This thesis presents six studies concerned with the psychological status of people with audiological disorders, particularly tinnitus and hearing loss. Study One (Part I of the thesis) employed a structured interview and the General Health Questionnaire to investigate the emotional status of subjects with a variety of audiological symptoms. Psychological disorder was found to be more prevalent among subjects complaining of vertigo (64%) than among those complaining of tinnitus (45%); the prevalence of psychological disorder among subjects complaining of hearing loss was lower than among tinnitus subjects (27%). A higher prevalence of disturbance was found among subjects with multiple symptoms. A previous history of psychological distress correlated with current ratings of disturbance. Studies Two and Three (Part II) are concerned with the psychology of cochlear implantation. Methodological issues concerning psychological assessment in this context are discussed. Study Two uses Repertory Grid Technique to assess the psychological consequences of using an implant. Eight out of ten subjects reported important changes in psychological well-being related to their use of the device. Study Three identifies a group of subjects applying for an implant while having a non-organic hearing loss. The implications for the use of standardised assessment procedures are discussed. Studies Four, Five and Six (Part III) assess the cognitive functioning of subjects with tinnitus. Tinnitus subjects' performance on neuropsychological tests is compared with that of hearing impaired control subjects. Subjects were also assessed using the Cognitive Failures Questionnaire (CFQ). The emotional status of the subjects was assessed using the Speilberger State-Trait Anxiety Inventory. The Beck Depression Inventory was also used in Study Six. The groups were not distinguished by a number of neuropsychological tests, however it was found, in Studies Four and Five, that Tinnitus subjects' performance on verbal fluency tests was Significantly poorer than the Control subjects, after hearing loss was controlled for. In Study Six it was found that both Tinnitus and Control subjects performed less well than expected on the STROOP test; this was more apparent in the Tinnitus group. The Tinnitus group also obtained higher CFQ scores in Studies Four and Five. Trait anxiety was a feature of the Tinnitus groups. The implications for the cognitive functioning of both tinnitus and hearing impaired subjects are discussed in terms of Baddeley's model of working memory. The importance of these findings for complaint about tinnitus and hearing loss are considered.

Background to the study: Cochlear implants (CI) can help to suppress tinnitus and often make existing tinnitus more bearable. However, a number of patients still suffer from tinnitus afterwards. In some cases the implantation makes existing tinnitus worse, or tinnitus may occur as a result of cochlear implantation. Because of the inconclusive aetiology of tinnitus it is difficult to treat its effects. So far, one of the most popular treatments for tinnitus is the widely used Cognitive Behavioural Therapy (CBT), which aims to influence dysfunctional emotions, behaviours and cognitions though a goal-orientated, systematic procedure. CBT aims to minimize the side-effects of tinnitus and help to manage it in a more efficient way. CBT has been investigated in several studies and shows promising results in reducing the debilitating effect of tinnitus. CBT has not yet been used specifically for, or investigated in, relation to treating CI users suffering from tinnitus. Aims and outline of the study: Our research aimed to investigate CBT’s effectiveness for cochlear implant users. Using a randomized control trial, we investigated whether two-hour Tinnitus Workshops for the control group were as equally as effective as CBT for the research group. We also explored if either type of treatment for cochlear implant users needed any modifications to make them more suitable for this group of tinnitus sufferers. Using Open Questions, we investigated tinnitus in cochlear implant users. We analysed the Open Questions from both groups, creating a profile of a typical cochlear implant user who suffers from tinnitus, and we also explored whether both interventions (Tinnitus Workshop or CBT) were suitable for this kind of patient. Data was gathered, pre- and post-interventions, by questionnaires; these were Tinnitus Questionnaires (TQ), Visual Analogue Scale (VAS), Quality of Life Short Form 36 Health Survey (SF-36) and Hospital Anxiety and Depression Scale (HADS). Results: In the control group, we found no significant differences between the TQ scores pre- and post-intervention. VAS scores post-intervention were lower than pre-intervention, indicating some improvement in individual tinnitus perception; however, the difference was not significant. In the research group, we found small, but not significant, differences in both TQ pre- and post-intervention (z =1.83, p>.05) and in VAS (z=0.14, p>.05). No significant differences were found between the control and the research group pre- and post-intervention. Conclusions: The questionnaires used in this study, such as TQ or VAS, showed a decrease in general tinnitus distress, but a larger-sized sample group may be needed for greater statistical certainty. The results from the Open Questions showed that cochlear implant users were affected by tinnitus in a similar way to non-cochlear implant users. Overall, both interventions need further, small modifications and adjustments to their protocols in order to be more effective for this type of tinnitus sufferer.

Evoked otoacoustic emissions (EOAEs) are produced by the cochlea and provide an objective and non-invasive measure of cochlear function. A new technique, based on Maximum Length Sequences (MLSs) enables stimulus rates of up to 5000 clicks/s to be used, and gives increased speed and sensitivity of testing. Volterra slice otoacoustic emissions (VSOAEs) can be extracted from the response using this technique. These represent nonlinear temporal interaction components and are more sensitive to changes in cochlear pathology than the conventional response. Conventional EOAE amplitude differs between ears and sexes; female subjects having responses of greater amplitude than male subjects and right ears larger responses than left ears. As a pre-requisite to clinical use it is necessary to establish if these differences occur with the Maximum length sequence otoacoustic (MLSOAE) technique and with VSOAEs and whether they change with stimulus rate, order or slice. The relationship between VSOAEs, Spontaneous otoacoustic emissions (SOAEs), Distortion product otoacoustic emissions (DPOAEs) and the input/output function (I/O) for click-evoked OAEs (CEOAEs) recorded at the conventional rate (40 clicks/s) was also investigated to assess if these measures of cochlear nonlinearity were related to one another. In the first set of experiments 80 ears of normally hearing adults were tested. MLSOAEs were recorded at eight stimulus rates and two stimulus levels. For the second and third experiments 45 ears of normally hearing adults were tested. SOAEs, DPOAEs, the input/output function (I/O) for CEOAEs at the conventional rate (40 clicks/s) and at four stimulus levels, and VSOAEs at three stimulus rates were recorded. Female subjects were found to have statistically significantly larger MLSOAEs than male subjects and gave larger amplitude responses in their right ears. This sex difference was observed with VSOAEs. A rate effect was also demonstrated with the amplitude of the MLSOAEs decreasing with an increase in rate. The VSOAE amplitude was greater for the second order compared with the third order response, and slice one had a greater amplitude than slice two. VSOAEs of higher amplitude were obtained in SOAE-positive ears. There was a significant relationship between the slope of the I/O function of the CEOAE and the VSOAEs. The study has provided normative data for MLSOAE testing and for VSOAEs. The data obtained suggest that the amplitude (CEOAE I/O function) and temporal (VSOAEs) nonlinearities arise from the same generators, whereas the frequency domain nonlinearities (SOAEs & DPOAEs) have different generators. MLSOAEs and VSOAEs have great potential for clinical use.

Laryngeal cancer affects tens of thousands worldwide every year. The standard of care of surgical resection, chemotherapy, and/or radiation therapy results in significant quality of life deficits including reliance on tracheostomy tubes, loss of voice, and inability to swallow. There are no therapeutic options that restore a functional larynx so that patients can live a more normal life. Laryngeal reconstruction using tissue engineering strategies offers the potential to solve this problem. Laryngeal anatomy is complex with multiple tissue types and therefore engineering approaches require consideration of a multi-layer, interfacial tissue design. Our strategy to overcome these challenges involves the use of advanced bio fabrication techniques where type I oligomeric collagen alone or in the presence of autologous stem cells is used to custom-make the cartilage, skeletal muscle, and mucosal layer of the larynx. This doctoral research project begins by describing the development of the tissue engineered skeletal muscle with aligned collagen matrix and autologous muscle progenitor cells induced to express motor endplates. Next, using this engineered muscle plus the cartilage layer developed by a colleague; we implanted the myochondral engineered construct in a rat hemilaryngectomy model. In this study we saw host-implant integration with no inflammatory foreign body response, neo cartilage and muscle formation, and some return of laryngeal function on the reconstructed side. Next, we worked to scale-up these technologies for use in a porcine model. The pig larynx is more similar in size and function to the human larynx and allows for a full thickness defect to be created. Using confined compression, we created 4-mm thick acellular and cellular cartilage constructs, as well as a 0.5-mm thick acellular mucosal layer. A 1-cm diameter muscle layer containing autologous muscle progenitor cells was created using flow alignment and cultured to induce expression of motor endplates before implantation. Tissue constructs were subjected to mechanical property analyses as well as PCR analysis to describe the differential gene expression by component cells within muscle and cartilage constructs. Each layer was individually sutured into a pig hemilaryngectomy model. The pigs recovered well from the surgery, were eating, had no difficulty breathing, and no aspiration events. At 2 months, respiratory epithelium had completely healed over the implant and was vascularized and had areas of submucosal gland growth. The motor endplate expressing muscle implants showed new, organized muscle ingrowth while the acellular implants showed a relative paucity of new, disorganized muscle. This work represents a significant advancement in the field of laryngeal reconstruction and is a first of its kind to use scalable tissue engineering technologies designed to specifically meet each layer’s functional criteria.

The main aim of this thesis was to evaluate the effect of prednisolone and valaciclovir in a large number of Bell's palsy patients. The incidence and intensity of pain around the ear, in the face or in the neck during the first two months of palsy, and its prognostic value, was also assessed. We also investigated how study design and choice of analysis method affect the rate of facial recovery. Furthermore, the agreement between the Sunnybrook, House-Brackmann and Yanagihara facial grading systems was evaluated. From May 2001 to September 2007, a prospective, randomised, double-blind, placebo-controlled, multicentre trial with 12-month follow-up was performed in patients with Bell's palsy. Of 839 randomised patients, 829 were included in the intention-to-treat analysis; 206 received placebo plus placebo, 210 prednisolone plus placebo, 207 valaciclovir plus placebo, and 206 prednisolone plus valaciclovir. Time to recovery was significantly shorter in the 416 patients who received prednisolone compared with the 413 who did not (p<0.0001). At 12 months, 300 of 416 patients (72%) in the prednisolone group had recovered compared with 237 of 413 patients (57%) in the no prednisolone group (p<0.0001). Valaciclovir was not found to affect time to facial recovery or outcome at 12 months. Prednisolone and/or valaciclovir did not affect the incidence or intensity of pain. Presence of pain at day 11 to 17 indicated a worse prognosis for facial recovery at 12 months. We also found that recovery rates in a Bell's palsy trial are substantially affected by the choice of analysis method and definition of facial recovery. We used weighted Kappa statistics in 100 examinations of patients with facial palsy to assess the agreement between the Sunnybrook, House-Brackmann and Yanagihara scales. The highest agreement was found between the regional Sunnybrook and Yanagihara scales. An evaluative difference between the Sunnybrook and House-Brackmann systems was observed.

No description available.

Sammanfattning Bakgrund Ett välfungerande samarbete mellan vårdpersonal och tolk är en förutsättning för en jämlik och rättssäker vård. Området logopedi är utmanande för tolkar eftersom översättningen ofta blir en del av den kliniska bedömningen. Tidigare studier har visat att utmaningar i ett logoped-tolk samarbete innefattar otydlig rollfördelning, tidsbrist och avsaknad av rutiner. Det har även framkommit osäkerheter kring hur exakt översättningen blir när tolken medlar. Dessvärre saknas svenska studier som kartlägger vad som skulle krävas för att uppnå ett optimalt samarbete mellan tolk och logoped i Sverige. Syfte Syftet med föreliggande studie var att synliggöra logopedens erfarenheter, känslor och attityder till tolksamarbete. Författarnas förhoppning var att lyfta fram såväl framgångsfaktorer som utmaningar och kartlägga logopedens syn på vad som krävs för ett optimalt samarbete. Metod Huvudsaklig metod utgjordes av två fokusgruppsintervjuer. Utifrån de fynd som framkom från intervjuerna utformades en webbenkät. Syftet med webbenkäten var att undersöka ifall de åsikter som framkommit under fokusgruppsintervjuerna delades av andra logopederrunt om i landet. Sammanlagt medverkade 79 deltagare, varav 9 i fokusgrupperna. Resultat De främsta utmaningarna som identifierades i studien var tidsbrist, att få tag på tolkar med tillräcklig kompetens, brister rutinerna samt osäkerheter kring hur precis översättningen blir. Samtidigt beskrevs tolksamarbeten som både underlättande och positivt av många deltagare. För att skapa ett så gynnsamt samarbete som möjligt föreslår studiens deltagare tydligare riktlinjer, tillgång till fler tolkar med erfarenheter av logopedsamarbete, samt att det ska finnas färdiga instruktioner och dokument att förbereda tolken med. Lättare tillgång till utbildade och auktoriserade tolkar uttrycktes även från flertal deltagare. Slutsats Svenska logopeder beskriver samarbetet med tolk som viktigt, givande och ytterstnödvändigt, men samtidigt även som svårt och tidskrävande. Många uttrycker oro inför hur tillförlitlig och högkvalitativ patientbesöken blir när tolk är involverad. Logopederna i denna studie påpekar flera förbättringsförslag vad gäller tillvägagångssätt samt rutiner och riktlinjer som skulle kunna höja kvaliteten på samarbetet mellan logoped och tolk. Ytterligare studier krävs för att undersöka hur förbättringsförslagen ska implementeras iden logopediska verksamheten.

Demenssjukdom innebär en progressiv nedsättning i kognitiva funktioner som språk, minne och exekutiva funktioner. I takt med det progredierande sjukdomsförloppet ökar kommunikationssvårigheterna hos personer med demens, vilket kan leda till försämrad livskvalitet. Gruppaktiviteter och kognitiv stimulans anses gynna livskvalitén hos personer med demens. Samtalsstöd som är baserade på reminiscensterapi kan underlätta för personer med demens att delta i samtal. Informations- och kommunikationsteknik har visat positiva resultat i relation till kommunikation vid demenssjukdom. Personer med demens har i tidigare studier uppvisat svårigheter avseende initiativtagande i kommunikativa situationer, vilket motiverar föreliggande studie.   Föreliggande studie syftade till att bidra med kunskap gällande om och hur personer med demens under gruppsamtal tar kommunikativa initiativ genom att ställa frågor. Fyra personer med demenssjukdom rekryterades på ett demensboende. Gruppsessionerna utgjordes av åtta samtalstillfällen, fyra med CIRCUS och fyra med icke-teknologiskt samtalsstöd. Materialet omfattade totalt 6 timmar 39 minuter och 50 sekunder. Analysen bestod av en kartläggning av interaktionsfenomenen inkluderande frågor, ämnesinitierande frågor och samtalsutvecklande frågor. Samtalsföreteelserna fintranskriberades och analyserades utifrån samtalsanalytiska principer. Intervjuer genomfördes för att kartlägga deltagarnas upplevelser av samtalssessionerna.   Resultatet visade att personer med demenssjukdom under gruppsamtal med CIRCUS och icketeknologiskt samtalsstöd aktivt tar kommunikativa initiativ i form av frågor i interaktionen med varandra. Det underlättade för personerna med demens att föra samtal med mer personligt innehåll och självständigt delta i samtalen då CIRCUS användes. Deltagarna uppskattade samtalssessionerna och att samtala utifrån de personliga fotografierna, men också den sociala interaktionen som uppstod i samtalen kring fotografierna från det gemensamma boendet. Till skillnad från tidigare studier indikerar föreliggande studie att personer med demens självständigt kan ta kommunikativa initiativ under gruppsamtal. Föreliggande studie indikerar även att både generiskt och personligt reminiscensmaterial kan utgöra ett stöd för personer med demens att självständigt delta i gruppsamtal. Det finns begränsad forskning om hur personer med demens tar kommunikativa initiativ i form av frågor i social interaktion varför ett behov av vidare forskning föreligger. Föreliggande studie indikerar att CIRCUS har god potential att användas som gruppintervention för personer med demens för att stimulera till samtal om deras liv och personliga erfarenheter, vilket skulle kunna främja livskvaliteten hos personer med demens. / Dementia means a progressive deficit in cognitive functions such as language, memory and executive functions. As the disease progresses the communication difficulties for people with dementia increases, which can lead to impaired quality of life. Group activities and cognitive stimulation is beneficial to the quality of life for people with dementia. Conversation support based on reminiscence therapy can help people with dementia to participate in conversations. Information and communication technology have shown positive results in relation to communication in dementia. In previous studies, people with dementia have shown difficulties regarding initiation in communicative situations, which justifies the present study. The present study aimed to contribute with knowledge regarding whether and how people with dementia take communicative initiatives by asking questions during group conversations. Four people with dementia were recruited in a dementia residence. The group sessions consisted of eight conversation sessions, four with CIRCUS and four with non-technological conversation support. The material consisted of a total of 6 hours 39 minutes and 50 seconds. The analysis consisted of a mapping of the interactional phenomena which consisted of including questions, topic-initiating questions and conversation-elaborating questions. The conversation phenomena were transcribed and analysed on the basis of conversation analytic principles. Interviews were conducted to map the participants' experiences of the conversation sessions. The results showed that people with dementia actively take communicative initiatives in the form of questions in the interaction with each other during group conversations with CIRCUS and with non-technological conversation support. The sessions with CIRCUS made it easier for people with dementia to hold conversations with more personal content and to independently participate in the conversations. The participants appreciated the conversation sessions and to talk based on the personal photographs, but also the social interaction that arose in the conversations about the photographs from the common accommodation. Unlike previous studies, the present study indicates that people with dementia independently can take communicative initiatives during group conversations. The present study indicates that both generic and personal reminiscence material can support people with dementia to independently participate in group discussions. There is limited research on how people with dementia take communicative initiatives in the form of questions in social interaction, why a need for further research exists. The present study indicates that CIRCUS has good potential to be used as a group intervention for people with dementia to stimulate conversation about people with dementia's life and personal experiences, which could promote the quality of life for people with dementia.

Head and neck cancer is a heterogeneous group of tumours, of which certain subgroups such as cancer of the mobile tongue frequently are associated with a relatively poor prognosis due to the high risk of regional failure and mortality rates that haven’t improved in a significant way over the last 3 decades, despite advancements in both diagnostics and treatment. Today we lack means to assess the biological aggressiveness of each individual tumour, which varies largely. Treatment comprises of surgery with additional radiotherapy and medical therapies in more advanced tumours. The focus in this thesis is on molecular biomarker expression in head and neck cancer and especially in association with radiotherapy. Increased knowledge paves the way to a more individualized cancer treatment aiming for better outcome and less overtreatment and sequelae. The aims of this thesis was: To map the effects of radiotherapy in both tumour and adjacent tissue for the possible markers hyaluronan, EGFR and mast cells. To investigate whether the expression of hyaluronan in the epithelium and connective tissue stroma and EGFR in the tumour correlates with the risk for developing cervical metastasis in N0 patients, and to find out whether the 3-year tumour-specific survival rates correlates with the expression of HA in the epithelium and EGFR in the tumour. To establish an animal model for radiation-induced mucositis and to use that model to examine the pattern of invading inflammatory cells. To investigate whether the expression of podoplanin in tongue cancer correlates with the risk for cervical metastasis and to determine whether the total amount of lymph vessels in the diagnostic biopsy has any impact on the clinical outcome. To investigate the differences in the metabolome of tongue cancer cell lines with different radiosensitivity. The most important findings of this thesis were: The expression of EGFR and hyaluronan hade the same pattern of expression in both tumour and adjacent tissues before radiotherapy. The expression of EGFR was increased in the epithelium of the adjacent tissue close to the tumour after radiotherapy. The intensity of the staining of hyaluronan was correlated to the 3-year survival rates in patients with tongue cancer. An experimental model for radiation-induced oral mucositis in rat was established and in this model a temporal pattern of macrophage invasion with two different subtypes of macrophages was found. There were no correlation between the expression of podoplanin in the tumour tissue and the cervical metastasis rate in patients with tongue cancer, but the younger patients were more likely to have a higher expression of podoplanin in their tumour than elder patients. Tongue cancer cell lines with different radiosensitivity respond to irradiation with different patterns of metabolic expressions.

<p><b>Aims</b></p><p>The aims of the thesis were to validate investigation instruments for stroke patients with dysphagia, and to improve oropharyngeal dysphagia therapies.</p><p><b>Methods/Results</b></p><p>A Lip Force Meter, LF 100, affirmed excellent intra- and inter-reliability, sensitivity and specificity. Controls had significantly stronger lip force (LF) and swallowing capacity (SC) than stroke patients. A normal lower limit of LF was set to 15 Newton. Dysphagia symptoms improved in 7 stroke patients after a 5-week sensorimotor stimulation therapy comprising manual body and facial regulation in combination with palatal plate application. Impaired LF and impaired SC were parallel phenomena in 22 acute stroke patients and did not differ regardless of presence or absence of facial palsy. LF and SC improved and were parallel phenomena in 30 stroke patients and did not differ regardless of presence or absence of facial palsy, time lag between stroke attack and start of treatment, or age. SC was normalized in 19 of 30 dysphagia patients after a 5-8-week daily lip muscle self-training with an oral screen. </p><p><b>Conclusions</b></p><p>LF100 is an appropriate and reliable instrument for measuring lip force. Dysphagia improvement, by body and facial sensorimotor stimulation in combination with palatal plate application, or by training with an oral screen is excellent examples of brain plasticity and cortical reorganisation. . Swallowing capacity and lip force in stroke patients are parallel phenomena. A sub clinical facial paresis seems to be present in most stroke patients. Training with an oral screen can improve LF and SC in stroke patients with oropharyngeal dysphagia. </p>