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Δευτέρα, 14 Νοεμβρίου 2016

Factors Influencing the Incidence of Severe Complications in Head and Neck Free Flap Reconstructions



Plastic and Reconstructive Surgery - Global Open:
doi: 10.1097/GOX.0000000000001013
Original Article

Factors Influencing the Incidence of Severe Complications in Head and Neck Free Flap Reconstructions

Broome, Martin MD, DDS; Juilland, Naline MD; Litzistorf, Yann MD; Monnier, Yan MD; Sandu, Kishore MD; Pasche, Philippe MD; Plinkert, Peter K. MD; Federspil, Philippe A. MD; Simon, Christian MD

Open Access
Switzerland
Article Outline
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Author Information

From the *Division of Maxillo-Facial Surgery, CHUV, University of Lausanne, Lausanne, Switzerland; Department of Otolaryngology—Head and Neck Surgery, CHUV, University of Lausanne, Lausanne, Switzerland; and Department of Otolaryngology—Head and Neck Surgery, University of Heidelberg, Heidelberg, Germany.
Received for publication December 30, 2015; accepted July 05, 2016.
Presented at the annual CORLAS-meeting 2015, San Francisco, Calif., USA.
Drs. Martin Broome and Naline Juilland contributed equally to this work.
Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
Christian Simon, MD, Department of Otolaryngology—Head and Neck Surgery, University of Lausanne, CHUV, Rue du Bugnon 21, 1006 Lausanne, Switzerland, E-mail:Christian.Simon@chuv.ch
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.
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Abstract

Background: Complications after head and neck free-flap reconstructions are detrimental and prolong hospital stay. In an effort to identify related variables in a tertiary regional head and neck unit, the microvascular reconstruction activity over the last 5 years was captured in a database along with patient-, provider-, and volume-outcome–related parameters.
Methods: Retrospective cohort study (level of evidence 3), a modified Clavien-Dindo classification, was used to assess severe complications.
Results: A database of 217 patients was created with consecutively reconstructed patients from 2009 to 2014. In the univariate analysis of severe complications, we found significant associations (P < 0.05) between type of flap used, American Society of Anesthesiologists classification, T-stage, microscope use, surgeon, flap frequency, and surgeon volume. Within a binomial logistic regression model, less frequently versus frequently performed flap (odds ratio [OR] = 3.2; confidence interval [CI] = 2.9–3.5; P = 0.000), high-volume versus low-volume surgeon (OR = 0.52; CI = −0.22 to 0.82; P = 0.007), and ASA classification (OR = 2.9; CI = 2.4–3.4; P = 0.033) were retained as independent predictors of severe complications. In a Cox-regression model, surgeon (P = 0.011), site of reconstruction (P = 0.000), T-stage (P = 0.001), and presence of severe complications (P = 0.015) correlated with a prolonged hospitalization.
Conclusions: In this study, we identified a correlation of patient-related factors with severe complications (ASA score) and prolonged hospital stay (T-stage, site). More importantly, we identified several provider- (surgeon) and volume-related (frequency with which a flap was performed and high-volume surgeon) factors as predictors of severe complications. Our data indicate that provider- and volume-related parameters play an important role in the outcome of microvascular free-flap procedures in the head and neck region.
The reconstruction of head and neck defects is of major importance in the complex treatment of head and neck cancer patients, allowing not only for an aesthetic closure of large defects after ablative surgery but also more importantly for functional recovery of swallowing, mastication, and speech.1 The use of microvascular anastomosed free flaps has gained wide acceptance within the last decades, based on the variety of donor sites and as a consequence of multitude of tissue compositions, allowing for a defect-specific approach of reconstruction.2–4
Currently used free flaps in the head and neck are fasciocutaneous, musculocutaneous, and bone flaps.2 The most commonly used fasciocutaneous flap in Europe is the radial forearm free flap,5 followed by the anterolateral thigh flap, which belongs to the family of perforator flaps.3,6–8 Other soft-tissue flaps are the rectus and latissimus dorsi flaps.9,10 For bony reconstructions, a fibular flap,11 an iliac crest, or a scapula flap can be used.12–14 For facial reanimation surgery, a free gracilis flap is the primary choice.2 In case of a complete pharyngeal reconstruction, a jejunum free flap is an option.15
Predictors of complications of free-flap surgeries in head and neck cancer patients have recently been delineated in a group of 185 patients and are found to be age, smoking status, American Society of Anesthesiologists classification, preoperative hemoglobin, and perioperative fluid management.16 A more recent study on 304 patients reports only stage of disease and pharyngoesophageal reconstruction to be associated with severe complications. A convincing association with flap type and indication was not found, neither with preoperative radiation nor with chemoradiation therapy.17
There is accumulating evidence that head and neck cancer is better treated in larger centers, in particular academic centers, and there is an evolving body of evidence for a volume–outcome association in the care of head and neck cancer patients, with high-volume hospitals and high-volume surgeons providing significantly better survival.18–22 In that sense, patients surgically treated in high-volume head and neck cancer centers have a 44% lower odds of mortality from acute complications than their counterparts treated in low-volume centers. Positive margins in the resection of oral cavity cancer are also associated with hospital case volume.18,23
Although there is ample evidence that surgeon volume, for example, in case of oral cavity cancers reconstructed with various pedicled and free flaps, impacts the survival of these head and neck cancer patients,24 data on how volume- and provider-related factors might influence complications and/or duration of hospitalization after microvascular tissue transfer procedures are lacking. An explanation for this lack of data is the fact that as of now, no or few databases exist that gather follow-up data on complications associated with free-flap procedures, and volume–outcome association studies are best performed based on population-based administrative databases that neither exist.
To understand parameters influencing the perioperative rate of severe complications and length of hospitalization, we constructed a database consisting of 217 consecutively performed free-flap procedures. Besides typical patient-related factors, we also analyzed factors related to the provider and to the volume of activity.
Toward the end of this study, we confirmed an association between severe complications and comorbidities measured via the ASA classification, but more interestingly, we found a correlation between severe complications and the frequency with which a flap was performed and moreover the operative volume of the surgeon.
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METHODS

From 2009 to 2014, 217 consecutive patients, of whom 202 were treated for a primary malignancy of the head and neck and 15 patients for secondary reconstructions and various head and neck traumas, underwent reconstruction with a free microvascular anastomosed flap. The reconstruction was performed by 6 microvascular head and neck surgeons. Data on the patients were retrospectively collected from the electronic patient charts, and a database was generated (Table 1). Given that immediate postoperative variables (severe complications and length of hospitalization) were assessed as primary endpoints, no patient was lost to follow-up. The study was approved by the institutional review board. One surgeon worked in 2 institutions, and this activity was included in the database. Patient- (T-stage, overall stage, ASA score, sex, prior radiation therapy, localization of the reconstruction, type of flap, and age) and provider-related (surgeon and microscope vs loupe use) variables and volume-sensitive variables (surgeon volume and flap frequency) were included. Volume-sensitive variables were derived from surgeon activity and frequency of flaps performed within the observation period of 5 years (Fig.  1).
Table 1
Table 1
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Fig. 1
Fig. 1
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Every cancer patient was discussed in a multidisciplinary tumor board of the medical centers for treatment decision making. Staging was performed via a triple endoscopy with biopsy and imaging. Imaging modalities consisted of either computed tomography with contrast or magnetic resonance imaging. The stage of the disease was determined after the surgical resection of the tumor according to the TNM system of the International Union against Cancer (7th edition). The indication for adjuvant treatment was based on nodal status and margins. In case of positive permanent margins, the patient received adjuvant chemoradiation.
The surgical approach was dependent on the location of the disease and the reconstructive needs. For oral cavity malignancies requiring a free-flap procedure, either a fasciocutaneous flap was used or a bone flap in case of mandible involvement. For oropharyngeal and laryngeal/hypopharyngeal reconstruction, fasciocutaneous flaps were used. For maxillary reconstruction bone flaps, fasciocutaneous and musculocutaneous flaps were used. Microvascular anastomosis was performed either with an operation microscope (Leica OH5, Leica Microsystems, Wetzlar, Germany; Zeiss S8, Carl Zeiss Meditec AG, Jena, Germany) or with magnifying loupes (3.5-fold). Arteries and veins were both sewn using either 8.0 or 9.0 Prolene sutures.
Surgical complications were rated using a modified Clavien-Dindo (CD) grading system.25,26 The modified grading system adds 1 additional category distinguishing between patients requiring a surgical, endoscopic, or radiological intervention for hematoma evacuation without wound-healing complications, minor wound dehiscence, or vascular complication with complete functional salvage of the flap and those requiring intervention for fistulas, or complete or partial flap loss resulting in additional procedures (Table 2). A severe complication according to this novel classification is a complication requiring a surgical, endoscopic, or radiological intervention for fistulas or complete or partial flap loss resulting in additional procedures (ie, fistula formation or flap losses/partial losses requiring additional major interventions, ie, additional [regional] flaps or repetitive wound dressings including vacuum-assisted systems), in case of single- or multiorgan failure or in case of death. An additional grouping according to late complications indicated by the suffix “d” in the original CD classification was not considered.
Table 2
Table 2
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All statistical analysis was performed using SPSS statistical software for Windows, version 20 (SPSS, Inc, an IBM Company, Chicago, Ill., USA). Pearson χ2 tests were used to determine the association between categorical variables. Binary logistic regression was used to identify independent predictors of increased severe complication rate with an inclusion threshold of P ≤ 0.05. To determine variables predicting length of hospitalization, a Cox-regression model was used with an inclusion threshold of P ≤ 0.05. Cases with covariate data missing or unknown were excluded from the multivariate analysis. Effects of categorical variables were reported as odds ratios (ORs). In all cases, a P ≤ 0.05 was considered statistically significant.
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RESULTS

Rates and Type of Complications
The overall rate of complications in this group of 217 patients based on the modified classification was 42%: 14.7% severe and 27.3% minor complications. Twelve patients (5.5%) were found with complete flap losses and 15 patients (6.9%) with fistulas requiring additional major interventions prolonging the length of hospitalization. Additional complications were death in 2 patients due to multiorgan failures as a consequence of a sepsis and hemorrhagic shock, a myocardial infarct, and a superinfected hematoma (Table 3).
Table 3
Table 3
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Univariate Analysis of Factors Associated with Severe Complications
To identify variables significantly associated with the occurrence of severe complications, a univariate analysis was performed. This analysis returned the variables type of flap (P < 0.0001), ASA classification (P = 0.045), frequently versus less frequently performed flap (P < 0.0001), microscope use for the anastomosis (P = 0.039), surgeon (P = 0.024), high- versus low-volume surgeon (P = 0.007), and T-stage (P = 0.009) as significant (Table 4).
Table 4
Table 4
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Logistic Regression Analysis of Factors Associated with Severe Complications
To identify factors independently associated with the occurrence of severe complications, a binomial logistic regression model was created. The model returned 3 variables independently associated with the occurrence of severe complications. Those were frequently versus less frequently performed flap (OR = 3.2; confidence interval [CI] = 1.7–5.8; P < 0.001), high- versus low-volume surgeon (OR = 0.52; CI = 0.29–0.93; P = 0.007), and ASA classification (OR = 2.85; CI = 1.1–7.5; P = 0.045) (Fig. 2) (Table 4).
Fig. 2
Fig. 2
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Predictors of Length of Hospitalization
To identify predictors of a prolongation of hospitalization, a Cox-regression model using a forward likelihood ratio strategy was employed. The 4 variables retained in the model found to independently correlate with the length of hospitalization were T-stage (P = 0.001), complication status (P = 0.015), site of the reconstruction (P < 0.001), and surgeon (P = 0.011) (Table 5).
Table 5
Table 5
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DISCUSSION

Within this series of 217 patients, we found a total of 42% complications, of which 14.7% were severe and 27.3% minor. Although these numbers may seem initially quite high, they actually compare favorably with currently published literature on complications after free-flap procedures for the head and neck region. A previously published study on 185 patients reconstructed with free flaps for head and neck defects reports 53% overall complications and 40% severe complications,16 whereas a similar study on 304 patients reconstructed with similar techniques reports an overall complication rate of 32.5% and a severe complication rate of 20%.17 Although seemingly favorable, the rates of severe complications in this study need to be considered in the context of the modified CD classification that reports complications only as severe that are rather prolonging hospital stay. It is likely that if the original CD classification would have been used, the results would have been similar to the published literature. A severe complication rate of nearly 15%, which is also associated with a high risk of prolongation of the hospitalization, has to be considered seriously. It means that major efforts are needed to reduce this number, not only to improve the quality of treatment for our patients but also to reduce the costs that are associated with the prolongation of hospitalization.
It is interesting to compare this rate of severe complications with the chemoradiation literature. However, there are difficulties to be considered, comparing the Radiation Therapy Oncology Group acute toxicity rating with the modified CD classification. One could assume that a grade IV acute toxicity in a patient treated with chemoradiation likely results in a prolongation of the hospitalization and thus could be considered a severe complication, at least comparable with a surgical severe complication. Considering this, the reported rate of 15% severe complications in this study does not compare unfavorably with the reported incidence of grade IV acute toxicity of 18% in the chemoradiation group in the RTOG 99-11 trial.27
The multivariate analysis of severe complications in this study returned 3 variables to be independently associated. Although 1 variable (ASA classification) belonged to the group of the patient-related variables, the other 2 variables are volume-sensitive variables: high-volume surgeon versus low-volume surgeon and frequently versus less frequently performed flap. The 2 latter parameters could be interpreted as volume–outcome indicators. They show that a surgeon who performs fewer than 20 flaps a year should probably either try either to increase his/her activity or to quit this activity. They also show that within the armamentarium of a free-flap surgeon, rarely used flaps should be rather avoided, because if performed seem to bring an additional risk of complication with them. Again, the surgeon can choose to either increase the frequency of this rare flap or abandon it and choose a flap he/she is more acquainted with. In summary, this type of surgery should not be done “occasionally” by surgeons. A steady volume throughout the year should be maintained.
But the analysis of these data should trigger additional measures with regard to training young free-flap surgeons and surgeon–surgeon collaboration. Young head and neck surgeons, who start out doing free flaps in smaller volume centers, should probably be supervised by experienced surgeons throughout their gaining of independence. This period of surveillance could eventually last until a solid activity of >20 free flaps per year for the younger surgeon is achieved. Adequate selection of patients “appropriate” to be taken to surgery by the younger colleague should be made by the more experienced supervisor. Other measures to take into consideration consist of early surgical simulation/training for surgeons in microvascular free-flap procedures. This might include training of flap harvest on cadavers before the interventions and computer-based surgical simulations making use of “virtual reality” environments.
The multivariate analysis in this study on duration of hospitalization returned the parameters “T-stage,” “severe complication,” “surgeon,” and “site of reconstruction” as independent predictors. The influence of larger T-stage on duration of hospitalization can be easily explained by the fact that larger tumors require more demanding reconstructions and thus a longer hospitalization for rehabilitation. Severe complications are logically associated with prolonged hospitalization. In the comparison of sites, mandibular reconstructions had the worst outcome. It is of great interest to note that 1 of the 4 variables related to the length of hospitalization in this study is provider related; in other words, the surgeon who performs the procedure has an impact on the length of the hospitalization likely through the quality of the surgery provided.
In summary, we provide evidence that besides typical patient-related factors such as comorbidities, volume-related parameters such as the frequency with which a flap is performed and the activity of a surgeon impact the outcome of microvascular free-flap procedures.
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REFERENCES

1. Pierre CS, Dassonville O, Chamorey E, et al.Long-term functional outcomes and quality of life after oncologic surgery and microvascular reconstruction in patients with oral or oropharyngeal cancer.Acta Otolaryngol20141341086–1093

2. Urken ML, Cheney ML, Sullivan MJ, Biller HFAtlas of Regional and Free Flaps for Head and Neck Reconstruction19951st edNew YorkRaven Press

3. Gedebou TM, Wei FC, Lin CHClinical experience of 1284 free anterolateral thigh flaps.Handchir Mikrochir Plast Chir200234239–244

4. Bak M, Jacobson AS, Buchbinder D, et al.Contemporary reconstruction of the mandible.Oral Oncol20104671–76

5. Kansy K, Mueller AA, Mücke T, et al.DÖSAK Collaborative Group for Microsurgical ReconstructionMicrosurgical reconstruction of the head and neck–current concepts of maxillofacial surgery in Europe.J Craniomaxillofac Surg2014421610–1613

6. Li W, Xu Z, Liu F, et al.Vascularized free forearm flap versus free anterolateral thigh perforator flaps for reconstruction in patients with head and neck cancer: assessment of quality of life.Head Neck2013351808–1813

7. Lyons AJPerforator flaps in head and neck surgery.Int J Oral Maxillofac Surg200635199–207

8. Mäkitie AA, Beasley NJ, Neligan PC, et al.Head and neck reconstruction with anterolateral thigh flap.Otolaryngol Head Neck Surg2003129547–555

9. L’Heureux-Lebeau B, Odobescu A, Harris PG, et al.Chimaeric subscapular system free flap for complex oro-facial defects.J Plast Reconstr Aesthet Surg201366900–905

10. Holom GH, Seland H, Strandenes E, et al.Head and neck reconstruction using microsurgery: a 9-year retrospective study.Eur Arch Otorhinolaryngol20132702737–2743

11. Mizukami T, Hyodo I, Fukamizu H, et al.Reconstruction of lateral mandibular defect: a comparison of functional and aesthetic outcomes of bony reconstruction vs soft tissue reconstruction—long-term follow-up.Acta Otolaryngol20131331304–1310

12. Sandel HD IV, Davison SPMicrosurgical reconstruction for radiation necrosis: an evolving disease.J Reconstr Microsurg200723225–230

13. Bulut OC, Federspil PA, Plinkert PK, et al.[Reconstruction of maxillary defects using a free scapular angle flap].HNO201361321–326

14. Clark JR, Vesely M, Gilbert RScapular angle osteomyogenous flap in postmaxillectomy reconstruction: defect, reconstruction, shoulder function, and harvest technique.Head Neck20083010–20

15. Yu P, Lewin JS, Reece GP, et al.Comparison of clinical and functional outcomes and hospital costs following pharyngoesophageal reconstruction with the anterolateral thigh free flap versus the jejunal flap.Plast Reconstr Surg2006117968–974

16. Clark JR, McCluskey SA, Hall F, et al.Predictors of morbidity following free flap reconstruction for cancer of the head and neck.Head Neck2007291090–1101

17. le Nobel GJ, Higgins KM, Enepekides DJPredictors of complications of free flap reconstruction in head and neck surgery: analysis of 304 free flap reconstruction procedures.Laryngoscope20121221014–1019

18. Luryi AL, Chen MM, Mehra S, et al.Positive surgical margins in early stage oral cavity cancer: an analysis of 20,602 cases.Otolaryngol Head Neck Surg2014151984–990

19. Garden AS, Kies MS, Morrison WH, et al.Outcomes and patterns of care of patients with locally advanced oropharyngeal carcinoma treated in the early 21st century.Radiat Oncol2013821

20. Derogar M, Sadr-Azodi O, Johar A, et al.Hospital and surgeon volume in relation to survival after esophageal cancer surgery in a population-based study.J Clin Oncol201331551–557

21. Eskander A, Merdad M, Irish JC, et al.Volume-outcome associations in head and neck cancer treatment: a systematic review and meta-analysis.Head Neck2014361820–1834

22. Gourin CG, Forastiere AA, Sanguineti G, et al.Impact of surgeon and hospital volume on short-term outcomes and cost of laryngeal cancer surgical care.Laryngoscope201112185–90

23. Mulvey CL, Pronovost PJ, Gourin CGHospital volume and failure to rescue after head and neck cancer surgery.Otolaryngol Head Neck Surg2015152783–789

24. Lee CC, Ho HC, Chou PMultivariate analyses to assess the effect of surgeon volume on survival rate in oral cancer: a nationwide population-based study in Taiwan.Oral Oncol201046271–275

25. Clavien PA, Barkun J, de Oliveira ML, et al.The Clavien-Dindo classification of surgical complications: five-year experience.Ann Surg2009250187–196

26. Perisanidis C, Herberger B, Papadogeorgakis N, et al.Complications after free flap surgery: do we need a standardized classification of surgical complications?Br J Oral Maxillofac Surg201250113–118

27. Forastiere AA, Goepfert H, Maor M, et al.Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer.N Engl J Med20033492091–2098
Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.




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Tinnitus

1. Chadha NK, Gordon KA, James AL, Papsin BC. Tinnitus is prevalent in children with cochlear implants. International Journal of Pediatric Otorhinolaryngology. 2009;73:671-675. [abstract]

2. Akdogan O, Ozcan I, Ozbek C, Dere H. Tinnitus after cochlear implantation. Auris Nasus Larynx. 2009;36:210-212. [abstract]

3. Pan T, Tyler RS, Ji H, Coelho C, Gehringer AK, Gogel SA. Changes in the tinnitus handicap questionnaire after cochlear implantation. American Journal of Audiology. 2009;18:144-151. [abstract]

4. Andersson G, Freijd A, Baguley DM, Idrizbegovic E. Tinnitus distress, anxiety, depression, and hearing problems among cochlear implant patients with tinnitus. Journal of the American Academy of Audiology. 2009;20:315-319. [abstract]

5. Rothholtz VS, Tang Q, Wu EC, Fine EL, Djalilian H, Zeng F-G. Exploring the parametric space of tinnitus suppression in a patient with a cochlear implant. Laryngoscope. 2009;119.

6. Di NW, Cianfrone F, Scorpecci A, Cantore I, Giannantonio S, Paludetti G. Transtympanic electrical stimulation for immediate and long-term tinnitus suppression. International Tinnitus Journal. 2009;15:100-106.[abstract]

7. Litre CF, Theret E, Tran H et al. Surgical treatment by electrical stimulation of the auditory cortex for intractable tinnitus. Brain Stimulation. 2009;2:132-137. [abstract]

8. Evans RW, Ishiyama G. Migraine with transient unilateral hearing loss and tinnitus. Headache: The Journal of Head & Face Pain. 2009;49:756-759. [abstract]

9. Pirodda A, Brandolini C, Raimondi MC, Ferri GG, Borghi C. Tinnitus as a warning for preventing vasovagal syncope. Medical Hypotheses. 2009;73:370-371. [abstract]

10. Anderson JE, Teitel D, Wu YW. Venous hum causing tinnitus: case report and review of the literature. Clinical Pediatrics. 2009;48:87-89. [abstract]

11. Liess BD, Lollar KW, Christiansen SG, Vaslow D. Pulsatile tinnitus: a harbinger of a greater ill? Head & Neck. 2009;31:269-273. [abstract]

12. Singh DP, Forte AJ, Brewer MB, Nowygrod R. Bilateral carotid endarterectomy as treatment of vascular pulsatile tinnitus. Journal of Vascular Surgery. 2009;50:183-185. [abstract]

13. Delgado F, Munoz F, Bravo-Rodriguez F, Jurado-Ramos A, Oteros R. Treatment of dural arteriovenous fistulas presenting as pulsatile tinnitus. Otology and Neurotology. 2009;30:897-902. [abstract]

14. Cowley PO, Jones R, Tuch P, McAuliffe W. Pulsatile tinnitus from reversal of flow in an aberrant occipital artery: Resolved after carotid artery stenting. American Journal of Neuroradiology. 2009;30:995-997. [abstract]

15. Stimmer H, Borrmann A, Loer C, Arnold W, Rummeny EJ. Monaural tinnitus from a contralateral inferior colliculus hemorrhage. Audiology & Neurotology. 2009;14:35-38. [abstract]

16. Latifpour DH, Grenner J, Sjodahl C. The effect of a new treatment based on somatosensory stimulation in a group of patients with somatically related tinnitus. International Tinnitus Journal. 2009;15:94-99. [abstract]

17. Department of Health. Provision of services for adults with tinnitus: a good practice guide. 2009. [full text]

18. DH. Tinnitus Map of Medicine care pathway. 2010. [Full text]

19. BTA. Tinnitus: guidelines for primary care. 2010. [Full text]

20. Schneider P, Andermann M, Wengenroth M et al. Reduced volume of Heschl's gyrus in tinnitus. NeuroImage. 2009;45:927-939. [abstract]

21. Landgrebe M, Langguth B, Rosengarth K et al. Structural brain changes in tinnitus: grey matter decrease in auditory and non-auditory brain areas. NeuroImage. 2009;46:213-218. [abstract]

22. Melcher JR, Levine RA, Bergevin C, Norris B. The auditory midbrain of people with tinnitus: Abnormal sound-evoked activity revisited. Hearing Research. 2009;257:63-74. [abstract]

23. Lanting CP, de KE, van DP. Neural activity underlying tinnitus generation: Results from PET and fMRI. Hearing Research. 2009;255:1-13. [abstract]

24. Kaltenbach JA. Insights on the origins of tinnitus: an overview of recent research. Hearing Journal. 2009;62:26-31. [Full text]

25. Shulman A, Goldstein B, Strashun AM. Final common pathway for tinnitus: theoretical and clinical implications of neuroanatomical substrates. International Tinnitus Journal. 2009;15:5-50. [abstract]

26. Schutte NS, Noble W, Malouff JM, Bhullar N. Evaluation of a model of distress related to tinnitus. International Journal of Audiology. 2009;48:428-432. [abstract]

27. Hesser H, Pereswetoff-Morath CE, Andersson G. Consequences of controlling background sounds: the effect of experiential avoidance on tinnitus interference. Rehabilitation Psychology. 2009;54:381-390.[abstract]

28. Argstatter H, Krick C, Bolay HV. Music therapy for chronic tinnitus. Heidelberg treatment model. Psychotherapeut. 2009;54:17-26. [abstract]

29. Lugli M, Romani R, Ponzi S, Bacciu S, Parmigiani S. The windowed sound therapy: A new empirical approach for an effective personalized treatment of tinnitus. International Tinnitus Journal. 2009;15:51-61.[abstract]

30. Langguth B, Salvi R, Elgoyhen AB. Emerging pharmacotherapy of tinnitus. Expert Opinion on Emerging Drugs. 2009;14:687-702. [abstract]

31. Campbell KCM. Emerging pharmacologic treatments for hearing loss and tinnitus. ASHA Leader. 2009;14:14-18. [Full text]

32. Hesser H, Westin V, Hayes SC, Andersson G. Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress. Behaviour Research & Therapy. 2009;47:523-528. [abstract]

33. Hesser H, Andersson G. The role of anxiety sensitivity and behavioral avoidance in tinnitus disability. International Journal of Audiology. 2009;48:295-299. [abstract]

34. Shulman A, Goldstein B. Subjective idiopathic tinnitus and palliative care: a plan for diagnosis and treatment. Otolaryngologic Clinics of North America. 2009;42:15-38. [abstract]

35. Forti S, Costanzo S, Crocetti A, Pignataro L, Del BL, Ambrosetti U. Are results of tinnitus retraining therapy maintained over time? 18-month follow-up after completion of therapy. Audiology & Neuro-Otology. 2009;14:286-289. [abstract]

36. Bessman P, Heider T, Watten VP, Watten RG. The tinnitus intensive therapy habituation program: a 2-year follow-up pilot study on subjective tinnitus. Rehabilitation Psychology. 2009;54:133-138. [abstract]

37. Gudex C, Skellgaard PH, West T, Sorensen J. Effectiveness of a tinnitus management programme: A 2-year follow-up study. BMC Ear, Nose and Throat Disorders. 2009;9. [Full text]

38. Henry J, Zaugg T, Myers P, Kendall C, Turbin M. Principles and application of educational counseling used in progressive audiologic tinnitus management. Noise and Health. 2009;11:33-48. [abstract]

1. Hazell JW, Jastreboff PJ. Tinnitus. I: Auditory mechanisms: a model for tinnitus and hearing impairment. J Otolaryngol. 1990;19:1-5. [Abstract]

2. Jastreboff PJ, Jastreboff MM. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol. 2000 Mar;11(3):162-77. [Abstract]

3. Marcondes RA, Sanchez TG, Kii MA, Langguth et al. Repetitive transcranial magnetic stimulation improve tinnitus in normal hearing patients: a double-blind controlled, clinical and neuroimaging outcome study. Eur J Neurol. 2009. [Epub ahead of print] ) [Abstract]

4. Cannon SC Pathomechanisms in channelopathies of skeletal muscle and brain. Annu Rev Neurosci. 2006;29:387-415. [Abstract]

5. Davies E, Knox E, Donaldson I. The usefulness of nimodipine, an L-calcium channel antagonist, in the treatment of tinnitus. Br J Audiol. 1994;28:125-129. [Abstract]

6. Baguley DM, Jones S, Wilkins I, Axon PR, Moffat DA. The inhibitory effect of intravenous lidocaine infusion on tinnitus after translabyrinthine removal of vestibular schwannoma: a double-blind, placebo-controlled, crossover study. Otol Neurotol. 2005;26:169-176. [Abstract]

Eggermont JJ. Cortical tonotopic map reorganization and its implications for treatment of tinnitus. Acta Otolaryngol Suppl. 2006;9-12. [Abstract]

Hoke ES, Muhlnickel W, Ross B, Hoke M. Tinnitus and event-related activity of the auditory cortex. Audiol Neurootol. 1998;3:300-331. [Abstract]

Mirz F, Pedersen B, Ishizu K et al. Positron emission tomography of cortical centers of tinnitus. Hear Res. 1999;134:133-144. [Abstract]

Muhlnickel W, Elbert T, Taub E, Flor H. Reorganization of auditory cortex in tinnitus. Proc Natl Acad Sci U S A. 1998;95:10340-10343. [Abstract]

Norena AJ, Eggermont JJ. Enriched acoustic environment after noise trauma abolishes neural signs of tinnitus. Neuroreport. 2006;17:559-563. [Abstract]

Schlee W, Hartmann T, Langguth B, Weisz N. Abnormal resting-state cortical coupling in chronic tinnitus. BMC Neurosci. 2009;10:11. [Full text]

Schlee W, Mueller N, Hartmann T, Keil J, Lorenz I, Weisz N. Mapping cortical hubs in tinnitus. BMC Biol. 2009;7:80. [Full text]

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HIPPOCRATE'S OATH

"I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessaryto cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."

MAIMONIDE'S PRAYER

"Almighty God, Thou has created the human body with infinite wisdom. Ten thousand times ten thousand organs hast Thou combined in it that act unceasingly and harmoniously to preserve the whole in all its beauty the body which is the envelope of the immortal soul. They are ever acting in perfect order, agreement and accord. Yet, when the frailty of matter or the unbridling of passions deranges this order or interrupts this accord, then forces clash and the body crumbles into the primal dust from which it came. Thou sendest to man diseases as beneficent messengers to foretell approaching danger and to urge him to avert it.

"Thou has blest Thine earth, Thy rivers and Thy mountains with healing substances; they enable Thy creatures to alleviate their sufferings and to heal their illnesses. Thou hast endowed man with the wisdom to relieve the suffering of his brother, to recognize his disorders, to extract the healing substances, to discover their powers and to prepare and to apply them to suit every ill. In Thine Eternal Providence Thou hast chosen me to watch over the life and health of Thy creatures. I am now about to apply myself to the duties of my profession. Support me, Almighty God, in these great labors that they may benefit mankind, for without Thy help not even the least thing will succeed.

"Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent- minded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures.

"Grant that my patients have confidence in me and my art and follow my directions and my counsel. Remove from their midst all charlatans and the whole host of officious relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our art and often lead Thy creatures to their death.

"Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of our art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard for age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death.

"Imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of advantage to me, for they know many things of which I am ignorant, but let not their arrogance give me pain. For they are old and old age is not master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God!

"Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding.

"Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed."

Information for Health Professionals

Information for Patients

Modern challenged parts of the oath:

  1. To teach medicine to the sons of my teacher. In the past, medical schools gave preferential consideration to the children of physicians.
  2. To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them. This beneficial intention is the purpose of the physician. However, this item is still invoked in the modern discussions of euthanasia.
  3. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan. Physician organizations in most countries have strongly denounced physician participation in legal executions. However, in a small number of cases, most notably the U.S. states of Oregon,[10] Washington,[11]Montana,[12] and in the Kingdom of the Netherlands,[13] a doctor can prescribe euthanasia with the patient's consent.
  4. Similarly, I will not give a woman a pessary to cause an abortion. Since the legalization of abortion in many countries, the inclusion of the anti-abortion sentence of the Hippocratic oath has been a source of contention.
  5. To avoid violating the morals of my community. Many licensing agencies will revoke a physician's license for offending the morals of the community ("moral turpitude").
  6. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. The "stones" referred to are kidney stones or bladder stones, removal of which was judged too menial for physicians, and therefore was left for barbers (the forerunners of modern surgeons). Surgery was not recognized as a specialty at that time. This sentence is now interpreted as acknowledging that it is impossible for any single physician to maintain expertise in all areas. It also highlights the different historical origins of the surgeon and the physician.
  7. To keep the good of the patient as the highest priority. There may be other conflicting 'good purposes,' such as community welfare, conserving economic resources, supporting the criminal justice system, or simply making money for the physician or his employer that provide recurring challenges to physicians
http://www.worldallergy.org/educational_programs/world_allergy_forum/barcelona2008/rabe/

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