Philipp P. Caffier

Outcomes of long-term outpatient tinnitus-coping therapy: psychometric changes and value of tinnitus-control instruments.

Objectives: Increasing tinnitus compliance and coping are desirable aims of successful treatment in chronic tinnitus. However, application of established procedures such as tinnitus retraining therapy (TRT) is often relatively short. In addition, the value of tinnitus control instruments (TCI) is questionable, especially for minor severity levels of tinnitus, and the comparability of treatment results is low. To evaluate long-term changes of tinnitus-related distress, defined psychometric data were collected in patients with compensated tinnitus (cT) or decompensated tinnitus (dT) during a standardized 2-yr outpatient tinnitus-coping therapy (TCT). Design: In a prospective clinical investigation, the data of 70 tinnitus patients were recorded at the beginning and at 6-mo intervals, with a final investigation after 24 mo. The first group consisted of 40 patients with cT and dT who were randomly assigned to a treatment group and a waiting-list control group. After a period of 12 mo without treatment, the control group was treated similarly. The tinnitus questionnaire (TQ) of Goebel and Hiller, visual analog scales (VAS), and a severity questionnaire for tinnitus-associated complaints were used as psychodiagnostic instruments. Therapy components consisted of counseling, fitting patients with TCIs (TCI provision), auditory and relaxation training, and psychosomatic care if necessary. A second group of 30 patients with cT receiving TCT without TCI devices was investigated to evaluate the additive efficacy of TCI in cT. Results: The initial TQ score did not differ between the treatment group and the waiting-list control group. After 12 mo, the control group did not show any significant changes, but the treatment group had improved significantly. During TCT, the combined data of both groups showed a statistically significant decrease of the TQ score in dT (59.1 to 34.8) and cT (32.8 to 24.0). These changes were especially reflected by the subscales of cognitive and emotional distress and also by the VAS and the severity questionnaire. dT patients benefitted without dependence on age or duration of pre-existing tinnitus; for cT patients, this was true mainly of the younger and older subjects and for tinnitus lasting for less than 1 yr. TCI provision improved the efficacy of TCT in patients with cT. Conclusions: The psychometric changes demonstrate a clear decrease of tinnitus-related distress in all severity levels of sufficiently treated chronic tinnitus. Long-term TCT induces improvement even up to the time of 24 mo. With TCIs established particularly in patients with dT, our results suggest that a supporting adjustment of TCI devices is helpful in cT to foster quicker rehabilitation. The outpatient interdisciplinary TCT, consisting of cognitive tinnitus desensitization, TCI provision, and psychosomatic support if required, represents a successful treatment strategy for both dT and cT patients.

Impact of laser eustachian tuboplasty on middle ear ventilation, hearing, and tinnitus in chronic tube dysfunction.

Objectives: Long-term Eustachian tube dysfunction (ETD) predisposes to various secondary middle ear diseases. Most surgical and prosthetical interventions on the Eustachian tube itself have proven to be ineffective, whereas middle ear surgeries treat the sequelae of ETD without major influence on the underlying tubal pathology. The purpose of our study was to evaluate the outcome of laser Eustachian tuboplasty (LETP) on tubal function and associated otological symptoms in topically anesthetized ETD patients with intact or perforated eardrums. Design: In a prospective clinical investigation, outpatient LETP was carried out in 31 subjects with therapy-refractory chronic ETD. The study population comprised two groups: 16 patients with mesotympanic eardrum perforations diagnosed with noninflammatory chronic otitis media (COM) and 15 patients with intact eardrums including otitis media with effusion, adhesion processes, and dysfunctional pressure equalization. Clinical examination and data acquisition were performed 2 wks before LETP as well as 8 wks and 1 yr postoperatively. On COM patients, LETP was done at 10-wk intervals before the scheduled tympanoplasty. Assessment of clinical effectiveness was based on transnasal videoendoscopy, ear microscopy, tubal function tests (Valsalva maneuver and passive tubal opening), audio- and tympanometric measurements, and visual analog scales. Tansnasal, fiber-guided laser surgery was performed in contact mode using a semiconductor diode laser (&lgr; = 830 nm, 4 W). We hypothesized that regulated laser ablation of hyperplastic mucosa at the epipharyngeal dorsal circumference of the tubal ostium could be effective in improving the associated symptoms such as dysfunctional pressure equalization, aural fullness, conductive hearing loss, and tinnitus. Results: LETP resulted in persistent volume reduction of the posterior tubal circumference in all patients. Objective parameters revealed significant improvement of tubal function tests and middle ear ventilation in 62% of subjects after 8 wks (66% after 1 yr). Significant long-term reduction of conductive hearing loss was achieved in both patient groups. Besides, tinnitus loudness was significantly reduced in COM subjects after tympanoplasty. Visual analog scales showed very low values for intraoperative pain and discomfort and high scores for long-term overall patient satisfaction as well as improvement of the symptoms such as dysfunctional pressure equalization and aural fullness. Subjects with post-LETP Valsalva feasibility marked higher values for satisfaction and symptom improvement than patients without successful Valsalva maneuver. COM subjects scored higher in hearing improvement and satisfaction after LETP and successful tympanoplasty than patients with intact eardrums. Conclusions: Outpatient LETP seems to be a suitable, safe, easily applicable, and well-tolerated treatment option before (revision) tympanoplasties and in all investigated diseases developing from long-lasting pathologic middle ear ventilation. Minimally invasive shaping of the hyperplastic nasopharyngeal Eustachian tube under topical anesthesia seems to be effective in improving tubal function as well as the associated symptoms such as dysfunctional pressure equalization, aural fullness, and conductive hearing loss in otherwise therapy-refractory chronic ETD.

Tacrolimus: A new option in therapy-resistant chronic external otitis

Objective: To evaluate the efficacy of the novel topical immune modulator tacrolimus in chronic uninfectious otherwise therapy‐resistant external otitis (EO).

Rhinitis medicamentosa: therapeutic effect of diode laser inferior turbinate reduction on nasal obstruction and decongestant abuse.

Background The purpose of this study was to evaluate long-term outcomes of an outpatient-based diode laser inferior turbinate reduction (ITR) in therapy-refractory rhinitis medicamentosa (RM). Methods In a prospective clinical investigation, 42 consecutive RM patients underwent videoendoscopic ITR with a diode laser after topical anesthetic preparation. Intra- and perioperative details were recorded including the occurrence of bleeding, crusting, pain, or discomfort. Treatment efficiency was assessed by follow-ups 1 and 6 weeks as well as 6 and 12 months after surgery. Subjective pre- and posttherapeutic nasal airflow (NA) and patient satisfaction were rated on visual analog scales (VASs). Assessment of the long-term objective clinical effectiveness was based on rhinomanometry, IT photodocumentation, and the recurrent need for decongestants. Results Preoperative addiction to decongestants lasted 5 ± 2 years (mean ± SD). There was no major bleeding requiring nasal packing, and there were no other perioperative complications. Postoperative edema disappeared within the 1st week and crusting within 6 weeks after surgery. VAS was characterized by very low values for intraoperative pain and discomfort and high postoperative patient satisfaction. After 6 months, NA data revealed a significant improvement of subjective VAS and objective rhinomanometry (250.4–413.9 cm3/s inspiration at 150 Pa). A total of 88% of patients managed to successfully stop decongestant abuse after 6 months (74% after 1 year). Conclusion In therapy-refractory RM, outpatient diode laser ITR of hyperplastic IT represents a highly effective, safe, and well-tolerated treatment option that provides long-lasting recovery by markedly improving NA and stopping addiction to nasal decongestants.

A comparison of white light laryngostroboscopy versus autofluorescence endoscopy in the evaluation of vocal fold pathology

To prove the diagnostic value of autofluorescence endoscopy (AFE) and white light laryngostroboscopy (WLS) versus the gold standard microlaryngoscopy with histopathological examination in differential diagnostics of laryngeal lesions for experienced phoniatricians and laryngologists, using the PENTAX SAFE‐3000 system.

Mikrolaryngoskopie und Phonomikrochirurgie

ZusammenfassungDie Mikrolaryngoskopie ist eine bewährte und die häufigste Methode bei Kehlkopfoperationen. Durch die Gestaltung neuer Laryngoskope und die Einbeziehung der Videoendoskopie können weitere Verbesserungen der Exposition und Schonung des Zugangswegs möglich werden. Die prinzipiellen mikrochirurgischen Vorgehensweisen zu Verbesserung, Wiederherstellung und Erhalt der Stimmfunktion dagegen haben sich kaum geändert. Sie sind orientiert an der minimalen Exzision pathologischen und maximalen Schonung gesunden Gewebes, insbesondere des Epithels der Stimmlippe und der Lamina propria, den Grundstrukturen für die phonatorische Beweglichkeit. Die Rechtfertigung für die Phonomikrochirurgie mit dem postoperativen Nachweis einer Verbesserung kann nur durch Stimmfunktionsuntersuchungen erbracht werden.AbstractMicrolaryngoscopy is a reliable technique and the most frequently applied method in laryngeal surgery. The design of new laryngoscopes and the application of video endoscopes may permit further improvements in laryngeal exposure, whilst minimizing the damage caused by their insertion. In contrast to this, the principle microsurgical procedures for improvement, restoration and preservation of the vocal function have remained almost unchanged. These techniques are oriented towards minimal excision of pathological tissue with maximal conservation of normal tissue, in particular the epithelium of the vocal folds and the lamina propria—the basic structures for vocal fold vibration. Phonomicrosurgy can only be justified on the basis of a proven improvement as evidenced by vocal function analysis.Microlaryngoscopy is a reliable technique and the most frequently applied method in laryngeal surgery. The design of new laryngoscopes and the application of video endoscopes may permit further improvements in laryngeal exposure, whilst minimizing the damage caused by their insertion. In contrast to this, the principle microsurgical procedures for improvement, restoration and preservation of the vocal function have remained almost unchanged. These techniques are oriented towards minimal excision of pathological tissue with maximal conservation of normal tissue, in particular the epithelium of the vocal folds and the lamina propria-the basic structures for vocal fold vibration. Phonomicrosurgy can only be justified on the basis of a proven improvement as evidenced by vocal function analysis.

Common Vocal Effects and Partial Glottal Vibration in Professional Nonclassical Singers

OBJECTIVE To multidimensionally investigate common vocal effects in experienced professional nonclassical singers, to examine their mechanism of production and reproducibility, to demonstrate the existence of partial glottal vibration, and to assess the potential of damage to the voice from nonclassical singing. STUDY DESIGN Individual cohort study. METHODS Ten male singers aged between 25 and 46 years (34 ± 7 years [mean ± SD]) with different stylistic backgrounds were recruited (five pop/rock/metal, five musical theater). Participants repeatedly presented the usual nonclassical vocal effects and techniques in their repertoire. All performances were documented and analyzed using established instruments (eg, auditory-perceptual assessment, videolaryngostroboscopy, electroglottography, voice function diagnostics). RESULTS The vocal apparatus of all singers was healthy and capable of high performance. Typical nonclassical vocal effects were breathy voice, creaky voice, vocal fry, grunting, distortion, rattle, belt, and twang. All effects could be easily differentiated from each other. They were intraindividually consistently repeatable and also interindividually produced in a similar manner. A special feature in one singer was the first evidence of partial glottal vibration when belting in the high register. The unintended transition to this reduced voice quality was accompanied by physical fatigue and inflexible respiratory support. CONCLUSION The long-lasting use of the investigated nonclassical vocal effects had no negative impact on trained singers. The possibility of long-term damage depends on the individual constitution, specific use, duration, and extent of the hyperfunction. The incidence of partial glottal vibration and its consequences require continuing research to learn more about efficient and healthy vocal function in nonclassical singing.

Microlaryngoscopy and phonomicrosurgery

ZusammenfassungDie Mikrolaryngoskopie ist eine bewährte und die häufigste Methode bei Kehlkopfoperationen. Durch die Gestaltung neuer Laryngoskope und die Einbeziehung der Videoendoskopie können weitere Verbesserungen der Exposition und Schonung des Zugangswegs möglich werden. Die prinzipiellen mikrochirurgischen Vorgehensweisen zu Verbesserung, Wiederherstellung und Erhalt der Stimmfunktion dagegen haben sich kaum geändert. Sie sind orientiert an der minimalen Exzision pathologischen und maximalen Schonung gesunden Gewebes, insbesondere des Epithels der Stimmlippe und der Lamina propria, den Grundstrukturen für die phonatorische Beweglichkeit. Die Rechtfertigung für die Phonomikrochirurgie mit dem postoperativen Nachweis einer Verbesserung kann nur durch Stimmfunktionsuntersuchungen erbracht werden.AbstractMicrolaryngoscopy is a reliable technique and the most frequently applied method in laryngeal surgery. The design of new laryngoscopes and the application of video endoscopes may permit further improvements in laryngeal exposure, whilst minimizing the damage caused by their insertion. In contrast to this, the principle microsurgical procedures for improvement, restoration and preservation of the vocal function have remained almost unchanged. These techniques are oriented towards minimal excision of pathological tissue with maximal conservation of normal tissue, in particular the epithelium of the vocal folds and the lamina propria—the basic structures for vocal fold vibration. Phonomicrosurgy can only be justified on the basis of a proven improvement as evidenced by vocal function analysis.Microlaryngoscopy is a reliable technique and the most frequently applied method in laryngeal surgery. The design of new laryngoscopes and the application of video endoscopes may permit further improvements in laryngeal exposure, whilst minimizing the damage caused by their insertion. In contrast to this, the principle microsurgical procedures for improvement, restoration and preservation of the vocal function have remained almost unchanged. These techniques are oriented towards minimal excision of pathological tissue with maximal conservation of normal tissue, in particular the epithelium of the vocal folds and the lamina propria-the basic structures for vocal fold vibration. Phonomicrosurgy can only be justified on the basis of a proven improvement as evidenced by vocal function analysis.

Laser-assisted cholesteatoma surgery: technical aspects, in vitro implementation and challenge of selective cell destruction.

Cholesteatoma is a destructive ear condition requiring complete surgical removal. One major problem lies in the frequent occurrence of residual cholesteatoma caused by squamous epithelium remaining in the middle ear. Our aim is to develop a laser treatment that is selectively directed against residual cholesteatoma cells and can be performed after cholesteatoma surgery in the same session. In a first trial, we studied the photodynamic effect of argon (AL) and diode lasers (DL) on cholesteatoma tissue. Intraoperatively harvested monolayer-cultured cholesteatoma cells were stained in vivo with different absorption enhancers: neutral red (NR), fluorescein diacetate (FDA), and indocyanine green (ICG). In vitro, staining tests on enhanced cellular dye absorption and laser tests were followed by cytotoxicity measurements to determine the respective amount of damage. To achieve selective cell destruction, antibody-mediated staining of cholesteatoma and middle ear mucosa cells was examined in a second trial. Cell cultures (cytospin and coverglass growing) and paraffin-embedded cholesteatoma tissue sections were studied immunohistochemically to determine the binding of monoclonal mouse antibodies against human cytokeratins CK5, CK10, CK14 and the epidermal growth factor receptor EGFR. Intracellular staining with absorption enhancers increased the optical density at the wavelength corresponding to the dye. Staining and subsequent laser irradiation destroyed up to 92% of cultured cholesteatoma cells. Unstained irradiated tissue was not affected. In cytospins, the antibody against CK5/6 showed strong staining of cholesteatoma and weak staining of mucosa cells. Reactivity for CK14 and EGFR was positive in both tissues. In coverglass cultures, staining of cholesteatoma cells was positive for CK5/6, CK14 and EGFR. Mucosa cells were positive for EGFR but negative for cytokeratins. Both cell types were negative for CK10. In embedded cholesteatoma tissue, CK5/6 and CK14 were localized in the basal layers of the matrix, while CK10 was situated in the suprabasal layers, and EGFR was present in all layers of the matrix and perimatrix. As for the technical aspects of laser-assisted cholesteatoma surgery, AL and DL have proved to be suitable devices; ICG and FDA are effective nontoxic absorption enhancers. The investigated antibodies against cytokeratins and EGFR show nonselective staining and thus appear to be inappropriate for avoiding unwanted cell damage. For safe and specific intraoperative application to intact tissue, the chromophore should be coupled to a particular antibody that binds solely to an easily accessible specific antigen at the surface of cholesteatoma cells.

The use of injectable calcium hydroxylapatite in the surgically pretreated larynx with glottal insufficiency.

To evaluate the efficacy of vocal fold (VF) augmentation with calcium hydroxylapatite (CaHA) microspheres in the surgically pretreated larynx with glottal insufficiency.