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Im Jahr 2003 begann die HNO-Universitätsklinik Frankfurt / Main mit der Einführung eines Qualitätsmanagement-Systems, die im August 2005 zur erfolgreichen Zertifizierung nach der vom Klinikumsvorstand geforderten DIN EN ISO 9001:2000 führte. Ziele unseres Qualitätsmanagements waren die Optimierung der internen Betriebsabläufe und die Standardisierung von Arbeitsvorgängen unter Einbeziehung von logistischen Schnittstellen mit externen Strukturen unter Berücksichtigung der besonderen Anforderungen einer Universitätsklinik. Neben einer grundsätzlichen Prüfung und Optimierung sämtlicher Organisationsabläufe wurden für die Kernprozesse unserer Klinik Zielvorgaben festgelegt. Diese Ziele betrafen die Qualität der Arbeitsabläufe für alle Bereiche der HNO-ärztlichen ambulanten und stationären Versorgung ebenso, wie Aufgaben in Forschung und Lehre, die durch ein Ausbildungscurriculum für Mitarbeiter und Sudenten abgebildet wurde. Es wurden aber auch Serviceaspekte, wie Terminvergabe und Befundübermittlung, sowie ökonomische und wirtschaftliche Aspekte unserer Arbeit optimiert. Durch Umstrukturierung und Neuorganisation konnte die Effizienz der Arbeitsabläufe deutlich gesteigert werden, wovon vor allem Patienten und Mitarbeiter erheblich profitieren. Die Einführung eines Qualitätsmanagementsystems in der Frankfurter HNO-Universitätsklinik war zunächst mit einem entsprechenden Arbeitsaufwand verbunden und erforderte ein Umdenken in den einzelnen Funktionsbereichen. Insgesamt überwiegt der positive Einfluss auf die Struktur und Arbeitsabläufe, sodass die Umsetzung eines Qualitätsmanagementsystems in der Universitätsklinik empfehlenswert ist.
Background Public health systems are confronted with constantly rising costs. Furthermore, diagnostic as well as treatment services become more and more specialized. These are the reasons for an interdisciplinary project on the one hand aiming at simplification of planning and scheduling patient appointments, on the other hand at fulfilling all requirements of efficiency and treatment quality. Methods As to understanding procedure and problem solving activities, the responsible project group strictly proceeded with four methodical steps: actual state analysis, analysis of causes, correcting measures, and examination of effectiveness. Various methods of quality management, as for instance opinion polls, data collections, and several procedures of problem identification as well as of solution proposals were applied. All activities were realized according to the requirements of the clinic's ISO 9001:2000 certified quality management system. The development of this project is described step by step from planning phase to inauguration into the daily routine of the clinic and subsequent control of effectiveness. Results Five significant problem fields could be identified. After an analysis of causes the major remedial measures were: installation of a patient telephone hotline, standardization of appointment arrangements for all patients, modification of the appointments book considering the reason for coming in planning defined working periods for certain symptoms and treatments, improvement of telephonic counselling, and transition to flexible time planning by daily updates of the appointments book. After implementation of these changes into the clinic's routine success could be demonstrated by significantly reduced waiting times and resulting increased patient satisfaction. Conclusion Systematic scrutiny of the existing organizational structures of the outpatients' department of our clinic by means of actual state analysis and analysis of causes revealed the necessity of improvement. According to rules of quality management correcting measures and subsequent examination of effectiveness were performed. These changes resulted in higher satisfaction of patients, referring colleagues and clinic staff the like. Additionally the clinic is able to cope with an increasing demand for appointments in outpatients' departments, and the clinic's human resources are employed more effectively.
Langzeiterfahrungen mit der ipsilateralen Elektroakustischen Stimulation (EAS) : meeting abstract
(2006)
Hochgradig hörgeschädigten Patienten mit einem Tieftonrestgehör (Steilabfall im Audiogramm) können mittels ipsilateraler EAS versorgt werden. Dabei wird der völlig taube Hochfrequenzbereich des Innenohres mit einem Cochleaimplantat stimuliert, und die tieffrequente Restfunktion der Schnecke bleibt erhalten. Voraussetzung für eine derartige Versorgung ist ein Erhalt des tieffrequenten Restgehöres bei der Cochlea-Implant-Elektrodeneinführung. Im Rahmen einer klinischen Studie wurden seit 1999 in Frankfurt 25 Patienten mit EAS versorgt. Des Weiteren wurden 16 Patienten im Rahmen einer europäischen Multicenterstudie für EAS implantiert. Ein zumindest teilweiser Erhalt des Restgehöres war in über 90% der Fälle möglich. Es wird über die Langzeitergebnisse (6 bis 70 Monate) nach EAS-Implantation berichtet. In 70% der Fälle blieb das erhaltene Restgehör stabil. Die Patienten zeigten überdurchschnittlich gute Werte bei der Sprachdiskrimination mit ihren Cochleaimplantaten, die durch zusätzliche akustische Stimulation noch verbessert wurden. Besonders deutlich waren die Hörleistungen unter Störgeräuscheinfluss. Seit Kurzem steht auch ein kombinierter Sprachprozessor für die elektrische und akustische Stimulation zur Verfügung.
Background: The standard electrode array for the MED-EL MAESTRO cochlear implant system is 31 mm in length which allows an insertion angle of approximately 720°. When fully inserted, this long electrode array is capable of stimulating the most apical region of the cochlea. No investigation has explored Electrically Evoked Compound Action Potential (ECAP) recordings in this region with a large number of subjects using a commercially available cochlear implant system. The aim of this study is to determine if certain properties of ECAP recordings vary, depending on the stimulation site in the cochlea. Methods: Recordings of auditory nerve responses were conducted in 67 subjects to demonstrate the feasibility of ECAP recordings using the Auditory Nerve Response Telemetry (ART™) feature of the MED-EL MAESTRO system software. These recordings were then analyzed based on the site of cochlear stimulation defined as basal, middle and apical to determine if the amplitude, threshold and slope of the amplitude growth function and the refractory time differs depending on the region of stimulation. Results: Findings show significant differences in the ECAP recordings depending on the stimulation site. Comparing the apical with the basal region, on average higher amplitudes, lower thresholds and steeper slopes of the amplitude growth function have been observed. The refractory time shows an overall dependence on cochlear region; however post-hoc tests showed no significant effect between individual regions. Conclusions :Obtaining ECAP recordings is also possible in the most apical region of the cochlea. However, differences can be observed depending on the region of the cochlea stimulated. Specifically, significant higher ECAP amplitude, lower thresholds and steeper amplitude growth function slopes have been observed in the apical region. These differences could be explained by the location of the stimulating electrode with respect to the neural tissue in the cochlea, a higher density, or an increased neural survival rate of neural tissue in the apex. Trial registration: The Clinical Investigation has the Competent Authority registration number DE/CA126/AP4/3332/18/05.
Objectives: To correlate the radiological assessment of the mastoid facial canal in postoperative cochlear implant (CI) cone-beam CT (CBCT) and other possible contributing clinical or implant-related factors with postoperative facial nerve stimulation (FNS) occurrence. Methods: Two experienced radiologists evaluated retrospectively 215 postoperative post-CI CBCT examinations. The mastoid facial canal diameter, wall thickness, distance between the electrode cable and mastoid facial canal, and facial-chorda tympani angle were assessed. Additionally, the intracochlear position and the insertion angle and depth of electrodes were evaluated. Clinical data were analyzed for postoperative FNS within 1.5-year follow-up, CI type, onset, and causes for hearing loss such as otosclerosis, meningitis, and history of previous ear surgeries. Postoperative FNS was correlated with the measurements and clinical data using logistic regression. Results: Within the study population (mean age: 56 ± 18 years), ten patients presented with FNS. The correlations between FNS and facial canal diameter (p = 0.09), wall thickness (p = 0.27), distance to CI cable (p = 0.44), and angle with chorda tympani (p = 0.75) were statistically non-significant. There were statistical significances for previous history of meningitis/encephalitis (p = 0.001), extracochlear-electrode-contacts (p = 0.002), scala-vestibuli position (p = 0.02), younger patients’ age (p = 0.03), lateral-wall-electrode type (p = 0.04), and early/childhood onset hearing loss (p = 0.04). Histories of meningitis/encephalitis and extracochlear-electrode-contacts were included in the first two steps of the multivariate logistic regression. Conclusion: The mastoid-facial canal radiological assessment and the positional relationship with the CI electrode provide no predictor of postoperative FNS. Histories of meningitis/encephalitis and extracochlear-electrode-contacts are important risk factors.
Objective: Vertigo is a common side effect of cochlear implant (CI) treatment. This prospective study examines the incidence of postoperative vertigo over time and aims to analyze influencing factors such as electrode design and insertion angle (IA).
Study Design and Setting: This is a prospective study which has been conducted at a tertiary referral center (academic hospital).
Patients: A total of 29 adults were enrolled and received a unilateral CI using one of six different electrode carriers, which were categorized into “structure-preserving” (I), “potentially structure-preserving” (II), and “not structure-preserving” (III).
Intervention: Subjective vertigo was assessed by questionnaires at five different time-points before up to 6 months after surgery. The participants were divided into four groups depending on the time of the presence of vertigo before and after surgery. Preoperatively and at 6 months postoperatively, a comprehensive vertigo diagnosis consisting of Romberg test, Unterberger test, subjective visual vertical, optokinetic test, video head impulse test, and caloric irrigation test was performed. In addition, the IA was determined, and the patients were divided in two groups (<430°; ≥430°).
Main Outcome Measures: The incidence of vertigo after CI surgery (group 1) was reported, as well as the correlation of subjective vertigo with electrode array categories (I–III) and IA.
Results: Among the participants, 45.8% experienced new vertigo after implantation. Based on the questionnaire data, a vestibular origin was suspected in 72.7%. The results did not show a significant correlation with subjective vertigo for any of the performed tests. In group 1 with postoperative vertigo, 18% of patients showed conspicuous results in a quantitative analysis of caloric irrigation test despite the fact that the category I or II electrodes were implanted, which are suitable for structure preservation. Average IA was 404° for the overall group and 409° for group 1. There was no statistically significant correlation between IA and perceived vertigo.
Conclusions: Though vertigo after CI surgery seems to be a common complication, the test battery used here could not objectify the symptoms. Further studies should clarify whether this is due to the multifactorial cause of vertigo or to the lack of sensitivity of the tests currently in use. The proof of reduced probability for vertigo when using atraumatic electrode carrier was not successful, nor was the proof of a negative influence of the insertion depth.
