Tesis sobre el tema "Otolaryngology"

Developing curricula to ensure that they are comprehensive but not overwhelming is an on-going challenge in undergraduate medical education. This research aimed to explore what we teach and why with regards to undergraduate otolaryngology. A longitudinal transformation approach was taken to this mixed methods study. This consisted of a comparison of undergraduate otolaryngology curricula in medical schools in the United Kingdom. Following this, a survey was devised, piloted and distributed nationally to a wide range of doctors. Four main groups were targeted including foundation year doctors, specialty trainees, general practitioners and consultants. Focus groups were then undertaken to explore results obtained from the preceding studies. The curriculum comparison provides an overview of the main topics included in undergraduate otolaryngology curricula in the UK. The comparison highlighted the large degree of variability in undergraduate otolaryngology curricula from both a content and methods perspective. Utilising results from the curriculum comparison, a national survey was devised. Results indicated that doctors felt that medical students should be able to perform the majority of otolaryngology examination skills. They should also be able to recognise, assess and initiate management for both common and life threatening acute conditions and be able to take an appropriate history and perform an appropriate examination for the majority of otolaryngology clinical conditions but manage only a select few. The survey indicated that the region in which a doctor works does not have a significant influence on their opinion, however, there was a large degree of variation in responses depending on the post of the respondent. Focus groups showed that variability in undergraduate otolaryngology curricula is multifactorial. Factors include resource allocation and a lack of standardisation. The focus groups highlighted that the perceived importance of a topic was an influencing factor in questionnaire responses and that this was linked to the perceived seriousness of a clinical condition, the complexity of a case and whether it would be possible to manage the condition in general practice. The results should aid curriculum development both in terms of curriculum content and how curricula are designed. A collaborative approach to curriculum development is recommended to reduce the risk of excluding important topics. The findings may be applicable to other specialties and have implications for curriculum development in general.

Thesis (Ph.D.)--Boston University PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you.
Cross-sectional imaging of rapidly vibrating tissues or biomaterials under rapid periodic motion is useful for medical diagnosis and tissue engineering. Optical coheret:tce tomography (OCT) is a powerful technique, but its relatively low frame rates limited its use in such applications. Here, we present a novel method that enables capturing 4-dimensional (4D) images of samples in motion at oscillation frequencies of up to 10kHz and potentially far beyond. Employing continuous axial-line acquisition, motion-triggered beam scanning, and subsequent space-time registration, phase-aligned snapshots of tissue oscillation over the entire vibratory cycle can be obtained. This technique is applied to structural and functional imaging of major systems of speech and hearing: aerodynamically driven vibrations of the vocal fold in an ex vivo calf larynx and acoustically driven vibrations of the middle ear in an ex vivo chinchilla and human cadaveric temporal bones. Oscillations of the surface and interior structure of both organs can be viewed and analyzed with high three-dimensional resolution of 10-15 µm, and temporal resolution of 20 µs· For functional middle ear imaging, we employed phase sensitive OCT to achieve sub-nanometer scale vibration sensitivity to differentiate simulated pathologies. The results suggest that the dynamic 4D OCT technique has the potential to become a powerful tool in clinical and research applications for assessing health and mechanical properties of vocal folds and middle ear in the field of otolaryngology.

In this thesis work, we develop an optoelectronic holographic platform to facilitate otologists' ability to quantitatively study and diagnose disorders of the tympanic membrane (TM) and middle ear of humans in full-field-of-view. The holographic platform consists of a laser delivery system, a handheld interferometer, and corresponding software, which allow nanometer scale 3D measurements of deformations of the TM.

Internet-based self-management interventions have the potential to reduce the current disparity in access to psychological support for people with tinnitus. One example is the Tinnitus E-Programme, which was developed in the United Kingdom to support self-management in people with tinnitus. Although freely available online, there was little understanding of how the intervention is used, its active ingredients, how it works, the circumstances in which it works best, and whom it works best for. This PhD aimed to address these issues by evaluating and optimising the Tinnitus E-Programme. A systematic review of self-help interventions for tinnitus was conducted, which concluded that there was a need for further evaluations of unguided self-help interventions in UK populations. A mixed methods study explored past, current, and new users’ (n=40) views and usage of the Tinnitus E-Programme (1.0), demonstrating that it was acceptable to people with tinnitus. However, its implementation was limited by instances of poor usability, user engagement, and adherence to behavioural goals. Consistent with a person-based approach, the findings from this mixed methods study were used alongside evidence-based (i.e. systematic and literature reviews) and theory-based (i.e. behavioural analysis and logic modelling) approaches to develop the Tinnitus E-Programme 2.0. Think aloud interviews with 19 people with tinnitus evaluated this new version of the intervention and findings revealed that the Tinnitus E-Programme 2.0 was acceptable to its target users. The two primary research studies highlighted how users’ pre-existing beliefs regarding tinnitus and self-management, their perceptions of relevance, and the nature of tinnitus can influence users’ engagement with the Tinnitus E-Programme 1.0 and 2.0. Several cognitive factors (e.g. illness beliefs), behavioural factors (e.g. practicing relaxation), and behavioural determinants (e.g. motivation to practice relaxation) were identified by users to explain how changes in intervention outcomes may occur. Further development and implementation work is needed that introduces and evaluates additional intervention content and design features, and explores how the intervention can fit into current clinical service models for tinnitus. Future evaluation work should test the hypothesised mechanisms of impact and contextual factors proposed in this work, and assess the acceptability and feasibility of procedures for subsequent randomised controlled trials that will assess the efficacy of the intervention.

Psychological treatment is effective at alleviating tinnitus distress when delivered by a psychologist. In the United Kingdom (UK), best practice guidance for tinnitus advises that audiologists should deliver Cognitive Behavioural Therapy (CBT) and other counselling techniques where psychologists are unavailable. However, there is a lack of evidence for the effectiveness of audiologist-delivered psychological tinnitus treatment, and no consensus among clinicians and researchers on what form, if any, this should take. Furthermore, training in CBT and other counselling techniques is not a part of standard audiologist training in the UK. The aims of this PhD were to define the components and measure the effects of an audiologist-delivered psychological tinnitus treatment for people with tinnitus. Potential treatment components to include were identified in two studies. The first study was a comprehensive scoping review in which components were extracted from 64 records on psychological tinnitus treatment delivered by psychologists. The components were predominantly extracted from studies of CBT. The second study was a Delphi survey of a panel of 39 patients and clinicians who were asked to rate the importance of 160 different treatment components for an audiologist-delivered psychological tinnitus treatment. These data were used to inform the development of a treatment manual, underpinned by a cognitive behavioural model of tinnitus distress. The manual comprised tinnitus education, psychoeducation, relaxation, graded exposure, thought challenging, physical exercise, sleep hygiene, an introduction to acceptance and defusion techniques, and sound enrichment, which could be implemented flexibly according to patient need. To measure the effects of the psychological tinnitus treatment, appropriate outcome domains and instruments were identified by applying template analysis to the treatment manual. Potential domains were selected from a list constructed by grounded theory using existing questionnaires. Outcome instruments were identified if they were responsive to therapeutic change and possessed good content validity and internal consistency. It was predicted that the treatment would affect tinnitus-specific emotional impact and negative thoughts. Based on current evidence, the Tinnitus Functional Index (TFI) and the Tinnitus Cognitions Questionnaire (TCQ) were identified to best measure these domains. A feasibility randomised controlled trial (RCT) was conducted over six months to determine the feasibility of a definitive RCT of audiologist-delivered psychological tinnitus treatment. Nineteen patients were recruited to the trial. Attrition rates were high, though all patient withdrawals occurred before their first appointment. The trial indicted that a definitive RCT of audiologist-delivered psychological tinnitus treatment is not feasible due to poor site compliance with returning questionnaires, and low recruitment rates in smaller trial sites. Patients and audiologists were invited to attend post-treatment semi-structured interviews to explore treatment fidelity and experience. Patients reported that the treatment was acceptable and effective in reassuring them about their tinnitus. Audiologists reported focusing on psychoeducation with limited use of specific techniques such as thought challenging and graded exposure. Patients and audiologists thought that the TFI and TCQ comprehensively measure the important tinnitus domains and are useful for planning treatment and encouraging discussion about patients’ negative thoughts. A lack of confidence due to the brevity of training was given by audiologists as a reason they avoided implementing certain treatment components.

Introduction Adaptive behaviour has become increasingly important in the assessment of intellectual disabilities (ID), but is also useful in terms of developing individual behavioural goals. Although measures of adaptive behaviour are widely used, there is little agreement on how to conceptualise the construct and how this may vary cross-culturally. Researchers have previously noted methodological and validity difficulties with the assessment of ID. This research aimed to clarify the construct of adaptive behaviour and consider how to measure this with d/Deaf adults with suspected ID. Methods A systematic literature review, identification of critique of current measures, and gaps within the literature formed the structure of a new item pool. An expert panel (N = 13) were consulted about the usefulness and relevance of these items through a Delphi consensus methodology. Based on the feedback obtained throughout the research process, the design was modified from pursuing a statistics-driven approach to item refinement, to using mixed-methods to clarify issues of construct validity before the content could be further addressed. The second round of the Delphi comprised a feedback report, concluding with a working definition of adaptive behaviour. Participants were asked to comment upon the findings, and provide additional responses to develop a normal base standard of adaptability of a Deaf adult of average functioning. Results The first round of the Delphi consensus yielded wide variation in item ratings. A thematic analysis of the questionnaire comments identified two overarching themes related to the way in which adaptive behaviour was conceptualised: ‘structure’ and ‘content’. The theme of structure contained sub-themes of ‘assessment’, ‘language’, and ‘repetition’ which are arguably common to all psychometric development. The ‘content’ factors pertained to ‘accessibility’, ‘developmental factors’, and ‘cultural differences’, highlighting differences in the expression of adaptive behaviour based on the unique experiences of d/Deaf people. The second round of the Delphi procedure elicited feedback on a working definition of adaptive behaviour generated from the analysis, showing that the adaptive behaviour of d/Deaf people may be conceptualised differently, particularly in hearing contexts where there are differential communication demands. These research findings have been summarised to form initial guidelines for the assessment of adaptive behaviour in Deaf people. Discussion This research provided some insight into how adaptive behaviour may be measured with Deaf people. Limitations of this research included not being able to generate consensus through the Delphi methodology used and, due to the newly developed understanding of adaptability for this population advanced throughout the research process, it was not possible to subject the items from the proposed scale to further psychometric testing. However, recommendations for further research were made in terms of expanding and validating this preliminary work with a sample of Deaf adults.

Gap-induced pre-pulse inhibition of the acoustic startle (GPIAS) is a behavioural test for tinnitus in animals. It relies on a short gap in a continuous background noise which provides a cue to the loud startling stimulus which follows. As a result, gap conditions demonstrate an inhibition of the response to the startling stimulus compared to no-gap conditions. The disrupting effect of tinnitus on the normal GPIAS has been shown in a number of species, including in humans. Such disruption was originally thought to be caused by tinnitus ‘filling in’ the gap, but recent studies have challenged this explanation. Preliminary work in humans measuring the eye blink reflex showed gap detection deficits in tinnitus subjects, but the underlying mechanisms of this effect are unclear. The eye blink response has a relatively long latency (>40ms) and therefore is not a simple primary reflex, nor is it specifically related to the auditory system. In small rodents the acoustic startle is measured by the whole body response involving axial muscles but in larger animals like the guinea pig this response habituates very quickly. Thus here a variation of the GPIAS method is used in which the acoustic startle is measured in guinea pigs using the simple pinna reflex. This reflex has been used to provide evidence of tinnitus in guinea pigs and postulated that it might be possible to use a similar method to obtain objective evidence of tinnitus in humans. The post-auricular muscle reflex (PAMR) is the human analogue of the pinna reflex and may represent a metric for an objective tinnitus test. The PAMR is a short-latency (15-18ms) response that involves only two or three synapses in the brainstem and provides a much tighter link between auditory input and motor output than the eye blink reflex. However, gap-induced pre-pulse inhibition (PPI) of the PAMR has not previously been demonstrated. This question is one of the main objectives examined in this thesis, using measures taken in guinea pigs and in humans, with and without tinnitus. The work reports two feasibility experiments and two-hypothesis testing studies in which I have sought to optimise the stimulus parameters for maximising the magnitude of the PAMR, and reflects on the challenges of working at the first translational gap developing adequate animal models of human hearing-related problems.

Hearing loss is a prevalent condition that can have negative implications on the day-to-day lives of those with hearing loss, and their communication partners. Several reviews have identified numerous questionnaires that explore the impact of hearing loss, with little consensus among researchers as to their preference. One reason for this is a lack of an agreed framework concerning exactly what is the impact of hearing loss, and what is important to those who live with the condition. To address this gap in understanding, the experiences of those living with hearing loss or with someone that has hearing loss was investigated using various systematic research methods and tools. A comprehensive review of published studies exploring the impact of hearing loss on those with hearing loss and/or their communication partner was conducted. An inductive (data-driven) synthesis of the research evidence led to the development of two frameworks; one for each perspective. Each framework comprised of three higher-level ‘supra-domains’ (i.e. Auditory, Social and Self) which capture the broader implications of hearing loss, and numerous lower-level ‘domains’ and ‘subdomains’ that tap into distinct aspects of life. The frameworks were evaluated for face-validity in focus groups with hearing aid users, communication partners and audiologists. Hearing aid users and communication partners were then asked to rank the domains in order of importance based on their experience of living with hearing loss. The domain ‘communicating’ was ranked most important from both perspectives. A subdomain mutual to both frameworks, ‘raising the volume of the television/radio’ was explored further in a case-control study. The preferred TV volume across 42 couples where one partner was a hearing aid user and the other was a non-hearing aid user was measured. A mean difference in volume preference of 6.3dB was observed between groups across the TV programmes viewed by all participants. The hearing aid prescription of hearing aid users was not verified. Future research should explore how domains in the frameworks are currently being measured and addressed in clinic. Also, data-driven methods should be applied to identify coping mechanisms adopted by people with hearing loss and their partner to accommodate for the diverse range of hearing-related difficulties depicted in the frameworks.

Tinnitus is the phantom perception of sound. For some people tinnitus can have a detrimental impact on their quality of life. Negative emotional feelings associated with tinnitus play a major role in enhancing and maintaining its continued presence. Despite its high prevalence across the world, its neurophysiological underpinnings remain elusive and there is no universal cure. This thesis utilises data derived from an open-label, non-randomised clinical trial whose original aim was to evaluate the effect of hearing aids for hearing-impaired individuals with tinnitus. To achieve this, a range of patient-reported clinical measures, as well as functional magnetic resonance imaging (fMRI) were used to identify both clinical and neurophysiological markers of treatment-related change over a six-month period. Evidence for clinical impact of hearing aid provision in the management of tinnitus was examined. In study 1, tinnitus handicap was compared amongst two groups of chronic tinnitus patients; those opting for hearing aids (n=42) and age-matched controls who were not (n=14). A small statistically significant reduction in tinnitus handicap as measured by the Tinnitus Handicap Questionnaire was observed in the hearing aid group six months post-fitting compared to controls. However this was not clinically significant. Given the lack of evidence for strong clinical benefit, three further investigations were conducted to identify objective neurophysiological markers associated with the presence of tinnitus. These used baseline fMRI data (i.e. prior to any hearing aid provision) derived from the same age and hearing-matched groups (chronic tinnitus, n=12 and no tinnitus controls, n=11). Independent Component Analysis, region of interest analysis and Patel’s conditional dependence measures were used to investigate resting-state brain activity across the auditory network (study 2) and within the amygdala (study 3). Neither study found any between-group differences. Study 4 examined sound-evoked differences between groups by measuring the amygdala response to emotionally evocative soundscapes using a general linear model approach. Soundscapes rated as very pleasant or very unpleasant elicited stronger amygdala activity than neutral soundscapes (replicating a previous finding). However, activity in the tinnitus group was reduced compared to controls, contrary to our expectations. While results demonstrate that the objective quantification of tinnitus is possible, this nevertheless remains a challenging field. The investigation of resting-state and sound-evoked fMRI data derived from the same participant groups illustrates how neurophysiological markers of tinnitus may only become apparent given the right choice of experimental paradigm. The identification of a potential tinnitus-related biomarker in limbic, not auditory, brain regions leads us to speculate that functional imaging may be more sensitive to the emotional consequences of the tinnitus than the neural signature of the sound perception itself. Challenges and recommendations for future tinnitus research are identified.

The Tinnitus Functional Index (TFI) was developed in the USA as a standard for assessing the functional impact of tinnitus based on eight tinnitus-related domains. The finalised 25-item version was never formally validated. This PhD seeks to assess the psychometric properties of the questionnaire and evaluate its suitability as the tool of choice for use in the diagnostic and outcome assessment of tinnitus for clinical and research purposes in the UK. The primary objectives were to (i) determine whether the TFI is reliable, (ii) verify its factor structure, and (iii) evaluate its responsiveness to treatment-related change. These objectives were evaluated in two UK studies. The first was a prospective multi-centre longitudinal validation study in which 255 NHS patients were recruited from audiology clinics to complete the TFI over four different time points in a nine-month period. The second was a retrospective analysis of data collected on the TFI and a battery of other health questionnaires from 294 members of the general public who had previously participated in two-centre randomised controlled trial of a novel tinnitus device. Approaches to psychometric analysis included classical and modern test theories, including Rasch measurement theory. Both approaches led to similar conclusions. Seven of the eight subscales were reliable and valid in both studies, although not as sensitive as the original developers proposed. Classical testing showed the auditory subscale to be reasonably reliable, but Rasch modelling indicated that it did not measure the functional impact of tinnitus. The overall factor structure was not confirmed. The sleep and auditory subscales did not relate to the other subscales and did not fit the model. My recommendation is to calculate the composite TFI score using only six subscales. The sleep subscale should be scored separately and the auditory subscale should not be used.

Introduction: This work explored the concept of ‘empowerment’ in health care. A concept map of ‘empowerment’ was generated based on theories of linguistic analysis to locate aspects of empowerment in conversational data. The process of empowerment was understood within the theory of transformative learning as ‘perspective change’. A ten phase model of the transformative learning process was used to provide evidence of perspective transformation. The empowerment process was explored through the delivery of the intervention Video Interaction Guidance to 16 hearing families of pre-lingual deaf children. Methods: The parents of the deaf children and the intervention guide engaged in conversations reviewing video clips of the parent and child in interaction. These conversations were processed through a corpus analysis software programme to discern key extracts of the participants’ conversational data. These extracts were to subject to discourse analysis to find evidence of transformative learning. Analysis: Transformative learning was observed in 10 families. Transcript extracts representing the model of transformative learning were variable. Principles of conversation analysis were applied to explore the learning process in interaction. Participant speech was tagged to assess their level of engagement. Outcomes: The corpus analysis-driven tagging process offers an original approach to representing the key content of large sets of interview data but in this work, was limited in showing how the interaction created opportunities for learning. Transformative learning processes were variable and the ten phase model could not be characterised in terms of discourse features alone. The intervention encouraged critical reflection but warrants directed focus to achieve learning. The participants were effective in acting as co-collaborators in the intervention process. Discussion and concluding remarks: Models of empowerment must focus on the process, of the ways in which the guide and the participant create learning opportunities and evidence of this must be multimodal. Patient-centred interventions should be supported by an open, communicative relationship with the health service provider.

Otitis Media with Effusion (OME) is a common childhood condition leading to hearing loss, and its treatment with ventilation tubes (VTs) is one of the commonest surgical procedures. However, aetiology of OME is poorly understood, and its current treatment requires improvement as OME frequently recurs once VTs extrude. The first, clinical part of this thesis showed that 63.6% of children randomised to VT insertion in a clinical trial will require VTs again, and even with additional adenoidectomy the need for repeat surgery remains high. Although published national guidelines set out criteria for surgery, the multicentre study presented here showed that only 32.2% of children that had VTs met these criteria, and guidelines' publication had limited impact on clinical practice. The second, laboratory part of this thesis demonstrated the importance that bacteria and biofilms play in aetiology of OME, as live bacteria were demonstrated in 91.9% of middle ear effusions (using culture and confocal microscopy). Following from this, a Staphylococcus aureus biofilm model was developed, and used to show that biofilm eradication requires antibiotic (rifampicin and lindamycin) levels 1,000 times higher than those required to inhibit planktonic bacteria, over a period of 2-3 weeks. To achieve this in the middle ear, a local delivery strategy using biodegradable poly (Iactic-coglycolic acid) antibiotic pellets was proposed. Drug release from these pellets was investigated with High Performance Liquid Chromatography and Serial Plate Transfer Testing, which demonstrated that antibiotics can be released for up to 3 weeks. Importantly, the pellets were able to eradicate biofilms in the in vitro model. This thesis has shown that current OME treatment has significant deficiencies, but better understanding of OME pathogenesis raises the possibility of rational new therapeutic strategies. Biodegradable antibiotic pellets designed to eradicate OME biofilms may be a better future treatment that could improve the lives of countless children.

Hearing loss is a widespread condition that can substantially affect not only auditory functioning but also social functioning. Therefore, it is essential to demonstrate that auditory rehabilitation can improve social participation in individuals with hearing loss. However, currently, there is a lack of agreed-upon, gold-standard, hearing-specific outcome measures. Consequently, the primary aim of this research was to develop a high quality measure of hearing-related social participation restrictions for use in research and practice. To achieve this aim, four consecutive studies were carried out using best practice questionnaire design techniques. Study 1 generated content for the Social Participation Restrictions Questionnaire (SPaRQ) through semi-structured interviews with 25 adults with hearing loss and nine hearing healthcare professionals. Study 2 evaluated the content of the measure through a subject matter expert panel with 20 hearing healthcare professionals and cognitive interviews with 14 adults with hearing loss. Study 3 assessed the psychometric properties of the SPaRQ by applying Rasch analysis to data collected from 279 adults with hearing loss. Finally, Study 4 further assessed the psychometric properties of the SPaRQ by applying traditional psychometric analysis to data collected from a further 102 adults with hearing loss. This research led to the development of a 19-item questionnaire that measured two key elements: social behaviours (e.g. difficulties with social interactions) and social perceptions (e.g. feelings of isolation). There was strong evidence to support the measurement properties of SPaRQ, including construct validity, person separation reliability, and internal consistency. Furthermore, the response scale was statistically justified and respondent burden was minimal. Future research should examine additional measurement properties, such as responsiveness and cross-cultural validity. Also, the best practice techniques used in this research should be applied to other new and existing hearing-specific questionnaires to ensure that they meet the requisite standards for use in clinical trials and clinical practice.

The aims of this research were to identify and compare auditory processing, speech intelligibility, cognitive, listening, language and communication abilities in (i) typically developing, mainstream school (MS) children (n = 122) for direct comparison with (ii) children presenting to clinical services with auditory processing disorder (APD) (n = 19) or specific language impairment (SLI) (n = 22), and in (iii) a large population sample (n = 1469) who were categorised by their functional listening and communication abilities according to parental report rather than clinical diagnosis. All had normal hearing sensitivity. The clinically referred APD and SLI groups shared many behavioural characteristics across the broad range of measures. Both clinical groups significantly underperformed compared to the MS children, and the APD and SLI groups were virtually indistinguishable. This suggests diagnosis was based more on the referral route than on the actual differences. There was little association of auditory processing deficits with listening or language problems in either the clinical or the population sample after accounting for nonverbal IQ. The only exceptions were backward masking and frequency discrimination, the AP tests with the highest cognitive load. Poor general cognitive abilities were evident in those children with listening or language problems. These results suggest that top-down processing influences listening and language more than bottom-up sensory processing. It is argued that the term APD is a misnomer and should be renamed listening impairment. The co-occurrence of APD, or listening impairment, with both language impairment and autistic behaviours in the clinical and population samples suggests that APD is not a discrete and categorical disorder. Instead, APD as it is currently conceptualised, is dimensional, positioned more towards the language than the autistic extreme. Children with listening impairment who attend Audiology or ENT clinics should be screened for functional everyday measures of language and autistic behaviours to ensure appropriate onward referrals.

Spatial attention is an essential mechanism that helps us perceive our surroundings by bringing into consciousness environmental occurrences or objects that may be of importance. Studies of spatial attention have classically recorded behavioural responses to targets presented in a region of space where attention had previously been allocated to. Such investigations show a behavioural facilitation at the same location due to cueing, but less in known about the effects of shifts of attention when the cued location is not the location of interest. This thesis presents seven experiments aimed at investigating this by implementing and revising the attentional repulsion effect (ARE). The ARE is a perceptual localisation error when attention is diverted from the region of interest and it has been extensively studied in the visual domain, however, the rising number of ARE studies has created numerous research methodologies used to evoke the effect, which may have led to isolated reports. This thesis attempts to combine past methodologies with a new approach to quantify the effect, and will address some methodological differences evident in the literature, in order to optimise the stimulus paradigms and maximise the effect. The results show that a robust ARE can be elicited in the visual modality, but the same is not observed in the auditory modality. Furthermore, when using cues that are of different modality than the targets, the ARE is only observed in the visual target modality. Using visual cues and auditory targets will produce an attraction effect, in line with the ventriloquism theory. However, the implementation of interstimuli intervals up to 1.5 seconds would be enough to disrupt the ventriloquism illusion, but it did not alter the resulted attraction. Lastly, one question regarding the role of attention in sensory adaptation was addressed. I hypothesise that sensory adaptation could be further a contributor to the ARE given that most psychophysics paradigms of the ARE repeat the same stimuli thousands of times, uninterruptedly. The results are inconclusive mainly due to experimental design. All results are discussed in relation with theories of spatial and multimodal attention.

Thesis (B.Sc)--University of Hong Kong, 2005.
"A dissertation submitted in partial fulfilment of the requirements for the Bachelor of Science (Speech and Hearing Sciences), The University of Hong Kong, June 30, 2005." Also available in print.

While cochlear implants (CIs) have transformed the lives of hundreds of thousands of profoundly deaf individuals worldwide, the ability of individual patients to understand speech through their CI varies widely. The longitudinal study reported in this thesis aimed to investigate the role of cortical function and plasticity in helping to predict and explain variability in individual CI outcome. Speech-evoked cortical activations, measured using functional near-infrared spectroscopy (fNIRS), and behavioural measures of speech perception were acquired in adult CI recipients before implantation through to six months after CI activation. As anticipated, cochlear implantation enabled the significant recovery of auditory speech perception over the first six months of CI use, yet individual performance varied widely across CI users. fNIRS enabled the measurement of speech-evoked cortical activations from bilateral superior temporal cortex (STC) that were free from CI-generated artefacts. Cortical activation to visual speech measured before implantation was able to significantly predict future CI outcome measured following six months of CI use. This pre-implant measure of brain activity provided unique predictive value above that of well-established clinical characteristics, including the age-at-onset and duration of deafness. When examining changes in cortical activation from before to after implantation, a greater increase in STC activation to visual speech was found to be related to better CI outcome. These visual-related changes also predicted changes in STC activation to auditory speech. These results highlight the importance of visual speech cues and coupling between the auditory and visual modalities during the recovery of auditory function with a CI. Together, the findings demonstrate the potential of fNIRS as a brain-imaging tool that is uniquely well-suited for use in cochlear implantation. Future applications of this technology could help to explain individual variability in CI success and to deliver more accurate clinical prognoses for CI candidates.

Introduction: The otolaryngology curriculum requires trainees to show evidence of operative competence before completion of training. The General Medical Council recommended that structured assessment be used throughout training to monitor and guide trainee progression. Despite the reduction in operative exposure and the variation in trainee performance, a ‘one size fits all’ approach continues to be applied. The number of procedures performed remains the main indicator of competence. Objectives: To analyse the utilisation, reliability and validity of workplace-based assessments in otolaryngology training. To identify, develop and validate a series of simulation platforms suitable for incorporation into the otolaryngology curriculum. To develop a model of interchangeable workplace- and simulation-based assessment that reflects trainee’s trajectory, audit the delivery of training and set milestones for modular learning. Methods: A detailed review of the literature identified a list of procedure-specific assessment tools as well as simulators suitable to be used as assessment platforms. A simulation-integrated training programme was piloted and models were tested for feasibility, face, content and construct validity before being incorporated into the North London training programme. The outcomes of workplace- and simulation-based assessments of all core and specialty otolaryngology trainees were collated and analysed. Results: The outcomes of 6535 workplace-based assessments were analysed. The strengths and weaknesses of 4 different assessment tools are highlighted. Validated platforms utilising cadavers, animal tissue, synthetic material and virtual reality simulators were incorporated into the curriculum. 60 trainees and 40 consultants participated in the process and found it of great educational value. Conclusion: Assessment with structured feedback is integral to surgical training. Assessment using validated simulation modules can complement that undertaken in the workplace. The outcomes of structures assessments can be used to monitor and guide trainee trajectory at individual and regional level. The derived learning curves can shape and audit future otolaryngological training.

Tinnitus, often defined as the perception of sound in the absence of an external stimulus, affects millions of people worldwide and, in extreme cases, can be severely debilitating. While certain changes within the auditory system have been linked to tinnitus, the exact underlying causes of the phenomenon have not, as yet, been elucidated. Animal models of tinnitus have considerably furthered understanding of the some of the changes associated with the condition, allowing researchers to examine changes following noise exposure, the most common trigger for tinnitus. This thesis documents the development of an animal model of tinnitus, using the guinea pig to examine neural changes following induction of tinnitus. In the first study, a novel adaptation of a behavioural test was developed, in order to be able to determine whether guinea pigs were experiencing tinnitus following the administration of sodium salicylate, a common inducer of tinnitus in humans. This test relies on a phenomenon known as prepulse inhibition, whereby a startle response can be reduced in amplitude by placing a gap in a low-level, continuous background noise immediately prior to the startling stimulus. The hypothesis for this test is that if the background sound is adjusted to be similar to an animal’s tinnitus (induced artificially following noise exposure or drug administration), the tinnitus percept will fill in the gap and the startle response will not be reduced. The results from this first study indicated that using the Preyer reflex (a flexion of the pinnae in response to a startling stimulus) as this startle measure was more robust in guinea pigs than the commonly-used whole-body startle. Furthermore, transient tinnitus was reliably identified following salicylate administration. Following the development and validation of this test, a study was conducted to determine whether guinea pigs experienced tinnitus following unilateral noise exposure. Neural changes commonly associated with the condition (increases in spontaneous firing rates and changes in auditory brainstem responses) were examined, to determine whether there were any differences between animals that did develop tinnitus following noise exposure and those that did not. Two different methods were applied to the behavioural data to determine which animals were experiencing tinnitus. Regardless of the behavioural criteria used, increased spontaneous firing rates were observed in the inferior colliculus of noise-exposed guinea pigs, in comparison to control animals, but there were no differences between tinnitus and no-tinnitus animals. Conversely, significant reductions in the latency of components of the auditory brainstem response were present only in the tinnitus animals. The final study examined whether the original hypothesis for the behavioural test (that tinnitus is filling in the gap) was valid, or whether there was an alternative explanation for the deficits in behavioural gap detection observed previously, such as changes in the temporal acuity of the auditory system preventing detection of the gap. Recordings were made in the inferior colliculus of noise-exposed animals, separated into tinnitus and no-tinnitus groups according to the behavioural test, as well as unexposed control animals, to determine whether there were changes in the responses of single-units in detecting gaps of varying duration embedded in background noise. While some minor changes were present in no-tinnitus animals, tinnitus animals showed no significant changes in neural gap detection thresholds, demonstrating that changes in temporal acuity cannot account for behavioural gap detection deficits observed following noise exposure. Interestingly, significant shifts in the response types of cells were observed which did appear to relate to tinnitus. The present data indicate that the Preyer reflex gap detection test is appropriate for examining tinnitus in guinea pigs. It also suggests that increases in spontaneous firing rates at the level of the inferior colliculus cannot solely account for tinnitus. Changes in auditory brainstem responses, as well as shifts in response types, do appear to relate to tinnitus and warrant further investigation.

Thesis (M.A.) PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you.
Hospital acquired pneumonia (HAP) causes significant mortality and morbidity and is now no longer reimbursed by Centers for Medicare and Medicaid (CMS). For all of these reasons, hospitals want to minimize their HAP rates. Aggressive oral care (tooth brushing 3 times a day) has been shown to reduce the incidence of HAP in the intensive care unit setting, but this has not been tested in the acute care setting, in which patients are more stable, less sick, and more ambulatory. In an attempt to address HAP rates in acute care settings, this clinical trial entailed providing all patients in four wards with a 3 times per day tooth-brushing oral care protocol, which was implemented or supervised by the nurses on each ward. Six matched wards on a separate campus that received normal standard of care served as controls. The goal of this clinical trial was to cut the pneumonia rate in half, from 2% to 1%. This clinical trial was conducted to determine whether an oral care regimen would reduce the incidence of aspiration pneumonia over the three months of intervention in the experimental group (HAC) versus the control group (ENC) from Nov 5, 2012 to Feb 15, 2013.
2031-01-01

Thesis (M.A.)--Boston University PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you.
The incidence and prevalence of cancers of the oropharynx has been on the rise over recent years, with approximately 13,000 new cases diagnosed each year in the United States. Increased incidence has been linked to increased alcohol consumption, tobacco use, and the human papilloma virus, and stresses the importance for the development of modern treatments. The majority of oral cancers are squamous cell carcinomas, originating in the mucosal tissue layer and metastasizing throughout the neck to surrounding lymph nodes and organs. Due to the difficulty in the detection of oropharyngeal cancers, they are often detected in late stage and must be removed surgically to maximize survival. Treatment of head and neck cancers falls under the responsibility of otolaryngologists, who utilize a wide variety of surgical and non-surgical procedures to minimize morbidity and maximize the patient's chances of survival while maintaining high quality of life. The classic approach to the treatment of head and neck cancers has been a combination of neck dissection, removal of lymph nodes, and radiation therapy to obliterate the disease in its entirety. Saving the life of the patient often results in many complications as a result of the invasive and aggressive treatments. In order to maximize the removal of the cancer, collateral damage to surrounding nerves, muscles, and other essential tissues often occurs with dissection of the neck. This radical approach often leaves little regard for the future quality of life of the patient, and alternatives are being sought to address these needs. Along with other surgical fields, otolaryngology is moving toward a minimally invasive approach in the treatment of oropharyngeal cancers. With the advent of modern technology and miniaturization of instruments, minimally invasive procedures such as endoscopic surgery, laser surgery, and concentrated radio- and chemotherapeutics have allowed otolaryngologists a greater range of possible treatments for their patients. In the recent evolution of surgical treatment, robots have been developed and adapted to assist surgeons in performing difficult procedures which are otherwise not possible. Utilizing robotic arms under the control of a trained surgeon, transoral robotic surgery allows for the removal of diseased tissue via the oral cavity. This recent procedural development allows surgeons to remove cancerous lesions from the head and neck without the need for a large external incisions. This approach minimizes tissue trauma, leaving unrelated organs and tissues of the neck intact. By reducing damage to surrounding structures, transoral robotic surgery improves the prognosis of, and speeds post-surgical recovery of the patient. Transoral robotic surgery is quickly gaining traction as an acceptable alternative to open surgeries in the management of head and neck cancers, allowing for preservation of structure and function. Although promising, many variables must be considered to determine whether it is in fact the most appropriate treatment. Factors such as quality of life, the ability to swallow and speak, recovery time, comorbidity, and survival must all be taken into consideration. While transoral robotic surgery presents many benefits to the surgical team and patient, there are inevitably some drawbacks and limitations to this new and promising technology. Only recently developed and approved for the minimally invasive treatment of head and neck cancers, it presents novel and exciting possibilities to the field of otolaryngology. By analyzing the literature on surgical treatment of oropharyngeal cancers over the past twenty years, I weigh the costs and benefits of transoral robotic surgery against traditional approaches to determine what role this new procedure plays in the contemporary management of oropharyngeal cancer.

Носовые кровотечения (НК) среди патологии ЛОР органов занимают особое место. Согласно исследованиям В.Т.Пальчуна и соавт. (1998) НК составляют 20,5% ургентных случаев. В.М.Аксенов и соавт. (1997), A.S.Lewandowski, M.SIiwinska-Kowalska (1993) сообщают, что больные с НК составляют 3 - 7,3% общего числа стационарных больных. в ЛОР клинике Ростовского ГМУ за 1999 г. составили 7,9% от общего числа стационарных больных (Н.В.Бойко и соавт., 2000; В.Л.Заволокина и соавт., 2000). При цитировании документа, используйте ссылку http://essuir.sumdu.edu.ua/handle/123456789/32657

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The present study aims to establish the level of diagnostic reliability provided by the transmission of a videolaryngoscopy by videoconference (VC), evaluating the quality of the transmitted images and its impact on diagnoses. Two DVDs with 60 laryngoscopy (30 fiberscopies and 30 telescopies) images, corresponding to 30 original and 30 transmitted by VC, were evaluated by 6 laryngologists who answered a questionnaire on the quality of the selected images (scores from 0 to 3) and on the diagnoses of the related disease. A third DVD with 26 pairs of images, an original and a VC, or two original, was also analyzed by the examiners who had to select which image presented the best quality, which corresponded to the VC image, and the possible impact of such differences on the quality of diagnoses. A high level of agreement (K = 0.911) was found among the examiners in relation to the identification of the VC (96,15% of accuracy) and to the best quality of the original image (K = 0,850). Although a partial agreement has been found among the examiners (K = 0,371), diagnoses was not jeopardized by the quality of the VC image in 75,64% of the cases. Original videotelescopy images (83,33% very good) showed the best quality and videofiberscopy VC the worst (36,66% very good and good). A high degree of correctness was found for the diagnoses by VC images (86,67% by fiberscopy and by telescopy). Consequently, the use of a VC to transmit videolaryngoscopy images has proved to be efficient for the remote diagnoses of larynx diseases

Vertigo is the presenting symptom of some peripheral vestibular disorders, like Benign Positional Vertigo (BPV), Ménière's disease, and vestibular neuritis, and for many other clinical conditions as well. Some clinicians from the Christchurch Public Hospital suspect that there is a significant need to improve the diagnostic accuracy and overall management of patients presenting with complaints of "acute vertigo or dizziness", especially BPV and Ménière's disease. The final diagnosis of many such patients treated for these conditions in the past has been suspected to be somewhat incomplete or inappropriate. These patients were commonly referred to various other departments, where they underwent a number of investigations, particularly medical imaging [head CT (Computed Tomography) / MRI (Magnetic Resonance Imaging) scans, which were in many cases not necessary. Such delays in the process led to an extra or unnecessary burden on the limited health funds available to the hospital or to the patient. Another drawback was an elevated patient stress and anxiety as critical time was lost with the increased number of admissions, or in transferring the patient between various departments without any conclusive diagnosis and treatment. It was proposed to conduct a retrospective study on the accuracy of diagnosis of those patients admitted to Christchurch Public Hospital with complaints of acute vertigo, particularly for suspected peripheral vestibular disorders (mainly BPV and Ménière's disease) over the period of 2004-2005. Implementation of a more specific and detailed management approach at the level of the initial clinical examination or diagnostic investigations (specifically, by an early Otolaryngology/Audiology intervention) was planned for the year 2006. The two groups of patients (2004-2005 and 2006) were compared to verify the final achievements concerning the diagnostic accuracy and at various other levels with the newly implemented changes in 2006.

Anxiety and depression are common comorbidities in people with chronic obstructive pulmonary disease (COPD), contributing to greater morbidity and mortality in an already vulnerable population. Despite the prevalence, few recommendations exist in global management guidelines for the detection and treatment of these comorbidities, reflecting the limited literature available on effective strategies for dealing with mental health issues in COPD populations. There is promising evidence that cognitive behavioural therapy (CBT) improves mental health outcomes in people with COPD. However, investigational studies have commonly reported participants’ lack of transport, lack of time and illness as barriers to recruitment and successful completion. This thesis was undertaken in response to a need identified in the literature for an alternative modality of CBT delivery for people with COPD suffering from psychological symptomatology. Thus, a novel home-based self-management CBT learning resource in a DVD format was developed with an accompanying manual. To investigate the primary aim of this thesis, a randomised controlled trial called the ‘Breathing New Life’ study was conducted to determine the efficacy of CBT to treat anxiety and depression in people living with COPD via two formats: group therapy with a reduced number of sessions or this novel home-based self-management DVD resource, compared to usual care. The secondary aim was to investigate the efficacy of these interventions on improvement in health-related quality of life (HRQoL). This thesis is presented as a series of papers (i.e. PhD with publication) from data collected from the Breathing New Life study (ACTRN12616001039471). Study One investigates the risk factors associated with concomitant anxiety and depression and found younger age and having no previous psychological medical history were risk factors for psychological symptomatology compared to those without psychological symptomatology. Study Two investigates the most suitable screening tool for detecting clinically significant anxiety and depression in COPD populations and found simple modifications to the commonly used Hospital Anxiety and Depression Scale (HADS) improved optimal sensitivity and specificity, whilst the Beck Inventories had acceptable sensitivity and specificity without any modifications. Study Three reports the results from the randomised controlled trial investigating the efficacy of CBT delivered in the two different formats. No significant differences over time between those receiving CBT and usual care for anxiety, depression or HRQoL were found in this COPD cohort. However, opinions of benefit expressed in Study Four—a qualitative investigation into the facilitators and barriers COPD participants face when enrolling and completing CBT—provide support that this population find CBT useful, despite being unable to detect any measureable difference. Globally, this thesis adds new knowledge to the body of literature supporting the importance of early screening and treatment for psychological symptomology in people living with COPD. Despite the inability of CBT to improve anxiety and depression, findings from this thesis have important implications towards industry discussion surrounding routine screening for concomitant anxiety and depression, the continued use of the HADS and Beck Inventories as appropriate screening tools in COPD populations and how best to engage and retain COPD participants in CBT.

Magnetic resonance imaging plays an important yet underutilized role in determining the natural history and prognosis of oral carcinoma. Depth of tumour invasion is an emergent factor in the oral cancer literature. However, problems exist with the definition of cut-points suitable for inclusion in TNM staging criteria. Statistical methodology represents a possible explanation but is underexplored. In this work, a review of the depth of invasion literature is conducted with emphasis on statistical technique. As well, statistical simulation is used to explore the implications of the of the minimum p-value method. The results demonstrate that the use of continuous variable categorization and multiple testing is widespread, and contributes to cut-point variability and false-positive tests. Depth, as a predictor of OCLNM and survival, must be questioned. The volume of tumour invasion is a promising prognostic factor that has not been fully investigated in the oral carcinoma literature. In this work, the volume of tumour invasion is measured on MRI and compared to thickness and maximum diameter in its capacity to predict 2-year all-cause, disease-related and disease-free survival, as well as occult cervical lymph node metastasis prediction. As part of a comprehensive approach, morphometric factors are incorporated into multifactor predictive models using regression, artificial neural networks and recursive partitioning. It is evident that MRI-based volume is superior all other linear measurements for both occult cervical lymph node metastasis and survival prediction. Artificial neural networks wee superior to all other techniques for survival prediction. There is a case for a unified artificial neural networks model for survival prediction that uses volume, midline invasion and N-stage to determine prognosis. This model can be used to determine individualized probabilities of 2-year survival. The lateral extrinsic muscles of the tongue lie just beneath the surface of the lateral tongue, yet their invasion is a criterion for T4 classification using the TNM staging system. In this work, the Visible Human Female is used to conduct an anatomic study of the extrinsic muscles of the tongue. Linear measurement is used to quantify the distance from the surface mucosa to the most superficial muscle fibres of the styloglossus and genioglossus. Further, the lateral extrinsic muscles are poorly demonstrated on MRI. An anatomic atlas of the tongue is fused with MRI images of oral carcinoma to demonstrate lateral muscle invasion. The results demonstrate that the styloglossus and hyoglossus lie very close to the surface of the lateral tongue, in some cases passing within 1 mm of the surface mucosa. These extrinsic muscles are readily invaded by even small tumours of the lateral tongue. Strict application of the TNM T4a criteria leads to unnecessary upstaging as these carcinomas do not warrant the prognosis and aggressive treatment of Stage IV disease. Extrinsic muscle invasion should be removed as a T4a criterion for the oral cavity. A separate category, T4a (oral tongue) specifying invasion of the genioglossus is also recommended. This work presented in this thesis is an original contribution to the field of oral cavity cancer research and has determined that there is capacity for improvement in current efforts to determine the natural history and prognosis of oral cavity squamous cell carcinoma. This thesis is the first to examine the role of statistical methodology in oral carcinoma depth of invasion cut-point variability. Further, this work presents an original approach to the prediction of regional metastasis and survival using advanced multivariate modeling techniques. No other work explored MRI-measured volume using the substantial sample size gathered in this thesis. Finally, this work is the first to demonstrate that lateral extrinsic muscle invasion is an unnecessary component of the T4a (oral cavity) classification criteria and should be reconsidered.

The employment of audiology assistants to relieve masters and doctoral level audiologists of routine tasks is a timely and controversial topic in our field. Berardino (2000) examined the roles of audiology assistants within Veteran’s Administration (VA) Hospitals using an e-mail survey that was sent out to VA audiologists. The results of that survey suggested that the majority of VA audiologists were in favor of the participation of audiology assistants in the clinic to varying degrees. The purpose of this survey was to determine the current attitudes of audiologists and otolaryngologists toward the role of audiology assistants in the hearing health care profession. The attitudes and opinions of otolaryngologists were of particular interest because this population had not been included in earlier surveys despite the fact that they often employ both audiologists and audiology assistants. The survey was e-mailed to a randomly selected group of audiologists and otolaryngologists. In addition to general opinion and demographic questions, participants were asked to rate specific audiology tasks on a six-point scale ranging from very appropriate to very inappropriate. Results indicate that audiologists and otolaryngologists generally agree on which tasks are appropriate for audiology assistants; however, audiologists feel audiology assistants may be a threat to the profession of audiology whereas otolaryngologists do not.

Tonsillectomy, adenoidectomy and myringotomy are the most common surgical procedures undergone by children. Medical opinion regarding the appropriateness of these procedures remains contentious, and considerable resources have been expended in the formulation and distribution of relevant practice guidelines. The impact of this surgery on the child, community and private and public health resources is considerable, yet there has been little examination of surgery rates and trends, or of the characteristics of children who undergo surgery. This thesis addressed five major questions regarding this surgery in New South Wales, Australia. The first three related to population rates: the level of surgery among NSW children, comparability with international rates, trends over time and the effect of guidelines. Comprehensive hospital data between 1981 and 1999 were analysed. Major findings were a higher myringotomy rate in NSW than reported internationally, the short-term effect of guidelines, and a major shift towards children having surgery at a younger age. The remaining questions asked whether children who had surgery differed from other children in their use of health services prior to surgery, and if so, whether their utilization reverted to the norm following surgery. Matched records of a population cohort of 6239 NSW children, born during January 1990, were extracted from Health Insurance Commission data, and their claims for medical services followed retrospectively from birth to 8 years. Children who had privately funded surgery were found to use more medical services than other children, and, most unexpectedly, this did not change following surgery. The results suggest potential non-clinical factors influencing this excess utilization. This is the first population study to examine health service utilisation by these children and it has identified an important new risk factor for surgery.

It is common practice in psychophysical studies to investigate speech processing by manipulating or reducing spectral and temporal information in the input signal. Such investigations, along with the often surprising performance of modern cochlear implants, have highlighted the robustness of the auditory system to severe degradations and suggest that the ability to discriminate speech sounds is fundamentally limited by the complexity of the input signal. It is not clear, however, how and to what extent this is underpinned by neural processing mechanisms. This thesis examines the effect on the neural representation of reducing spectral and temporal information in the signal. A stimulus set from an existing psychophysical study was emulated, comprising a set of 16 vowel-consonant-vowel phoneme sequences (VCVs) each produced by multiple talkers, which were parametrically degraded using a noise-vocoder. Neuronal representations were simulated using a published computational model of the auditory nerve. Representations were also recorded in the inferior colliculus (IC) and auditory cortex (AC) of anaesthetised guinea pigs. Their discriminability was quantified using a novel neural classifier. Commensurate with investigations using simple stimuli, high rate envelope modulations in complex signals are represented in the auditory nerve and midbrain. It is demonstrated here that representations of these features are efficacious in a closed-set speech recognition task where appropriate decoding mechanisms are available, yet do not appear to be accessible perceptually. Optimal encoding windows for speech discrimination increase from of the order of 1 millisecond in the auditory nerve to 10s of milliseconds in the IC and the AC. Recent publications suggest that millisecond-precise neuronal activity is important for speech recognition. It is demonstrated here that the relevance of millisecond-precise responses in this context is highly dependent on the brain region, the nature of the speech recognition task and the complexity of the stimulus set.

The experiments described in this thesis investigate the temporal relationship between frequency bands in a cochlear implant sound processor. Initial studies were of cochlea-based traveling wave delays for cochlear implant sound processing strategies. These were later broadened into studies of an ensemble of across-frequency delays.
Before incorporating cochlear delays into a cochlear implant processor, a set of suitable delays was determined with a psychoacoustic calibration to pitch perception, since normal cochlear delays are a function of frequency. The first experiment assessed the perception of pitch evoked by electrical stimuli from cochlear implant electrodes. Six cochlear implant users with acoustic hearing in their non-implanted ears were recruited for this, since they were able to compare electric stimuli to acoustic tones. Traveling wave delays were then computed for each subject using the frequencies matched to their electrodes. These were similar across subjects, ranging over 0-6 milliseconds along the electrode array.
The next experiment applied the calibrated delays to the ACE strategy filter outputs before maxima selection. The effects upon speech perception in noise were assessed with cochlear implant users, and a small but significant improvement was observed. A subsequent sensitivity analysis indicated that accurate calibration of the delays might not be necessary after all; instead, a range of across-frequency delays might be similarly beneficial.
A computational investigation was performed next, where a corpus of recorded speech was passed through the ACE cochlear implant sound processing strategy in order to determine how across-frequency delays altered the patterns of stimulation. A range of delay vectors were used in combination with a number of processing parameter sets and noise levels. The results showed that additional stimuli from broadband sounds (such as the glottal pulses of vowels) are selected when frequency bands are desynchronized with across-frequency delays. Background noise contains fewer dominant impulses than a single talker and so is not enhanced in this way.
In the following experiment, speech perception with an ensemble of across-frequency delays was assessed with eight cochlear implant users. Reverse cochlear delays (high frequency delays) were equivalent to conventional cochlear delays. Benefit was diminished for larger delays. Speech recognition scores were at baseline with random delay assignments. An information transmission analysis of speech in quiet indicated that the discrimination of voiced cues was most improved with across-frequency delays. For some subjects, this was seen as improved vowel discrimination based on formant locations and improved transmission of the place of articulation of consonants.
A final study indicated that benefits to speech perception with across-frequency delays are diminished when the number of maxima selected per frame is increased above 8-out-of-22 frequency bands.

Chronic otitis media (OM) is an archetypal complex disease, which is particularly prevalent in childhood. Epidemiological data suggest high heritability for disease susceptibility, but previous genetic association studies have had methodological flaws, and none have specifically focused on chronic OM phenotypes. Mouse models represent one way to ascertain candidate loci for human association testing. A number of mouse models of middle ear inflammation have been reported, but many susceptibility loci remain undiscovered. I demonstrate that oto-endoscopy is a robust and scalable phenotyping platform for OM in the mouse, and discuss its value in new model discovery. Chronic OM is also a feature of trisomy HSA21 (Down Syndrome). Through an interrogation of the mouse library of segmental trisomy models of Down Syndrome, I identify a critical trisomic region for chronic otitis media. This region may underlie OM susceptibility in Down Syndrome, but could also contribute to disease susceptibility in non-syndromic disease. Mouse models can also be used to interrogate disease mechanisms. Our previous work has shown that the chronically inflamed middle ear is hypoxic, and that hypoxia signalling is a potential therapeutic target. Exploiting the Junbo mouse model, I demonstrate that surgical ventilation of the Junbo ear improves inflammation, and that this is associated with loss of hypoxia signalling. I present preliminary results from transcript analyses of human middle ear effusions showing marked upregulation of hypoxia signalling. A systematic review of existing mouse models suggests that the loci FBXO11, EVI1, SMAD2, and TGIF1 are good candidates genes for human association testing. I detail recruitment and collection of DNA from families in the UK where a child is undergoing grommet insertion. Association testing using a variant of the transmission disequilibrium test shows susceptibility associated with polymorphisms at FBXO11, and possibly also SMAD2 and TGIF1.

Professional research project (Au.D.)--University of South Florida, 2002.
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ABSTRACT: The employment of audiology assistants to relieve masters and doctoral level audiologists of routine tasks is a timely and controversial topic in our field. Berardino (2000) examined the roles of audiology assistants within Veteran's Administration (VA) Hospitals using an e-mail survey that was sent out to VA audiologists. The results of that survey suggested that the majority of VA audiologists were in favor of the participation of audiology assistants in the clinic to varying degrees.
The purpose of this survey was to determine the current attitudes of audiologists and otolaryngologists toward the role of audiology assistants in the hearing health care profession. The attitudes and opinions of otolaryngologists were of particular interest because this population had not been included in earlier surveys despite the fact that they often employ both audiologists and audiology assistants. The survey was e-mailed to a randomly selected group of audiologists and otolaryngologists. In addition to general opinion and demographic questions, participants were asked to rate specific audiology tasks on a six-point scale ranging from very appropriate to very inappropriate.
Results indicate that audiologists and otolaryngologists generally agree on which tasks are appropriate for audiology assistants; however, audiologists feel audiology assistants may be a threat to the profession of audiology whereas otolaryngologists do not.
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Deterioration in voice quality following radiation therapy for the treatment of laryngeal cancers (LC) is well documented in literature. The majority of studies show that these voice problems are long term and in some cases permanent. Deterioration in voice quality, especially over a period of time could lead to significant communication difficulties in daily life or in some cases could even result in loss of profession. Despite the negative effects of radiation therapy on voice quality being well documented, few studies have focused on the efficacy of voice therapy in the irradiated LC population. The purpose of this study was to investigate the efficacy of a well researched, evidence based voice therapy approach, known as Vocal Function Exercises (VFEs) in improving vocal function in patients who have been irradiated for LCs. The present study conducted in three systematic stages with distinct and related study aims. The first involved characterizing the head and neck cancer treatment seeking population at the University of Kentucky (UK). Stage 2 involved characterizing vocal function following irradiation for LC using a multidimensional assessment approach. Stage 3 was a phase 2 clinical trial aimed at treating these deficits in vocal function identified through stage 2 using a systematic evidence based voice therapy approach, Vocal Function Exercises. For the phase 2 clinical trial, the comparison group received vocal hygiene (VH) counseling. Observations from stage 1 showed that majority of patients from the treatment seeking population at UK between a 3 year time period from 2008 to 2010 were diagnosed with laryngeal cancers and were treated with chemoradiation therapy. Stage 2 demonstrated a multidimensional deterioration in vocal function following radiation therapy for laryngeal cancers. Stage 3 demonstrated a significant improvement in vocal function across the primary outcome measure (Voice Handicap Index) as a result of VFE+VH. Improvements were also seen in select parameters across the five domains of voice assessment in the VFE group. No significant improvements were observed in the vocal hygiene group in any parameters in each domain of voice assessment. Our study demonstrated adults irradiated for laryngeal cancers demonstrated a multi-dimensional deterioration of vocal function. These changes were long term since study participants were 2- 7 years post radiation therapy. Implementation of VFE+VH demonstrated a significant improvement in voice related quality of life and select parameters across the five domains of voice assessment. The present study demonstrated promising preliminary evidence for the use of VFE+VH to improve vocal function in patients irradiated for laryngeal cancers.

O Projeto Jovem Doutor propicia a transmissão de conhecimentos para jovens do ensino fundamental sobre diversos temas da saúde. A Síndrome da Apneia e Hipopneia Obstrutiva do Sono (SAHOS) deve ser destacada, uma vez que esse quadro clínico implica em consequências impactantes ao indivíduo, e que se estendem para a população em uma escala ampla, tendo como exemplos acidentes de trânsito e de trabalho. Sendo assim, o objetivo foi de implementar um modelo de educação em saúde sobre o tema da SAHOS, fundamentado na dinâmica do Projeto Jovem Doutor. Para isso, realizou-se a parceria com uma escola estadual interessada em participar da dinâmica. A pesquisa foi estruturada em três etapas: organização da estrutura básica e elaboração do material educacional (1ª etapa); aplicação do programa (2ª etapa) e avaliação do modelo de educação em saúde (3ª etapa). Para a elaboração do material educacional (aulas presenciais, cybertutor, banner e folder), realizaram-se buscas em bases de dados, selecionando conteúdos, simplificando e adequando o nível de legibilidade do texto, além de inserir ilustrações (1ª etapa). Na 2ª etapa, houve a participação de 5 alunos nas duas aulas presenciais, acesso ao cybertutor, atividade prática e por fim, executaram a ação social para a disseminação do conhecimento. Foram realizadas orientações sobre o tema por meio do banner, folder, telejornal, teatro de fantoches e jogo de mímica. Ao final da Feira Cultural, houve a multiplicação do conhecimento para 985 pessoas, dentre elas, pais, professores e alunos da escola, que receberam o conhecimento diretamente pelas ações sustentadas dos Jovens Doutores. Em relação à 3ª etapa, observou-se no questionário de investigação do conhecimento o aumento em média de acertos sobre o conteúdo teórico; no acesso ao cybertutor, verificou-se que 100% dos alunos realizaram os materiais complementares e na análise da pesquisa motivacional, foi possível verificar que o curso foi considerado um Curso Impressionante!. Portanto, um modelo de educação em saúde sobre SAHOS, fundamentado na dinâmica do Projeto Jovem Doutor foi implementado, verificandose êxito no seu desenvolvimento, no aspecto motivacional dos alunos e na disseminação do conhecimento.
The Young Doctor Project provides the transmission of new knowledge for elementary school kids about various health topics. The Obstructive Sleep Apnea- Hypopnea Syndrome (OSAHS) should be emphasized, once the disorder implies at impactful consequences for the individual and extends to the population in a large scale, as an example car and work accident. With that been said, this research aims the implementation of a health educational model about OSAHS based on the pattern of the Young Doctor Project. In order to this, a partnership with a public state school interested to participate of dynamic. This research was structured around 3 stages: organization of the basic structure and the educational material elaboration (1st stage); the program application (2nd stage); and an evaluation of the health educational model (3rd stage). To develop the educational material (class attendance, cybertutor, banner and folder), were made searches in databases, selecting content, simplifying and adjusting the text legibility, besides insert illustrations (1st stage). On 2nd stage, were involved 5 students in the two classes, accessed the cybertutor, practical activity, an also executed a social action in order to spread the knowledge. Orientations were made by banner, folder, TV newscast, pupet show and mime game. At the end the Cultural Fair, the dissemination of learning were spread to 985 people, including parents, teachers and students whose knowledge were sustained by the Young Doctors actions. At the 3rd stage, on the learning investigation questionary, were noticed an increase of right answers about the theory; at the cybertutor, 100% of the students realized the complementary material and at the motivational research, was possible to verify that the course was classified as Impressive course!. Therefore, a model of health education about OSAHS based on the Young Doctor Project pattern was implemented and it was verified its success at the motivational aspect such as at the spread of knowledge.

En la pràctica clínica habitual no és infreqüent trobar pacients pediàtrics amb rinitis al·lèrgica persistent (PER) que són derivats al servei d’ Otorrinolaringologia per manca de resposta al tractament mèdic. Per aquest motiu, es va decidir estudiar els factors de risc associats a la manca de resposta al tractament mèdic en nens i adolescents amb PER moderada i greu, especialment les alteracions anatòmiques intranasals. Segons la resposta al tractament mèdic es van avaluar i comparar dos grups de pacients, els responedors (R) i els no responedors (NR). Els pacients pediàtrics amb PER van ser estudiats prospectivament després de rebre tractament amb corticoides intranasals (fluticasona o mometasona) durant almenys 2 mesos consecutius. La gravetat de la PER va ser estratificada amb la classificació ARIA-m. Segons l'edat, els pacients es van estratificar en nens (6-11 anys) i adolescents (12-17 anys). Els símptomes nasals es van avaluar mitjançant una EVA (0-10 cm) i l’EVA total dels símptomes nasals es va utilitzar per definir la resposta (EVA ≤5 cm) o la resistència (EVA >5 cm) al tractament mèdic. Les alteraciones anatòmiques nasals van ser evaluades mitjançant un endoscopi flexible de 2,4 milímetres i van ser classificades en obstructives o no obstructives. El grup NR va presentar una major prevalença de dismòrfia septal obstructiva (45,3% vs. 11,4%; p=0,0002) i d’hiperplàsia de cornets obstructiva (64,0% vs. 0%; p=0,00001) que el grup R. L’exploració mitjançant endoscòpia nasal demostra que gairebé el 90% dels pacients pediàtrics amb PER que no responen al tractament mèdic tenen algun dels 7 tipus de dismòrfia septal (DS). Les DS anteriors unilaterals i bilaterals estan fortament associades amb una mala resposta al tractament mèdic, una major gravetat de la rinitis i una puntuació superior en EVA d’obstrucció nasal. A més, prevalença de PER greu va ser major en el grup NR que en el grup R i el bon control de l'asma es va associar amb una probabilitat de millora de la PER amb el tractament mèdic. La qualitat de vida (QdV) es va evaluar mitjançant qüestionaris específics per RA, el PRQLQ per als nens i el AdolQRLQ per adolescents. Els pacients NR van presentar una major afectació de la QdV que els responedors tant en adolescents com en nens. Així mateix, la presència d'una dismòrfia septal obstructiva, d'una hiperplàsia de cornets obstructiva i de totes dues alhora es va associar amb una pitjor qualitat de vida en els adolescents. Respecte a les comorbilitats, la presència de conjuntivitis va afectar negativament la QdV dels nens i dels adolescents. Addicionalment, vam trobar una forta correlació entre els símptomes mesurats amb l’EVA i la puntuació global de QdV dels dos grups d’edat. Per últim, la presència d’hipòsmia es va associar amb un major risc de patir PER greu i de resistència al tractament mèdic. D'altra banda, el bon control de la RA es va associar inversament amb la hipòsmia. L’EVA d'olfacte va ser pitjor en els NR o en aquells pacients amb hiperplàsia de cornets obstructiva i amb PER greu. Com a conclusió final, considerem que cal incloure l'endoscòpia nasal, l’escala visual analògica de símptomes nasals, sobretot la pèrdua de l’olfacte, i la classificació de gravetat ARIA modificada tant en la pràctica clínica diària com en els futurs protocols d’estudi clínic de la rinitis al·lèrgica en pediatria així com en les guies nacionals i internacionals. Són eines senzilles, ràpides de fer i molt valuoses per al maneig dels pacients pediàtrics amb rinitis al·lèrgica ja que permeten donar un millor diagnòstic, avaluar la millor opció terapèutica (mèdica i/o quirúrgica) i, en conseqüència, millorar la seva qualitat de vida.
In clinical practice it is common to find pediatric patients with persistent allergic rhinitis (PER) who are referred to Otorhinolaryngology due to lack of response to medical treatment. Our objective was to assess the risk factors associated with the lack of response to medical treatment in children and adolescents with moderate and severe PER, especially nasal obstructive disorders (NOD). According to the response to medical treatment, two groups of patients, the responders (R) and the non-responders (NR), were evaluated and compared. The patients were studied prospectively after receiving treatment with intranasal corticosteroids for at least 2 consecutive months. The severity of the PER was stratified by the ARIA-m classification. According to age, patients were divided into two groups: children (6-11 years) and adolescents (12-17 years). Nasal symptoms were assessed by the visual analogue scale (VAS), and the total VAS of nasal symptoms was used to define the response (VAS ≤5 cm) or resistance (> 5 cm) to medical treatment. NOD were evaluated by flexible endoscopy. The NR group presented a higher prevalence of obstructive septal deformity and severe inferior turbinate enlargement when compared with the R group. Higher septal deformity and turbinate enlargement scores were strongly associated with treatment refractoriness. The prevalence of severe PER was also higher for the NR group. Higher asthma control scores were associated with the probability of treatment-induced improvement. Quality of life (QoL) was assessed using specific questionnaires for RA, the PRQLQ for children and the AdolQRLQ for adolescents. The NR patients presented a greater involvement of the QOL than the R patients in both adolescents and children. Likewise, the presence of obstructive DS, obstructive turbinates hyperplasia and both at the same time was associated with a worse QOL in adolescents. Finally, the presence of hyposmia was associated with an increased risk of severe PER, turbinate hyperplasia and resistance to medical treatment. On the other hand, good control of RA was inversely associated with hyposmia. In conclusion, medical therapy refractoriness in pediatric PER patients was associated with the presence of nasal obstructive disorders, impaired QoL and hyposmia. In those patients, ENT examination will facilitate an early NOD diagnosis in order to indicate potential corrective surgery.

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Head and neck cancer is responsible for a high death rate. Single nucleotide polymorphisms (SNPs) are the most common variation of human genome and can be associated to the molecular basis of cancer. Objectives: To establish the incidence of this disease in the Otorhinolaryngology and Head and Neck Surgery Service of Hospital de Base in São José do Rio Preto; to investigate the frequency of SNPs in the MTR, VEGF, KiSS-1, NINJ1, TAX1BP1 and LAD1 genes in head and neck cancer patients and a control population; to evaluate the association of these polymorphisms with smoking, alcoholism, gender and age and to verify the association between polymorphisms and clinicopathological features of the disease. Subjects and Methods: The epidemiological data of head and neck cancer patients consulted in the Otorhinolaryngology and Head and Neck Surgery Service in the period from 2000 to 2005 were analyzed. Eight hundred and five individuals (254 head and neck cancer patients and 551 controls) were included in the study for molecular investigation. The molecular analyses were performed with genomic DNA utilizing Real Time PCR (VEGF gene), PCR-SSCP (KiSS-1 gene), PCR RFLP (MTR, NINJ1 and TAX1BP1 genes) and automatic sequencing (LAD 1 gene) techniques. Results: An analysis of epidemiological data shows a prevalence of men (86%), smokers (83%) and alcoholics (77.95%). The most common primary tumor site was the oral cavity (35.37%). Statistical differences were found in the MTR A2756G polymorphism distribution (OR = 1.69; CI 95% 1.09-2.62; p = 0.019) by molecular analysis between patients and controls. On analyzing the primary tumor site, an increased frequency of KISS-1 polymorphic alleles was identified in laryngeal cancer (OR = 2.32; 95% CI 1.12 4.82; p = 0.02); an increased frequency of the NINJ1 polymorphism was found in oral cavity cancer (OR = 1.86; 95% CI 1.05-3.30; p = 0.03) and a decreased frequency in laryngeal cancer (OR = 0.40; 95% CI 0.22-0.74; p = 0.003); and an increase of the TAX1BP1 gene polymorphism was seen in oral cavity cancer (OR = 2.25; 95% CI 1.20-4.21; p = 0.01). A decreased frequency of the VEGF gene polymorphism was observed in advanced (T3 and T4) tumors (OR = 0.36; CI 95% 0.14-0.93; p = 0.0345) and a lower frequency of the LAD1 polymorphism in stage III and IV tumors (OR = 0.39 95% CI 0.18-0.83; p = 0.01). Conclusions: Head and neck cancer is more frequent in men, smokers and alcoholics with the most common primary tumor site being the oral cavity. MTR A2756G is associated with head and neck cancer. There is evidence of an association between this polymorphism and smoking, alcoholism, gender and age. There is also evidence of an association between the KiSS-1 gene polymorphism and laryngeal cancer, of NINJ1 and TAX1BP1 polymorphisms in oral cavity tumors, lower frequencies of the VEGF polymorphism in T3 and T4 tumors and the LAD1 polymorphism in stage III and IV tumors.
O câncer de cabeça e pescoço é responsável por uma alta incidência de óbitos. Os polimorfismos de nucleotídeos únicos (SNPs) constituem a variação mais comum do genoma humano e podem estar associados à base molecular do câncer. Objetivo: Estabelecer a incidência da doença no Serviço Ambulatorial de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço do Hospital de Base de São José do Rio Preto; investigar a freqüência de SNPs nos genes MTR, VEGF, KiSS-1, NINJ1, TAX1BP1 e LAD1 em pacientes com câncer de cabeça e pescoço e em uma população controle; avaliar a associação dos polimorfismos com os hábitos tabagista e etilista, gênero e idade e verificar a associação entre os polimorfismos e os parâmetros clínicos da doença. Casuística e Método: Foram analisados os dados epidemiológicos de pacientes atendidos no Serviço Ambulatorial de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço do Hospital de Base de São José do Rio Preto, no período de 2000 a 2005. Para a investigação molecular foram incluídos no estudo 805 indivíduos (254 pacientes com câncer de cabeça e pescoço e 551 controles). A análise molecular foi realizada com DNA genômico, e foram utilizadas as técnicas de PCR em Tempo Real (gene VEGF), PCR-SSCP (gene KiSS-1), PCR-RFLP (genes MTR, NINJ1 e TAX1BP1) e seqüenciamento automático (gene LAD1). Resultados: A análise dos dados epidemiológicos mostrou predominância de pacientes do sexo masculino (86%), hábitos tabagista (83%) e etilista (77,95%). O sítio anatômico primário mais freqüente foi a cavidade oral (35,37 %). Na análise molecular, foram encontradas diferenças estatísticas na distribuição do polimorfismo MTR A2756G (OR = 1,69; IC 95% 1,09-2,62; p = 0,019) entre pacientes e controles. Para o sítio anatômico primário do tumor, foi encontrada uma freqüência aumentada do alelo polimórfico na laringe (OR = 2,32; IC 95% 1,12 4,82; p = 0,02) para o gene KiSS-1; uma freqüência aumentada do polimorfismo para NINJ1 em cavidade oral (OR = 1,86; IC 95% 1,05 -3,30; p = 0,03) e reduzida na laringe (OR = 0,40 IC 95% 0,22-0,74; p =0,003) e um aumento da freqüência do polimorfismo para o gene TAX1BP1 na cavidade oral (OR =2,25; IC 95% 1,20-4,21; p =0,01). Foi observada uma menor freqüência do polimorfismo do gene VEGF em tumores com extensão T3 e T4 (OR = 0,36; IC 95% 0,14 0,93; p = 0,0345) e uma freqüência menor do polimorfismo do gene LAD1 em tumores com estádios III e IV (OR = 0,39 IC 95% 0,18-0,83; p = 0,01). Conclusões: O câncer de cabeça e pescoço é mais freqüente em homens, em indivíduos com hábitos tabagista e etilista e o sítio anatômico primário mais representativo é a cavidade oral. O genótipo MTR A2756G está associado ao câncer de cabeça e pescoço. Não há evidência de associação entre os polimorfismos e os hábitos tabagista, etilista, gênero e idade. Há evidências de associação entre o polimorfismo do gene KiSS-1 e laringe, entre os polimorfismos dos genes NINJ1 e TAX1BP1 e cavidade oral, e uma menor freqüência dos polimorfismos do genes VEGF em tumores com extensão T3 e T4 e LAD1 em tumores com estádios III e IV.

碩士
高雄醫學大學
職業安全衛生研究所
97
Minimally Invasive Surgery is advanced surgical technique reducing risk of infection and shortened post-operation recovery period. The surgeons must maintain certain postures to do sophisticated procedures, due to the specific feature of the operation, and musculoskeletal disorders (MSDs) happened. It may generate negative impacts on the health of the surgeons and the success of the operations. The methods were to survey the musculoskeletal disorder symptoms by NMQ (Nordic Musculoskeletal Questionnaire), to observe in the work field and to analysis by ergonomics checklists, to measure EMG and Electrogoniometer. The results of work field survey show the high occurrence of musculoskeletal disorder symptoms were in the segments of neck (91%), low back (64%), and shoulder (54%). The results of simulation experiment show the muscle fatigued at the 30 minutes, and the median frequency decreased most at the 30 to 60 minutes. And the wrist and elbow show flexion during the experiment and the median frequency of wrist are higher. Results showed that the minimally invasive surgery have potential ergonomics hazards result in occurring musculoskeletal disorders. For decreasing and preventing the hazard risks, we recommend adjusting the operating table and taking more break times.

碩士
國立勤益科技大學
工業工程與管理系
95
This research aims to find important factors to help diagnose Otolaryngological patients. Rough sets theory was applied in this research. The rough sets theory includes attributes that can be classified into conditions or decisions. We selected twelve condition attributes and one decision attribute. Condition attributes include: fever, cough, sputum, nasal, nasal obstruction, nasal pain, posterior nasal dripping, sneezing, acute upper respiratory infection, throat, headache, and dizziness. The decision attribute has three categories according to the severity of the diagnosis, including: nasosinusitis, upper respiratory infection, and nasosinusitis & upper respiratory infection. The research obtained the rules of knowledge to help diagnose effectively. This research was based on the data from a local clinic of Otolaryngology. After discussing the results with the doctor, we obtained two reducts. The doctor did not expect to eliminate acute upper respiratory infection and dizziness from the set of condition attributes. And the doctor thinks that acute upper respiratory infection is more important.

碩士
國立臺灣科技大學
企業管理系
107
This study constructs a panel data regression model to examine the determinants affecting the operational performance of otolaryngology or ear, nose and throat (ENT in short) clinics using data for 1,375 such clinics in Taiwan covering the period from 1998 to 2012. The study employs the fixed-effects model (FEM) as the appropriate empirical model after conducting three tests including the Breusch-Pagan Lagrange multiplier (BP-LM) test, the Hausman test and the over-identification test of the Hausman-Taylor model. The empirical results reveal that the numbers of physicians, nurses and the implementation of the Global Budget system have significant positive effects on the performance of ENT clinics. This situation implies that increasing the numbers of medical personnel could improve the efficiency of outpatient services and increase the numbers of points awarded to clinics. Furthermore, the implementation of the Global Budget system has a positive impact on the total number of points. The reason for this may be due to the phenomenon of supply-induced demand, which has led to a fiercely competitive market in the medical industry. On the other hand, the unemployment rate, the number of reported cases of infectious diseases, and the period of the SARS outbreak all a have negative impact on the total points earned by ENT clinics.

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2017
The mucopolysaccharidoses (MPS) belong to a group of rare lysosomal storage diseases and are caused by a deficiency in enzymes involved in the sequential degradation of glycosaminoglycans (GAGs) leading to a substrate accumulation in various tissues and organs, which can cause multisystemic manifestations. The accumulation of partially degraded GAGs in tissues leads to clinical symptoms that characterize particular MPS subtypes, including growth retardation and progressive damage to respiratory, cardiovascular, musculoskeletal, nervous, gastrointestinal, auditory and visual systems. People with this disorder can be born already with symptoms but are generally born without these alterations and develop them progressively, with potentially life-threatening consequences. The otorhinolaryngologic abnormalities of these patients encompass otologic alterations, adenotonsilar hypertrophy and airway alterations, to name but a few. Hearing loss is initially mechanical due to otitis media with effusion and thickening of the outer ear structures and, later, with progressive deterioration, with sensorineural component. Being a progressive disease it is essential to be aware to worsening symptoms and ENT (ear, nose and throat manifestations) evaluation should be done periodically. Thus, otolaryngologists have an opportunity to play an increasingly integral role in the multidisciplinary approach to the diagnosis and management of many children with MPS. Clinical suspicion, early recognition, and prompt diagnosis of these challenging disorders is crucial, as outcomes of treatment in many cases appear time-sensitive, with better results being achieved when intervention is initiated at a younger age or prior to progression of the disease.
As MPS pertencem a um grupo de doenças de depósito lisossomal e têm uma incidência global entre 1 em150,000 e os 1 em 10,000 nascimentos vivos. São causadas por deficiência das enzimas envolvidas na degradação sequencial de glicosaminoglicanos, presentes em todos os tecidos conjuntivos, levando a uma acumulação de substrato em vários tecidos e órgãos, podendo causar manifestações multissistémicas, nomeadamente falência multiorgânica progressiva . Estão descritos sete subtipos de MPS, cada um com uma deficiência congénita de enzimas lisossomais diferente. No entanto, uma caracterização de cada um destes subtipos ultrapassa os objectivos desta revisão. Todas as MPS seguem uma padrão autossómico recessivo, com exceção da MPS II, que tem um padrão ligado ao X. Nos doentes afectados, esta doença pode estar presente desde o nascimento, ou mais tarde à medida que a mesma vai progredindo. A acumulação de GAGs parcialmente degradados nos tecidos causa uma grande variedade de sintomas clínicos, com desenvolvimento crónico e progressivo, incluindo atraso de crescimento e danos progressivos nos sistemas respiratório, cardiovascular, músculo-esquelético (dismorfismo facial e displasia das articulações e esqueleto, incluindo contracturas e mãos caracteristicamente grandes), nervoso (atraso no desenvolvimento ou atraso mental), gastrointestinal, auditivo e visual. Complicações respiratórias recorrentes também são prevalentes e correspondem a uma porção significativa de morbilidade e mortalidade associadas a estas condições. As anomalias otorrinolaringológicas destes doentes estão entre as manifestações mais frequentes e abrangem, entre outras, obstrução da via aérea (causa da apneia do sono nestes doentes), infecções recorrentes (otites, sinusites e rinites) e défices auditivos. De facto, a avaliação por otorrinolaringologia precede o diagnóstico em 30% dos casos. Vários factores podem contribuir para o estreitamento da via área nos doentes com MPS e este pode ocorrer apenas ao nível superior ou em vários níveis simultaneamente. A acumulação de GAGs tanto nas amígdalas ,causando hipertrofia das mesmas, como nas paredes da faringe e laringe, causando macroglossia e espessamento dos tecidos moles da laringofaringe é o principal fator, levando a estreitamento da via área superior. Para esta contribuem também a presença de deformidades no crâneo ou coluna, tal como pescoço curto, ponte nasal achatada, laringe anterior alta, cavidade nasofaríngea funda e estreita, deformações mandibulares ou vértebras cervicais com alterações, nomeadamente instabilidade da articulação atlantoaxial. Se estes fatores (que definem a presença de obstrução da via superior) forem acompanhados de traqueobroncomalácia ou acumulação de GAG na mucosa da traqueia, distorção da traqueia em combinação com laxidez do tecido da mesma ou secreções excessivamente espessas podemos estar perante uma obstrução da via aérea em múltiplos níveis. É importante avaliar o grau de obstrução durante o sono, uma vez que é um factor importante na apresentação clinica. Apneia obstrutiva do sono ocorre em mais de 80% dos doentes (AOS nos adultos é definida como IAH>5, AOS pediátrico aceite como IAH>ou=1,5). nfecções recorrentes como traqueítes e laringites são frequentes e relacionam-se com a presença de muco viscoso e clearance mucociliar reduzida devido à acumulação de GAG. Para além disto, os depósitos de GAG nas aéreas retronasais, trompas de eustáquio e ouvido médio aumentam o risco de otite media com efusão e otite media aguda. A Perda auditiva verificada é inicialmente mecânica, devido a otite media com efusão e outras infecções recorrentes ou espessamento das estruturas do ouvido externo ou deformações na cadeia ossicular e, mais tarde, com deterioração progressiva, com componente sensorineural. No passado poucas pessoas com fenótipos graves de MPS atingiam o estado adulto. No entanto, avanços ao nível de métodos de diagnóstico, tratamento multidisciplinar e novas descobertas terapêuticas que aumentam a sobrevida levaram a um aumento do número de indivíduos que sobrevivem para além da infância. Em adultos a diminuição da acuidade auditiva e as alterações mecânicas na laringe são responsáveis por provocar alterações no discurso e dificuldades na comunicação, que por sua vez podem levar a depressão, isolamento e menor compromisso nos cuidados de saúde. A abordagem diagnóstica destes casos é baseada na suspeita clínica (baseada nas alterações mencionadas anteriormente), exames imagiológicos e avaliação laboratorial, incluindo resultados de analise de GAG urinários e ensaios da actividade enzimática. Análise de mutações ou testes moleculares têm sido utilizados para confirmar o diagnóstico de um tipo particular de mucopolissacaridoses ou para avaliar membros da família quando o tipo de MPS e a mutação familiar já é conhecida; testes moleculares podem ter valor prognóstico se as mutações identificadas estiverem bem caracterizadas. Como o diagnóstico destas patologias pode ser complexo, é recomendado que os doentes com suspeita de diagnóstico de mucopolissacaridoses sejam referenciados a um geneticista ou especialista metabólico para avaliação. Nas MPS é recomendado avaliação audiológica sistemática (anualmente), polissonografia e exames fibróticos da via aérea superior e estudos imagiológicos da traqueia e laringe, nomeadamente tomografia computorizada e ressonância magnética). A Polissonografia é a primeira linha de investigação para qualquer individuo com suspeita de MPS e AOS. As técnicas imagiológicas da via aérea superior têm um papel importante na avaliação não invasiva da obstrução da via aérea uma vez que informam sobre diversos locais de possível obstrução e, para além disso, a Tomografia computorizada foi selecionada como uma medida de outcome fiável para a eficácia de intervenção médica e não-médica da AOS. Tradicionalmente, este grupo de doenças era considerado incurável, com tratamento apenas sintomático e paliativo. Mais recentemente , têm sido feitos esforços no sentido de controlar os processos patológicos com um todo, numa tentativa de bloquear ou pelo menos atrasar a evolução da doença. Como as mucopolissacaridoses afetam múltiplos sistemas é necessário controlar um diverso espectro de manifestações como parte dos cuidados integrados. A gestão destes sintomas pode incluir utilização de aparelhos adaptativos ou de suporte, terapia física e ocupacional, terapêutica sintomática, intervenções cirúrgicas e terapêuticas para fornecer a enzima em défice. Neste contexto, a terapêutica de reposição enzimática e transplantes de células hematopoiéticas têm tido sucesso em casos selecionados. Vários estudos revelam que o transplante de células hematopoiéticas pode alterar o curso natural da doença, aumentando a esperança media de vida e melhorando algumas anomalias sistémicas. No entanto, este é um procedimento de alto risco com elevada morbilidade e mortalidade. Assim, a sua indicação depende do tipo de MPS, situação clinica do doente, idade e presença ou não de défices neurológicos. Mais recentemente, a terapia de reposição enzimática (TRE) tem sido desenvolvida e usada no tratamento de diferentes tipos de mucopolissacaridoses. Actualmente há quatro fármacos aprovados para o tratamento da MPS I (Laronidase; AldurazymeTM – Biomarin Pharmaceutical/Genzyme Co.), MPS II (Idursulfase; ElapraseTM – Shire Human Genetic Therapies Inc.), MPS IV (GALNS-elosulfase alfa; VimzymTM – Biomarin Pharmaceutical) e MPS VI (Galsulfase; NaglazymeTM – Biomarin Pharmaceuticals) e consistem na administração endovenosa periódica da enzima especifica em falta, permitindo uma maior degradação de GAG nos órgãos e tecidos e promovendo uma melhoria significativa em algumas manifestações clinicas. Esta terapêutica tem também as suas limitações: uma vez que é necessária uma administração semanal, pode cursar com risco de reações alérgicas e pode necessitar de um acesso venoso central com risco inerente de infecção e risco subsequente de endocardite. O elevado custo económico e baixa penetração no sistema nervosa central são outras das limitações desta terapêutica. Apesar dos ensaios clínicos parecerem promissores, ainda não há extensa experiência com estas terapêuticas, e ainda não estão disponíveis dados de longa duração quanto à sua eficácia. O tratamento cirúrgico das manifestações otorrinolaringológicas melhora significativamente a qualidade de vida destes indivíduos. O tratamento cirúrgico actual não é curativo e é limitado aos doentes sintomáticos, mas pode ser usado como uma abordagem preventiva para evitar futuras complicações e melhorar consideravelmente a qualidade de vida destes doentes, reduzindo a rinorreia persistente, reduzindo a frequência e gravidade das infecções otológicas e aliviando os sintomas da obstrução da via aérea superior. Como se trata uma doença progressiva é essencial ter atenção ao agravamento de sintomas e uma avaliação de otorrinolaringologia deve ser feita periodicamente. Os otorrinolaringologistas têm a oportunidade de desempenhar um papel integrante na abordagem multidisciplinar ao diagnostico e tratamento das crianças com MPS. Uma vez que estas são referenciadas para o tratamento de otites médias recorrentes, perda de capacidade auditiva e obstrução da via aérea superior. Suspeita clinica, reconhecimento precoce e diagnóstico imediato destas doenças é crucial, uma vez que os resultados do tratamento são muitas vezes sensíveis ao tempo, com melhores resultados quando a intervenção é iniciada numa idade mais precoce ou anteriormente à progressão da doença