Doppler vibrometer. Based on the multibody system approach, a mechanical computer model was generated to describe the spatial motions of the reconstructed ossicular chain. Varying some significant parameters, simulations have been carried out. To describe the dynamical behavior of the system consisting of middle and inner ear, the computer model used in the second step has been enlarged by adding a simplified structure of the inner ear. The results were compared with in situ measurements taken from living humans.

Quality of life in patients with oropharyngeal carcinoma after primary surgery and postoperative irradiation.

OBJECTIVE To assess quality of life in patients with oropharyngeal carcinoma after primary surgery and postoperative irradiation. STUDY DESIGN Retrospective chart review and patient response to the Short Form 36 (SF-36) Health Survey and the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-H&N35 questionnaires. SETTING A tertiary care university hospital. RESULTS One hundred sixty-nine patients with oropharyngeal carcinoma underwent primary surgery followed by postoperative irradiation between January 1997 and February 2002. Eighty-eight disease-free survivors were identified in September 2002 and included in this study. The questionnaires were completed by 34 patients (39% completion rate). Median follow-up was 2.3 years (range 0.5-4.9 years). In oropharyngeal carcinoma patients, five scales of the SF-36 showed significantly reduced scores in comparison with the normal German population: physical functioning, role functioning - physical, general health, social functioning, and role functioning - emotional. Posttreatment scores from the literature fell within the 95% confidence interval of our data except one out of fifteen scales of the EORTC QLQ-C30 questionnaire and six out of eighteen scales of the EORTC QLQ H&N35 questionnaire. The comparison of our data with data from the reviewed literature produced similar results. CONCLUSIONS General quality of life was reduced in our oropharyngeal carcinoma patients. Primary surgery and postoperative irradiation demonstrated similar results in different studies.

Ein osseointegrierter Mikromanipulator als Halterung für implantierbare Hörgerätewandler Teil 1: Anpassung an die chirurgische Anatomie des Felsenbeins und operationstechnische Eigenschaften

ZusammenfassungFür die Versorgung von Schwerhörigkeiten stehen heute erste elektronische Hörimplantate zur Verfügung, die während der Implantation an eines der Ossikel oder an die Perilymphe angekoppelt werden. Ein neuartiges Implantat ist das aus Mikrophon und Wandler bestehende TICA® Implantat, das für die operative Versorgung von Innenohrschwerhörigkeiten geeignet ist. Zur Vermeidung intraoperativer Hörschäden wird der Wandler zunächst im Mastoid fixiert, um anschließend mit einer möglichst großen Anzahl geometrischer Freiheitsgrade und größtmöglicher Sicherheit quasi stereotaktisch an den gewünschten Ankoppelpunkt der Ossikelkette geführt zu werden. Dazu wurde ein nur 0,7 g wiegender Mikromanipulator entwickelt, der zusammen mit dem Wandler und dem Mikrophonmodul in die Mastoidhöhle implantiert wird. Der hier gezeigte Mikromanipulator zeichnet sich durch eine einfache intraoperative Handhabbarkeit, eine ausreichend präzise, vierachsige Führung des Wandlers bis zu seiner Ankopplung am Ossikel sowie durch eine dauerhafte Fixierung der endgültigen räumlichen Wandlerlage in der Mastoidhöhle aus. Dem Prinzip der integrierten Sicherheit folgend wird durch geeignete konzeptionelle Maßnahmen eine Verletzungsgefahr für Ossikel oder Innenohr, hervorgerufen, z.B. durch unbeabsichtigte Handbewegungen des Chirurgen oder Kopfbewegungen des Patienten ausgeschlossen. Der Mikromanipulator dient somit quasi als vibrationsarme, „künstliche Hand” des Operateurs. Auf die Entwicklung des Tübinger Mikromanipulators sowie seiner schrittweisen Anpassung an die Anatomie der Mastoidhöhle durch Probeimplantation in n=50 Humanfelsenbeinen wird näher eingegangen. Die In-vitro-Probeimplantationen ergaben, daß sich der Wandler zusammen mit Mikromanipulator und Mikrophon bei Ankopplung an den Amboßkörper in 76% aller Mastoidhöhlen implantieren ließ, ohne daß ein Implantatteil die Wölbung der Schädelkalotte überragte. Bei Ankopplung an den langen Amboßfortsatz betrug die Implantierbarkeit ohne Prominenz 78%.SummaryThe first electronic implantable hearing aids for patients with hearing loss are coupled to the ossicular chain or perilymph during implantation and are now available. Our new Tübingen implant designed for sensorineural hearing loss (SNHL) is the combination of an implantable microphone and piezotransducer. To avoid hearing losses during implantation, the Tübingen piezotransducer will be (1) fixed to the mastoid cavity and (2) positioned to one of the ossicular target points. This can be done with a micromanipulator which will be implanted together with transducer and microphone in the mastoid cavity. The manipulator weights 0.7 g. With four degrees of freedom, it allows highly secure and safe positioning of the transducer´s probe tip to the ossicular chain under close to stereotactic conditions. The main advantages of the present micromanipulator are (1) easy handling during surgery, (2) the transducer’s precise positioning to the ossicular target point with sufficient degrees of freedom, and (3) the transducer’s stable fixation in the mastoid cavity in the final position. Following integrated safety as the leading principle, ossicular or inner ear injuries caused, e.g., by the patient’s head movement or unintentional manual contact by the surgeon, are minimized. The micromanipulator is, as it were, the surgeon’s vibration-free ”artificial hand”. The manipulator’s development and its optimization to the mastoid cavity by test implantation in 50 human temporal bones are shown in detail. While coupling the transducer to the body of the incus, transducer, microphone, and micromanipulator can be implanted into 76% of all mastoid cavities without protrusion. In the case of transducers coupling to the long process of the incus, the protrusion-free implantation rate of the above-mentioned three implant modules is 78%.

In Vitro Model for Intraoperative Adjustments in an Implantable Hearing Aid (MET)

Objective: Assessment of the optimal static preloading of Otologics Middle Ear Transducer (MET) Ossicular Stimulator, when coupled to the incus.

Safe and Reliable Sound Threshold Measures with Direct Vibration of the Ossicular Chain

Objectives: The aim of the study was to evaluate the safety and feasibility of piezoelectric malleus vibration audiometer (MVA), which presents micromechanical vibrations to the umbo membranae tympani.