Operative ear, nose and throat (ENT) medicine in Germany is facing a profound structural change, which is significantly influenced by the ongoing hospital reform, the expansion of outpatient surgery services and technical innovations. University and peripheral hospitals, practices, medical care centres and private clinics differ significantly in terms of resources, specialisation, remuneration systems and training opportunities. The reform is leading to a greater concentration of complex ENT services in high-performance centres, while standardised procedures are increasingly being performed on an outpatient basis. Hybrid forms of diagnosis-related groups (DRGs) and the Ambulantes Operieren im Krankenhaus (AOP; outpatient surgery) catalogue extensions are intended to promote sector-specific remuneration but are creating new economic tensions, especially for clinics with high standby costs. At the same time, outpatient surgery centres and practices are gaining in importance, but some face structural disadvantages. Digitalisation, artificial intelligence-based planning, robotic assistance and intraoperative imaging are fundamentally changing surgical work and opening up new possibilities in precision, documentation and training. This creates new requirements for surgical training: while highly complex procedures remain centre based, basic procedures must increasingly be learned in the outpatient sector. This requires cross-sectoral rotation models, consolidated curricula, digital simulation and reliable funding for outpatient training positions. Overall, the future of surgical ENT care lies in coordinated interaction between hospitals and practices, structural cooperation, modern remuneration systems, and technical and ecological innovation.

BACKGROUND:Individuals with intellectual disabilities are at higher risk of undiagnosed or inadequately treated hearing loss. This situation requires easily accessible hearing screening, diagnostics and intervention programmes in the living environment, i.e., in nurseries, schools, workplaces and homes. However, a full audiometric assessment is not always possible in nonclinical settings. The multicentre cohort study HörGeist investigated the effectiveness, feasibility and costs of an outreach programme of repeated hearing screening, diagnostics, intervention and monitoring of children, adolescents and adults with intellectual disabilities in their living environment in comparison with an invitation-only programme comprising a control cohort in a clinical setting and with standard care. This paper reports on the HörGeist substudy of the outreach cohort, focusing on participants referred for 'external' diagnostics in clinical settings after failing on-site screening, and evaluating both referral uptake and outcomes. METHODS:Because none of the 141 individuals in the control cohort provided informed consent to attend the programme in a clinical setting, our results pertain solely to the outcomes and feasibility within the outreach cohort. All of the 1053 participants in the outreach cohort who failed the hearing screening tests underwent full on-site audiometric assessment. Where on-site screening and/or diagnostics were not feasible, referrals to external medical institutions were provided. Participants who were referred to external diagnostics were tracked via telephone interviews using a questionnaire and asked about their utilisation and the outcome of diagnostics. In cases where referrals were not pursued, reasons for non-compliance were recorded. RESULTS:A referral for external diagnostics was received by 262 of the 1053 participants of the outreach cohort. Of these, 19 dropped out of the study. Of the 248 referrals received by the remaining 243 participants, 93 (37.5%) were attended and 155 (62.5%) were not. The main reasons for non-attendance were 'no attempt to arrange an appointment' (32.9%), 'refusal by caregivers' (23.2%) and 'refusal by participants' (18.1%). Approximately 4% did not receive an appointment for external diagnostics. Referral uptake declined with age, with uptake rates of 50.8% in young children, 41.3% in school-aged participants and 24.7% in adults. Telephone tracking of a subsample of 48 participants who primarily did not attend for external assessment led to further clinical diagnostics in eight cases (16.7%). CONCLUSIONS:In order to achieve an improvement in the hearing situation of people with intellectual disabilities, a screening, diagnostic and intervention programme in their living environment seems both feasible and beneficial. However, reliable assessment of the hearing status of the participants of such a programme requires education of participants, caregivers and medical professionals regarding its necessity and fostering of close collaboration with healthcare providers in outpatient and clinical settings. TRIAL REGISTRATION:German Clinical Trials Register (DRKS-ID: DRKS00024804).

People with intellectual disabilities (ID) are 5-10 times more likely to have hearing loss than the general population, yet it often remains undetected and untreated. To address this gap, the study HörGeist examined the feasibility, outcomes, barriers, and costs of an outreach program with hearing screening, diagnostics, intervention, and monitoring in everyday environments to implement a universal program in Germany. This report outlines ear and hearing care status before and after inclusion in the program and compares outcomes with standard care and a clinic-based invitation model. In a population-based, age-stratified cohort study, 1053 participants with ID (37% female; age 1-90 years) received screening and reference measurements in nurseries, schools, workplaces, and residences. When screening indicated possible hearing loss, on-site diagnostics and therapy were provided or referrals issued. A comparison cohort of 141 individuals with ID was invited to a clinic for identical procedures; none participated. All procedures were repeated after 1 year. Hearing loss was known in 14% of outreach participants at study entry; 8.7% had previously received hearing aids, but fewer than half (4.3%) used them. The program diagnosed hearing loss in 44% of participants, with 70% previously undiagnosed. After screening, 27% received therapy recommendations, but only 37% adhered to them (30% for hearing-aid prescriptions). Undertreated hearing loss declined only slightly, from 43% to 38%, over time. Major barriers included refusal by caregivers (31%) and participants (33%), often appearing to be linked to limited awareness of the treatability and consequences of hearing loss, as well as time and staff shortages. Outreach hearing screening programs are highly necessary, feasible, and effective in detecting hearing loss in people with ID, but substantial care gaps persist. Implementation requires public and professional awareness and rehabilitation strategies that include hearing and communication training and actively involve individuals with ID and their caregivers.

Electrode migration and magnet dislocation are uncommon but clinically relevant complications following cochlear implant (CI) surgery. Most previously published studies are limited by small sample sizes, restricting the ability to precisely estimate incidence rates and risk factors. To determine the frequency, mechanisms, and clinical correlates of rare CI complications in one of the largest contemporary single-center CI cohorts. This retrospective study analyzed 1,035 CI surgeries performed between 2015 and 2025 at a tertiary referral center. Clinical, demographic, surgical, and audiologic data were extracted from institutional databases. Electrode migration was confirmed via imaging and surgical exploration. Electrode migration occurred in 16 cases (1.55

Background Fitting of a cochlear implant (CI) influences the development of auditory memory and thus the development of speech. Speech development is a prerequisite for the acquisition of written language and reading and, thus, the later educational biography. Materials and methods Language development tests for 3-5-year-old children (SETK 3-5) represent a standardized procedure to assess receptive and expressive speech development as well as auditory memory. In a retrospective cross-sectional study, data of children who were fitted with bilateral CIs from six CI centers of the ACIR (Arbeitsgemeinschaft CI Rehabilitation) were evaluated. The study group was divided into groups that were analyzed on the basis of age (chronological age; LA) and hearing experience with CI (hearing age; HA). In addition, a distinction was made between CI surgery before the age of 1 year (CI <= 12 months) and CI surgery from the second to the fourth year of life (CI > 12 <= 48 months). The study group was then subdivided according to the SETK 3;0-3;11 years test into G1LA (CI <= 12 months), G2LA (CI > 12 <= 48 months), G1HA (CI <= 12 months), and G2HA (CI > 12 <= 48 months). The study group for the SETK 4;0-5;11 years test was subdivided into G3LA (CI <= 12 months), G4LA (CI > 12 <= 48 months), G3HA (CI <= 12 months), and G4HA (CI > 12 <= 48 months). Results The groups G1LA, G1HA, G3LA, and G3HA (CI <= 12 months) achieved age-appropriate values in all subtests of the SETK (3-5). Children who receive CI within the second year of life catch up in terms of language acquisition and some also develop language skills, but the T scores are below the age-adapted norm values. Children with a multilingual background show results below the norm of their hearing peers in both test settings (chronological age and hearing age). Conclusion Early provision of CI in the first year of life is an important prerequisite for children to develop age-appropriate language skills. Nevertheless, there is wide variation within the groups, so that speech diagnostics and therapy are required as part of follow-up treatment during primary language acquisition to detect and avoid major language delay.

Die Versorgung mit einem Cochleaimplantat (CI) beeinflusst die Ausbildung des auditiven Gedächtnisses und die Sprachentwicklung. Letztere ist eine Voraussetzung für den Erwerb der Schriftsprache und des Lesens und somit entscheidend für die spätere Bildungsbiografie. Die Sprachentwicklungstests für drei- bis fünfjährige Kinder (SETK 3–5) wurden zur Beurteilung der rezeptiven und produktiven Sprachentwicklung sowie der auditiven Gedächtnisleistung während der Folgetherapie eingesetzt. Mit einer retrospektiven Querschnittsstudie wurden die Daten von Kindern, die bilateral mit Cochleaimplantaten (CI) versorgt wurden, aus 6 CI-Zentren der ACIR (Arbeitsgemeinschaft CI Rehabilitation) ausgewertet. Die Unterteilung der Studiengruppe erfolgt in Gruppen, die einerseits anhand des Lebensalters (LA) und anderseits nach ihrer Hörerfahrung mit CI, dem „Höralter“ (HA), ausgewertet wurden. Darüber hinaus wurde differenziert nach CI-Operation vor dem ersten Lebensjahr (CI ≤ 12 Monate) und CI-Operation ab dem zweiten Lebensjahr bis zum vierten Lebensjahr (CI > 12 ≤ 48 Monate). So entstehen die Gruppen für den SETK 3;0–3;11 Jahre: G1LA (CI ≤ 12 Monate), G2LA (CI > 12 ≤ 48 Monate), G1HA (CI ≤ 12 Monate), G2HA (CI > 12 ≤ 48 Monate). Für den SETK 4;0–5;11 Jahre sind es folgende Gruppen: G3LA (CI ≤ 12 Monate); G4LA (CI > 12 ≤ 48 Monate), G3HA (CI ≤ 12 Monate) und G4HA (CI > 12 ≤ 48 Monate). Die Gruppen G1LA, G1HA, G3LA, G3HA (CI ≤ 12 Monate) erreichen altersgerechte Werte in allen Untertests des SETK (3–5). Kinder, die im zweiten Lebensjahr versorgt wurden, holen im Spracherwerb auf. Einige Kinder entwickeln ebenfalls sprachliche Fähigkeiten, jedoch liegen die T-Werte unterhalb der Norm in Bezug zum Lebensalter. Kinder, die mit Deutsch als Zweitsprache aufwachsen, zeigen Entwicklungen im Zweitspracherwerb. Ihre Ergebnisse sind in den Auswertungen bezogen auf das Lebensalter und der Hörerfahrung mit CI nicht altersgerecht. Die frühe Versorgung im ersten Lebensjahr ist eine wichtige Voraussetzung dafür, dass Kinder mit CI-Versorgung sprachliche Fähigkeiten entwickeln, die altersgerecht sind. Dennoch ist die Streuung innerhalb der Gruppen breit, sodass Sprachentwicklungsdiagnostik und Therapie im Rahmen der Folgetherapie während des primären Spracherwerbs erforderlich ist, damit Verzögerungen während des primären Spracherwerbs rechtzeitig erkannt werden.

Background/Objectives: Sentence stress as part of linguistic prosody plays an important role for verbal communication. It emphasizes particularly important words in a phrase and is reflected by acoustic cues such as the voice fundamental frequency. However, visual cues, especially facial movements, are also important for sentence stress perception. Since cochlear implant (CI) recipients are limited in their use of acoustic prosody cues, the question arises as to what extent they are able to exploit visual features. Methods: Virtual characters were used to provide highly realistic but controllable stimuli for investigating sentence stress in groups of experienced CI recipients and typical-hearing (TH) peers. In addition to the proportion of correctly identified stressed words, task load was assessed via reaction times (RTs) and task-evoked pupil dilation (TEPD), and visual attention was estimated via eye tracking. Experiment 1 considered congruent combinations of auditory and visual cues, while Experiment 2 presented incongruent stimuli. Results: In Experiment 1, CI users and TH participants performed similarly in the congruent audiovisual condition, while the former were better at using visual cues. RTs were generally faster in the AV condition, whereas TEPD revealed a more detailed picture, with TH subjects showing greater pupil dilation in the visual condition. The incongruent stimuli in Experiment 2 showed that modality use varied individually among CI recipients, while TH participants relied primarily on auditory cues. Conclusions: Visual cues are generally useful for perceiving sentence stress. As a group, CI users are better at using facial cues than their TH peers. However, CI users show individual differences in the reliability of the various cues.

OBJECTIVE:This study investigated whether the SONNET 2 audio processor's ambient noise reduction (ANR) algorithm improves speech recognition and listening effort in cochlear implant (CI) users as a function of different noise signals. DESIGN:Speech recognition and listening effort were measured in the presence of four different noise signals, including stationary and fluctuating noise, and including a speech masker. Speech was presented from the front (S0) and noise from two sources from the back (N ± 135). STUDY SAMPLE:20 adult CI users. RESULTS:With the ANR, speech recognition significantly improved in the presence of one stationary noise and in the presence of one fluctuating noise. The ANR had no significant effect on listening effort. CONCLUSIONS:When activating the ANR algorithm of the SONNET 2 audio processor, speech recognition improved in some conditions. Listening effort was equal in all conditions. In corresponding everyday situations, it can be recommended to use the ANR algorithm.

Although a cochlear implant (CI) can partially restore auditory function, CI recipients show alterations not only in auditory but also in visual cortical processing. Yet, it is not well understood how these visual changes relate to the CI outcome and to what extent these changes are induced by auditory deprivation and the limited CI input, respectively. Here, we present a prospective longitudinal electroencephalography study which examined the deprivation- and CI-induced alterations on cortical face processing by comparing visual evoked potentials (VEP) in CI users before and 6 months after implantation. A group of normal-hearing (NH) listeners served as a control. The participants performed a word-identification task and a face-categorization task to study the cortical processing of static and articulating faces in attended and unattended conditions. The CI candidates and CI users showed a reduced visual-cortex activation, a stronger functional connectivity between the visual and auditory cortex, and a reduced attention effect in the (extended) alpha frequency range (8-18 Hz) when compared to NH listeners. There was a positive correlation between the P1 VEP amplitude recorded before implantation and the speech recognition ability after implantation. Our results suggest that the CI users' alterations in cortical face processing are mainly induced by auditory deprivation and not by CI experience. Importantly, these deprivation-induced changes seem to be related to the CI outcome. Our results suggest that the visual P1 amplitude as recorded before implantation provides an objective index of cortical visual reorganization that may help predict the CI outcome.

Purpose: The adaptation of existing questionnaires is a valuable method to make instruments available in multiple languages. It is necessary to assure the quality of an adaptation by following adaptation guidelines. The Cochlear Implant Quality of Life–35 Profile (CIQOL-35 Profile) was developed and validated to measure the functional abilities in English-speaking adult CI users but is not yet available in German. In this study, we performed a cross-cultural adaptation of this instrument to make it applicable in research and rehabilitation with German-speaking patients. Method: This study followed established practice guidelines for translating and adapting hearing-related questionnaires. Professional translators and health care professionals with experience with patients with hearing loss translated all items forward and backward multiple times. A committee reviewed the process and decided when a satisfactory consensus was achieved. Next, we examined the intelligibility of the German version using cognitive interviews with 15 adult CI users. Results: For most items, there was no difficulty with direct translation. In items that turned out to be more difficult to translate, it proved to be very helpful to compare the back translation to the original version, discuss the wording in the committee, and ask the source-language questionnaire developer. During the interviews, issues of comprehension for some phrases were identified. These phrases were changed according to the participant's questions and suggestions. Conclusions: The CIQOL-35 Profile was successfully adapted into German. The German version of the questionnaire is now available for research and clinical practice. Further validation of the German CIQOL-35 Profile is in progress. Supplemental Material: https://doi.org/10.23641/asha.25386571

Background Using Otoplan software, it is possible to measure the cochlea before cochlear implant surgery. Until now, computed tomography (CT) of the cochlea has been necessary for this purpose. The aim of this study was to find out whether measuring the cochlea with magnetic resonance imaging (MRI) using Otoplan is possible with the same accuracy.Methods The cochlea of 44 patients of the local cochlear implant centre was measured by Otoplan using high-resolution CT-bone and MRI images, and the determined lengths were compared.Results No significant difference was found between the cochlear lengths measured, regardless of whether the length measurement was based on a CT or an MRI data set.Conclusion For the determination of cochlear length prior to cochlear implant surgery, MRI images are just as suitable as CT images, therefore CT is not mandatory for length measurement by Otoplan, which could reduce the patient's radiation exposure.

Limited auditory input, whether caused by hearing loss or by electrical stimulation through a cochlear implant (CI), can be compensated by the remaining senses. Specifically for CI users, previous studies reported not only improved visual skills, but also altered cortical processing of unisensory visual and auditory stimuli. However, in multisensory scenarios, it is still unclear how auditory deprivation (before implantation) and electrical hearing experience (after implantation) affect cortical audiovisual speech processing.Here, we present a prospective longitudinal electroencephalography (EEG) study which systematically examined the deprivation- and CI-induced alterations of cortical processing of audiovisual words by comparing event-related potentials (ERPs) in postlingually deafened CI users before and after implantation (five weeks and six months of CI use). A group of matched normal-hearing (NH) listeners served as controls. The participants performed a word-identification task with congruent and incongruent audiovisual words, focusing their attention on either the visual (lip movement) or the auditory speech signal. This allowed us to study the (top-down) attention effect on the (bottom-up) sensory cortical processing of audiovisual speech.When compared to the NH listeners, the CI candidates (before implantation) and the CI users (after implantation) exhibited enhanced lipreading abilities and an altered cortical response at the N1 latency range (90-150 ms) that was characterized by a decreased theta oscillation power (4-8 Hz) and a smaller amplitude in the auditory cortex. After implantation, however, the auditory-cortex response gradually increased and developed a stronger intra-modal connectivity. Nevertheless, task efficiency and activation in the visual cortex was significantly modulated in both groups by focusing attention on the visual as compared to the auditory speech signal, with the NH listeners additionally showing an attention-dependent decrease in beta oscillation power (13-30 Hz).In sum, these results suggest remarkable deprivation effects on audiovisual speech processing in the auditory cortex, which partially reverse after implantation. Although even experienced CI users still show distinct audiovisual speech processing compared to NH listeners, pronounced effects of (top-down) direction of attention on (bottom-up) audiovisual processing can be observed in both groups. However, NH listeners but not CI users appear to show enhanced allocation of cognitive resources in visually as compared to auditory attended audiovisual speech conditions, which supports our behavioural observations of poorer lipreading abilities and reduced visual influence on audition in NH listeners as compared to CI users.

Einführung Wir berichteten über das Neugeborenenhörscreening Programm für Nordrhein und das krankenhausbasierte Screening in diesem Rahmen an einer Universitäts-Kinderklinik für den Zeitraum 2007-2016.

Regular reporting of quality control is important in newborn hearing screening, ensuring early diagnosis and intervention. This study reports on a population-based newborn hearing screening program in North-Rhine, Germany and a hospital-based screening at a University Hospital for 2007–2016. The two-staged ‘screening’ and ‘follow-up’ program involving TEOAE and AABR recruited newborns through participating birth facilities. Results were sent to the regional tracking center, and the data were analyzed based on recommended benchmarks. The percentage of newborns from the participating birth facilities in the region increased from 1.4% in 2007 to 57.5% in 2016. The 10-year coverage rate for these newborns was 98.7%, the referral rate after a failed two-step screening was 3.4%, and the lost-to-follow-up rate was 1%. At the hospital, >95% of the screened newborns completed screening within 30 days, the 10-year referral rate was 5%, and 64% were referred within 3 months of age. The median time for screening completion was 6 days after birth, for referral it was 74 days after birth, and for diagnosis it was 55 days after birth. Regional–centralized tracking centers with uniform structure are necessary for proper quality control. Obligatory participation of birthing facilities and quality reports may improve performance, but the recommended quality criteria need considerable financial and infrastructural expenditure.

AimMore studies exploring referral rates and false-positive rates are needed to make hearing screening programs in newborns better and cost-effective. Our aim was to study the referral and false-positivity rates among high-risk newborns in our hearing screening program and to analyze the factors potentially associated with false-positive hearing screening test results.MethodsA retrospective cohort study was done among the newborns hospitalized at a university hospital from January 2009 to December 2014 that underwent hearing screening with a two-staged AABR screening protocol. Referral rates and false-positivity rates were calculated and possible risk factors for false-positivity were analyzed.Results4512 newborns were screened for hearing loss in the neonatology department. The referral rate for the two-staged AABR-only screening was 3.8% with false-positivity being 2.9%. Our study showed that the higher the birthweight or gestational age of the newborn, the lower the odds of the hearing screening results being false-positive, and the higher the chronological age of the infant at the time of screening, the higher the odds of the results being false-positive. Our study did not show a clear association between the mode of delivery or gender and false-positivity.ConclusionAmong high-risk infants, prematurity and low-birthweight increased the rate of false-positivity in the hearing screening, and the chronological age at the time of the test seems to be significantly associated with false-positivity.

Objective: Hearing with a cochlear implant (CI) is difficult in noisy environments, but the use of noise reduction algorithms, specifically ForwardFocus, can improve speech intelligibility. The current eventrelated potentials (ERP) study examined the electrophysiological correlates of this perceptual improvement. Methods: Ten bimodal CI users performed a syllable-identification task in auditory and audiovisual conditions, with syllables presented from the front and stationary noise presented from the sides. Brainstorm was used for spatio-temporal evaluation of ERPs. Results: CI users revealed an audiovisual benefit as reflected by shorter response times and greater activation in temporal and occipital regions at P2 latency. However, in auditory and audiovisual conditions, background noise hampered speech processing, leading to longer response times and delayed auditorycortex-activation at N1 latency. Nevertheless, activating ForwardFocus resulted in shorter response times, reduced listening effort and enhanced superior-frontal-cortex-activation at P2 latency, particularly in audiovisual conditions. Conclusions: ForwardFocus enhances speech intelligibility in audiovisual speech conditions by potentially allowing the reallocation of attentional resources to relevant auditory speech cues. Significance: This study shows for CI users that background noise and ForwardFocus differentially affect spatio-temporal cortical response patterns, both in auditory and audiovisual speech conditions. & COPY; 2023 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Purpose We hypothesized that using a 3D-exoscope (3Dex) in microlaryngoscopic phonosurgery is non-inferior to using a standard operating microscope (OM). To compare the above, we utilized a 3Dex and an OM for microlaryngoscopic vocal fold augmentation with autologous fat in patients with glottic insufficiency and compared the procedure itself and the long-term impact of vocal fold augmentation on subjective and objective voice parameters in both groups. Methods 36 patients with glottic insufficiency received microlaryngoscopic laryngeal augmentation with autologous fat. A 3Dex was utilized in 24 cases for visualization and compared to twelve cases in which an OM was used. Voice parameters were evaluated over a period of twelve months. Results Comparison of operation time and voice parameters between the 3Dex and OM groups did not reveal significant differences. Significant improvement of mean voice quality in all parameters excluding roughness was observed at 3 and 6 months followed then by a slight decrease of voice quality parameters between the 6 and 12 months interval in both groups. Conclusion Our findings indicate no difference concerning operation time and outcome between the use of a 3Dex and an OM in phonosurgery. Our results highlight a significant voice improvement after vocal fold augmentation with autologous fat in glottic insufficiency mediated dysphonia. The smaller viewing system, better ergonomics for the primary surgeon and the assistant and a direct view for the entire surgical team make a 3Dex an interesting alternative for visualization in microlaryngoscopic phonosurgery.

Auditory synaptopathy/neuropathy (AS/AN) is a distinct type of sensorineural hearing loss in which the cochlear sensitivity to sound (i.e. active cochlear amplification by outer hair cells) is preserved whereas sound encoding by inner hair cells and/or auditory nerve fibers is disrupted owing to genetic or environmental factors. Autosomal-dominant auditory neuropathy type 2 (AUNA2) was linked either to chromosomal bands 12q24 or 13q34 in a large German family in 2017. By whole-genome sequencing, we now detected a 5500 bp deletion in ATP11A on chromosome 13q34 segregating with the phenotype in this family. ATP11A encodes a P-type ATPase that translocates phospholipids from the exoplasmic to the cytoplasmic leaflet of the plasma membrane. The deletion affects both isoforms of ATP11A and activates a cryptic splice site leading to the formation of an alternative last exon. ATP11A carrying the altered C-terminus loses its flippase activity for phosphatidylserine. Atp11a is expressed in fibers and synaptic contacts of the auditory nerve and in the cochlear nucleus in mice, and conditional Atp11a knockout mice show a progressive reduction of the spiral ganglion neuron compound action potential, recapitulating the human phenotype of AN. By combining whole-genome sequencing, immunohistochemistry, in vitro functional assays and generation of a mouse model, we could thus identify a partial deletion of ATP11A as the genetic cause of AUNA2.