Recently, EAONO/JOS's joint consensus paper on definitions, classification, and staging of middle ear cholesteatoma was published 1 .As it is the era of collection of and report on uniform and comparable data, this is a welcome consensus statement. Currently, we are setting up a new nationwide multicenter study in the Netherlands, entitled Dutch Cholesteatoma Data, in which we would like to implement this guideline. To inform colleagues about our local experiences and choices so far, we are writing this letter.Although the EAONO/JOS consensus statements are clearly presented, we encountered some difficulties with the classification. First, we believe that the divisions of the middle ear space need further specifications. The anatomical sites as presented in the figure and the text of the consensus statements 1 can be variously interpreted and show some "blank spots. " For instance, the borders used for the anterior epitympanic space are unclear, which, in addition to the variation in anatomy and exposition in this area (canal wall up, canal wall down, microscopic, and endoscopic), will most likely result in a non-uniform registration. Second, we strongly believe that there is a primary need to elaborate on the classification rather than simplify it with a staging system. Gathering classification data on extent, complication, and ossicular state, using an easy format will make it possible to monitor surgical outcomes. This will allow comparisons of data among different hospitals, publications, and classifications. When large numbers of data on outcomes in relation to classification become available, results can be used to propose different stages. To improve the practical applicability of the EAONO/JOS joint statement in our national study, we have proposed to our participating ENT surgeons the following modifications:1. The borders of divisions of the middle ear and mastoid are further defined, and consequently, the figure of the consensus paper is refined [1] . In the EAONO/JOS consensus statement, the middle ear and mastoid spaces are divided into four sites to classify the extent of the cholesteatoma: difficult access sites (S), tympanic cavity (T), attic (A), and mastoid and antrum (M). The difficult access sites (S) further include S1 (the supratubal recess) and S2 (the sinus tympani). We propose to define the anatomical divisions of the middle ear and mastoid in more detail using surgical and anatomical landmarks. These landmarks based on a selection of published papers on this topic are highly likely to be identified both on CT scans and during all types of surgical approaches and are thus less prone to various interpretations [2][3][4] . Table 1 summarizes our suggestions for further specification of borders between the different sites of the middle ear and mastoid. In addition, Figure 1 shows the updated illustration based on those refined borders.An advantage of a more detailed description of these borders can be illustrated by the following examples that describe the difference between A and S1 ant...

Audiometric improvement does not necessarily mean an improvement in perceived sound and vice versa. But the audiometric outcome is significantly related to the patient's experienced handicap, benefit of the operation, residual difficulty, and overall satisfaction.

Background: In laryngectomized patients, tracheoesophageal voice generally provides a better voice quality than esophageal voice. Understanding the aerodynamics of voice production in patients with a voice prosthesis is important for optimizing prosthetic designs and successful voice rehabilitation. Objectives: To measure the aerodynamics and sound intensity in tracheoesophageal voice production. Study Design and Methods: We built a special setup, which consisted of a Pentium 200 MHz computer with an AD-DA interface card and Labview 4.01 software. In an oral/nasal mask we constructed several mass flow sensors and a microphone. This measured both the oral airflow and the level of sound. For the measurement of endotracheal pressure, which is the driving force behind the airflow, we used a transducer which was connected to the tracheostoma. The endoesophageal pressure was measured at the level of the prosthesis in the esophagus by a Mikrotip transducer. Using this we could determine how much the voice prosthesis contributes to the overall pressure drop of the phonatory tract. Furthermore, the average airflow rate as a function of the sound pressure levels could be determined. Results: In our population, 6 out of 7 patients showed a positive relationship between trans-source airflow and generated sound intensity. We compared our prosthesis pressure drop values with in vitro data and found that there are some differences, possibly due to difference in age of the prosthesis and physiological circumstances in vivo. The overall contribution of the voice prosthesis to the airway resistance depends on the level of phonation and the type of device. In our patient group it is apparent that the pharyngoesophageal (PE) segment has the greatest share of the total pressure drop, especially at higher airflow rates. We measured a 27% pressure drop in airflow over the voice prosthesis. Different tracheostoma occlusion methods did not have any effect on the aerodynamics and sound intensity. One patient that had had a jejunal graft for reconstruction showed, not unexpectedly, extremely different aerodynamic values. We were unable to define optimal airflow rates or optimal resistance values for sound production in the PE segment. Conclusion: The aerodynamic characteristics of voice production in laryngectomized patients with voice prostheses are determined by both prosthetic factors and PE segment tissue factors. In our patient group the PE segment is responsible for the greatest pressure drop. We found no significant difference in pressure drop and sound intensity for different tracheostoma occlusion methods.

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