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Abstract Introduction The upper esophageal sphincter (UES) is a muscular structure located at the transition from the pharynx to the esophagus, with the cricopharyngeal muscle as the most important component. During gastroesophageal reflux, the pressure in the UES elevates, which is apparently a protective mechanism to prevent esophagopharyngeal reflux and airway aspiration. In gastroesophageal reflux disease (GERD), there may be functional changes in the UES. Objective The objective of the present review was to determine UES functional changes in GERD. Data Synthesis In healthy individuals, gastroesophageal reflux causes an increase in the UES pressure. This response of the sphincter is at least partially impaired in patients with GERD. In the disease, the UES has a reduced length and decreased resting pressure. However, other publications found that in chronic gastroesophageal reflux the basal sphincter pressure increase, differences which may be consequent to the measurement method or to disease severity. The UES opening during swallowing has a smaller diameter, and the bolus transit time through the sphincter is longer. Conclusion The UES of patients with GERD does not open as expected and the bolus flow through the sphincter is longer. This behavior may be associated with dysphagia, a frequent complaint in patients with GERD.

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Abstract Introduction Iatrogenic bilateral vocal fold immobility (BVFI) often arises from posterior glottic stenosis (PGS) after endotracheal intubation, whereby posterior commissure mucosal disruption leads to fibrosis and ankylosis of the cricoarytenoid joints. Sequelae can be devastating, resulting in dyspnea, stridor, and death due to asphyxiation. Objectives We sought to review features associated with PGS to better understand how to prevent this condition. A secondary aim is to analyze factors correlating to tracheostomy dependence. Methods Charts from January 2010 to November 2020 were retrospectively reviewed, and adult patients with the diagnosis of BVFI after intubation were included. Data on comorbidities, duration of intubation, laryngoscopy, and decannulation status was analyzed. Results Out of the 68 patients included in the present study, 60.3% were male, and the mean duration of intubation 14.3 ± 8.5 days. A total of 94% of the patients were intubated for at least 7 days, diabetic, and/or obese. Although association with prolonged intubation >7 days was not significant (p = 0.064), complete BVFI on fiberoptic exam (n = 47) was significantly associated with tracheostomy dependence both in the entire cohort (p = 0.036) and in the 56 patients with tracheostomy (p = 0.0086). Patients without cardiovascular disease (CVD) were less likely to be tracheostomy dependent compared with those with CVD (odds ratio [OR]: 0.23 [0.053–0.79]; p = 0.028). Conclusions We identified duration of intubation, DM, and obesity as potential risk factors for PGS. Complete immobility and CVD were significantly associated with tracheostomy dependence. Our findings may have important implications for earlier tracheostomy in high-risk intubated patients, as well as for closer monitoring of disease progression and earlier intervention in those predisposed to tracheostomy dependence.

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Abstract Introduction Olfactory and gustative alterations are frequent in the initial stages of the COVID-19 infection. Vitamin B12 deficiency has been linked to olfactory dysfunction. Objective The present study aimed to assess the relationship between vitamin B12 levels and smell affection in COVID-19 patients. Methods The present study included 201 laboratory-confirmed COVID-19 patients. Smell affection was assessed using self-rated olfactory function. Serum vitamin B12 levels were assessed using commercial enzyme-linked immunosorbent assay (ELISA) kits. Results According to the smell function assessment, the patients were classified into three categories: normal osmesis (n = 77), hyposmia (n = 49), and anosmia (n = 75) (►Fig. 1). Four weeks later, 195 patients (97.0%) had their normal smell function restored. The remainder 6 patients included 4 anosmic and 2 hyposmic patients. Patients with hyposmia or anosmia had significantly lower vitamin B12 levels when compared with patients with normal osmesis (median [IQR]: 363.0 [198.0–539.0] versus 337.0 [175.0–467.0] and 491.0 [364.5–584.5] pg/ml, respectively, p < 0.001). Conclusion Vitamin B12 appears to have some contribution to smell affection in patients with COVID-19 infection.

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Abstract Introduction Patients with head and neck cancer (HNC) experience unique physical and psychosocial challenges that impact their health and quality of life. Early implementation of palliative care has been shown to improve various health care outcomes. Objective The aim of the present study was to evaluate the patterns of referral of patients with HNC to outpatient palliative care as they relate to utilization of resources and end-of-life discussions. Methods We performed a retrospective review of 245 patients with HNC referred to outpatient palliative care services at two Louisiana tertiary care centers from June 1, 2014, to October 1, 2019. The control group consisted of those that were referred but did not follow-up. Reasons for referral were obtained, and outcome measures such as emergency department (ED) visits, hospital readmissions, and advance care planning (ACP) documentation were assessed according to predictive variables. Results There were 177 patients in the treatment group and 68 in the control group. Patients were more likely to follow up to outpatient palliative care services if referred for pain management. Hospital system, prior inpatient palliative care, and number of outpatient visits were associated with an increased likelihood for ED visits and hospital readmissions. Those in the palliative care treatment group were also more likely to have ACP discussions. Conclusion Early implementation of outpatient palliative care among patients with HNC can initiate ACP discussions. However, there are discrepancies in referral reasons to palliative care and continued existing barriers to its effective utilization.

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Abstract Introduction The maxillary sinus and its variations are very important to dentistry and rhinology. Objective To investigate the effect of the accessory maxillary ostium (AMO) on the variations of adjacent structures of the maxillary sinus. Methods The computed tomography (CT) images of 400 patients were retrospectively evaluated. The prevalence of AMO was calculated. The relationship between morphological variations of adjacent structures of maxillary sinus such as agger nasi cell (ANC), Haller cell (HC), nasal septum deviation (NSD), hypertrophy of inferior concha (HIC), pneumatization of middle concha (PMC), mucus retention cyst (MRC), mucosal thickening (MT), and maxillary sinusitis (MS), as well as the presence of AMO, were investigated. Results Presence of AMO was diagnosed in 42 patients (10.5%), having been found in 4.5% of the patients only on the right side, in 1.25% of the patients only on the left side, and in 4.75% of the patients on both sides. There is an increasing incidence of ANC, HC, NSD, HIC, and PMC in the presence of AMO and MS. There is a decreasing incidence of MRC in the presence of AMO. Furthermore, AMO does not affect the incidence of MT. Conclusion This study showed that most parameters, except for MRC and MT, had increasing incidence in the presence of AMO. It is important for radiologists and rhinologists to have knowledge about the location of AMO and the presence of variations of MS adjacent structures to avoid surgical complications.

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Abstract Introduction Temporal bone surgery is a unique and complicated surgical skill that requires extensive training. There is an educational requirement to maximize trainee experience and provide effective feedback. Objective We evaluate three temporal bone dissection scales for efficacy, reliability, and accuracy in identifying resident skill during temporal bone surgery. Methods Residents of various skill levels performed a mastoidectomy with posterior tympanotomy on identic 3D-printed temporal bone models. Four blinded otologic surgeons evaluated each specimen at two separate intervals using three separate dissection scales: the Welling Scale (WS), the Iowa Temporal Bone Assessment Tool (ITBAT), and the CanadaWest Scale (CWS). Scores from each scale were compared in their ability to accurately separate residents by skill level, inter- and intrarater reliability, and efficiency in application. Results Nineteen residents from 9 postgraduate programs participated. Assessment was clustered into junior (postgraduate year or PGY 1, 2), intermediate (PGY 3) and senior resident (PGY 4, 5) cohorts. Analysis of variance (ANOVA) found significant differences between cohort performance (p < 0.05) for all 3 scales considering the PGY level and the subjective account of temporal bone surgical experience. The inter-rater reliability was consistent across each scale. The intrarater reliability was comparable between the CWS (0.711) and the WS (0.713), but not the ITBAT (0.289). Time (in seconds) to complete scoring for each scale was also comparable between the CWS (42.7 ± 16.8), the WS (76.6 ± 14.5), and the ITBAT (105.6 ± 38.9). Conclusion All three scales demonstrated construct validity and consistency in performance, and consideration should be given to judicious use in training.

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Abstract Introduction Alterations in endolymphatic pressure have long been suspected of being associated with the development of endolymphatic hydrops and rupture of the membranous labyrinth. More recently, there has been a focus on how membrane mechanics might contribute to membrane rupture. This is suspected to involve the viscoelastoplastic properties of these membranes. Objective To construct a rupture risk envelope for the cochleo-saccular membranes based on viscoelastoplasticity to provide insight into lesion behavior in Meniere disease. Methods Reported deformation data from a collagen model of the cochleo-saccular membranes was utilized. Yield stress was defined as 80% of ultimate failure stress. The yield points at various strain rates were used to construct a rupture risk envelope for the membranes. Results The rupture risk envelope was found to be downward sloping in configuration. At the highest strain rate of 385% per minute, the membrane yield was associated with greater stress (7.0 kPa) and lesser strain (30%); while at the lowest strain rate of 19.2% per minute, there was substantially less membrane yield stress (4.3 kPa) but it was associated with greater strain (44%). Conclusion The concept of a rupture risk envelope based on viscoelastoplasticity provides insight into hydropic lesion behavior in Meniere disease. This concept helps to explain how variations in membrane distensibility might occur as suspected in the double hit theory of lesion generation in Meniere disease. Slowly developing lesions would appear have a lower rupture risk while rapidly developing lesions would appear to have a greater risk of early membrane rupture.

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Abstract Introduction Measurement of the electrically-evoked stapedial reflex threshold (ESRT) is an objective tool used to set the comfort levels in pediatric cochlear implant (PCI) users. The levels of ESRT have a strong correlation with comfort levels. However, the clinical utility of ESRT is limited because the ESRT response is not observed in all cochlear implant users. Objective To assess the effects of probe-tone frequency on ESRT and its relationship with the behavioral comfort levels in PCI users. Methods A total of 14 PCI users aged between 5 and 8 years participated in the study. The ESRT levels were measured using high-frequency probe tones (678 Hz and 1,000 Hz), and the default 226 Hz probe tone. The ESRT was measured with single-electrode stimulation across the three electrode locations (basal [E01]; middle [E11]; and apical [E22]). The ESRT levels measured with different probe tone frequencies were compared with the behavioral comfort levels. Results The mean ESRT levels using 1,000Hz and 678 Hz were lower than those measured using 226 Hz, but there was no main effect of probe-tone frequency (p > 0.05). A significantly high incidence of successful ESRT measurements occurred with higher-frequency probe tone (p < 0.039). Additionally, ESRT using higher probe tones significantly correlated with comfort levels. Conclusion The ESRT with higher probe tones was correlated with behavioral comfort levels and increased the success rate of the measurements. Higher-frequency probe tones may be useful whenever ESRT with 226 Hz is not measurable.

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Abstract Introduction Management of the thyroid gland during laryngectomy has been controversial. The primary tumor may invade the thyroid gland by direct invasion or lymphovascular spread. Hypothyroidism and hypoparathyroidism are potential risks when lobectomy or total thyroidectomy are performed simultaneously. Objective To report the frequency of thyroid gland involvement by primary laryngeal squamous cell carcinoma in patients undergoing laryngectomy and to identify possible risk factors for thyroid gland involvement so that judicious excision of thyroid gland can be attained. Methods We performed a retrospective review of 9 years. Data was collected from medical records of patients dated from December 2009 to October 2018. All patients with laryngeal cancer who underwent laryngectomy with lobectomy or total thyroidectomy were included in the present study. Results We reviewed 151 laryngectomy records. A total of 130 surgeries included the thyroid gland with the excised specimen and were available for analysis. There were 124 males and 6 females. The mean age was 59.4 years old. The glottis was the most common subsite involved, in 70 patients, followed by 38 transglottic, 16 supraglottic and 03 subglottic tumors. On histology, 12 out of 130 excised thyroid glands were involved by squamous cell carcinoma. Only subglottic involvement (p = 0.01) was significantly associated with thyroid gland invasion (TGI). Type of laryngectomy, subsite of the primary tumor, thyroid cartilage involvement, neck nodal metastases, and perineural and lymphatic invasion by the primary tumor were not associated with TGI. Conclusion Only subglottic involvement is associated with TGI; therefore, preoperative and intraoperative assessment is necessary prior to considering excision of the thyroid gland.

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Abstract Introduction Middle turbinate resection (MTR) is commonly performed during endonasal endoscopic sinus and skull base surgery. Objective The purpose of this study was to characterize the additional orbital soft-tissue volume expansion during endoscopic medial orbital wall decompression with adjunctive MTR. Methods A retrospective review of patients who underwent endoscopic medial wall decompression with MTR was performed. The imaging software AW (GE Healthcare, Chicago, IL, USA) was used to overlay pre and postoperative orbital computed tomography (CT) images to visualize the preoperative position of the middle turbinate and the postoperative orbital soft tissue in the ethmoid bed. The imaging software Vitrea (Vital Images Inc., Minnetonka, MN, USA) was used to manually segment postoperative scans to determine the volume of orbital tissue which had filled the space previously occupied by the middle turbinate or medial to it. Results Nine orbits from 5 patients were included in this study; all patients were female with a history of hyperthyroidism. The average age was 55.6 years (range 32– 74). Of the 9 orbits, 7 (78%) had orbital soft tissue within the space of the resected middle turbinate postoperatively. The average volume of orbital tissue within or medial to this space was 0.83 +/– 0.67 cc. No patients had any postoperative complications. Conclusions In this patient cohort, adjunctive middle turbinate resection for endoscopic medial orbital wall decompression added ~ 0.83 cc of volume for orbital soft tissue after medial wall decompression. Middle turbinate resection is a useful adjunct to the orbital surgeon’s armamentarium to augment the results of a medial orbital decompression for select patients.

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Abstract Introduction Neck space infection in the pediatric age group is common but can be life-threatening if not diagnosed properly. Since it is a polymicrobial disease, antibiotic usage should be guided by culture sensitivity pattern. Objectives To assess the microbiology, antibiotic resistance pattern and the outcome of the medical and surgical management of deep neck space infection in children. Methods This was a prospective study of children admitted for management of neck space infection from August 2017 to August 2018. The age, gender, organisms isolated, sensitivity and resistance to antibiotics, length of hospital stay, complications, and recurrence were noted. The descriptive data were analyzed. Results Out of 108 cases, there were 51 males (47.2%) and 57 females (52.8%) ranging from 1 month to 15 years, with a mean age of 5.32 +/– 4.35 years. The mean period of hospitalization was 6.98 days. Staphylococcus aureus was the most common organism isolated with less coagulase-negative staphylococci and streptococci. Clindamycin was the most sensitive drug (82.35%) followed by vancomycin and cloxcillin, while amoxicillin/ampicillin, a commonly used drug, was the least sensitive (20.58%). The abscess recurrence rate was 9.28%. The outcomes of either medical treatment or a combined medical or surgical treatment in properly selected cases were comparable. Conclusion Clindamycin or cloxacillin can be used as a first-line option for neck infection in children. Ampicillin/amoxicillin alone has a small role in neck abscess because of high resistance to this type of antibiotic.

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Abstract Introduction Postural instability is considered one of the most disabling symptoms of relapsing-remitting multiple sclerosis (RRMS). Objective To evaluate postural control in patients with RRMS. Method A total of 79 individuals between 18 and 65 years old, of both genders, were distributed into an experimental group composed of patients with RRMS (n = 51) and in a control group composed by healthy individuals (n = 28). The evaluation consisted of anamnesis, Dizziness Handicap Inventory (DHI), visual vertigo analog scale (WAS), and static posturography (Tetrax IBS). Results Patients with RRMS presented mild degree in the DHI and in the VVAS; in Tetrax IBS, they presented higher or lower values of the indices of general stability, weight distribution, synchronization of postural oscillation, fall risk, and frequency bands of postural oscillation in two, five or all eight sensory conditions, in relation to the control group. Vestibular, visual and/or somatosensory dysfunction of peripheral type (51.0%) prevailed over the central type. The RRMS group, with an expanded scale of disability status > 3 points, presented a higher fall risk than with a score ≤ 3 points (p = 0.003). There was a positive correlation of the Fall Risk Index with the total DHI Score (s = 0.380; p = 0.006) and with the VVAS score (s = 0.348; p = 0.012). Conclusion Patients with RRMS may present with inability to maintain postural control due to general instability, desynchronization and increased postural oscillation at frequencies that suggest deficiencies in the vestibular, visual, and somatosensory systems; as well as fall risk related to the state and intensity of functional disability and self-perception of the influence of dizziness on quality of life.

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Abstract Introduction Cortisol is a hormone involved in the response to stress. Attention is a function that can change due to exposure to stress. Objectives To verify the correlation between the level of salivary cortisol and sustained auditory attention in children with cleft lip and palate, as well as to compare the results of the variables analyzed between female and male patients. Methods In total, 103 children aged 6 to 11 years, were divided into 2 groups: those with cleft lip and palate (experimental group, EG; n = 69) and the control group (CG; n = 34). The Sustained Auditory Attention Ability Test (SAAAT) and salivary cortisol levels, measured by an enzyme immunoassay kit (Salimetrics, Stage College, PA, US), were calculated and compared regarding the two groups. The statistical tests used were the Mann-Whitney test and the Spearman correlation. Results The median level of salivary cortisol was of 0.03615 μl/dL and 0.18000 μl/dL respectively for the EG and CG, with a significant difference between the groups (p =0.000). Absence of statistical significance (total error score = 0.656; vigilance decrement = 0.051) was observed the for SAAAT among the EG (median total error score = 12.00; 25th percentile [25%] = 7.00; 75th percentile [75%] = 21.00; and vigilance decrement = 1.00; 25% = 0.00; 75% = 2.50) and the CG (median total error score = 12.00; 25% = 6.00; 75% = 24.00; and vigilance decrement = 0.00; 25% = -1.00; 75% = 2.00). Conclusion All children had median levels of salivary cortisol and scores for sustained auditory attention within normal parameters. A significant correlation between the level of salivary cortisol and the ability to sustain auditory attention was observed in children without cleft lip and palate. There were no differences regarding the SAAAT and salivary cortisol between female and male patients.

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Abstract Introduction Quality of life is closely linked to retronasal olfactory function. Familiarity with odors vary, so tests need validation. Testing can be time-consuming, so a quick test and a thorough test are needed for clinical and research settings. Objectives The objectives of this study were to validate the original retronasal powder olfactory test in a Danish population and to develop a novel quick retronasal test for easy application. Methods Ninety-seven participants were included in the study, 59 healthy controls and 38 patients with olfactory impairment. The retronasal test was modified by substituting unfamiliar odors and descriptors and validated with a criterion of correct identification rate of 50% in the original test and 90% in the quick test. Items with over 90% correct identification rate in the modified original test were included in the quick test, resulting in a 10-item test. Results The modified retronasal olfactory test achieved good test characteristics, with a 10th percentile cut-off value of 13: sensitivity was 88.9%, specificity 83.0%, positive predictive value 78%, negative predictive value 91.7%, and the receiver operating characteristics area under the curve (ROC-AUC) was 0.86. The quick test achieved acceptable test characteristics, with a 10th percentile cut-off value of 8.2: sensitivity was 72.2%, specificity 90.6%, positive predictive value 83.9%, negative predictive value was 82.8%, and ROC-AUC 0.81. Conclusion Validation of both tests demonstrated satisfactory accuracy. We recommend the quick test for screening purposes, and the modified original version for a thorough evaluation. The tests are easily implemented as they are easy to understand and very affordable.

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Abstract Introduction Inactive squamosal disease is unique for having a conflicting treatment protocol, with an age-old debate between early surgical intervention or keeping patients in a long-term follow-up. The shifting paradigm is early intervention to prevent further progress into active disease and improve hearing outcome in its nascent stage. Objective To evaluate recurrence and hearing outcome in cases of inactive squamosal disease after cartilage strengthening tympanoplasty. Methods The study was conducted on 50 patients with inactive squamosal disease. Detailed examination was done to grade the retraction. All patients underwent autologous conchal cartilage tympanomastoidectomy with temporalis fascia grafting. Recurrence and hearing evaluations were done by pure tone audiogram at regular intervals for one year. Results Hearing loss was the most common presenting symptom. Isolated pars tensa retractions were more common (54%) than pars flaccida (12%), or those involving both (34%). Ossicular status was normal in only 14% of the cases, and the most common ossicular damage was to the lenticular process of the incus (52%). Three of the patients (6%) had residual perforation at the 3rd month of follow-up. Subjective improvement in hearing was reported by 42% patients. Hearing improvement greater than 10 dB was found in 24 patients (48%). Air–bone gap reduced from 25.16 ± 8.15 dB preoperatively to 12.90 ± 6.20 at 1 year of follow-up. Recurrence was seen in three patients (6%). Conclusion Early intervention by cartilage strengthening of weakened tympanic membrane and ossicular reconstruction not only offers better hearing results, but also prevents progress to active disease.

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Abstract Introduction Selective neck dissection inclinically node-negative neckisconsidered the standard of care for oral squamous cell carcinomas (SCCs). Controversy still prevailsinnode-positive disease regarding the extent of neck dissection. In our part of the world, comprehensive neck dissection is mostly considered to be the minimal optimal treatment for palpable neck disease. Objective To compare regional control and disease-specific survival between clinically node-positive and node-negative patients undergoing selective neck dissection for oral SCC. Methods This was a retrospective cohort study conducted in the department of ENT, Head and Neck surgery at a tertiary care hospital. All patients with biopsy-proven oral and lip SCC, with or without nodal disease, who underwent selective neck dissection between April 2006 and July 2015 were included in the study. Results During the study period, 111 patients with oral SCC underwent selective neck dissection, of whom 71 (62%) were clinically node-negative and 40 (38%) patients had clinically positive nodes in the neck. The mean follow-up was 16.62 months (standard deviation [SD]: 17.03). The overall regional control rates were 95 versus 96% for clinical negative versus positive nodes, respectively (p = 0.589). The disease-specific survival was 84.5% in the node negative group versus 82.5% in the node-positive group (p = 0.703). Conclusion Selective neck dissection in node-positive neck oral SCC has similar regional control rates when compared with node-negative neck SCC. The difference in disease-specific survival between the two groups is also not significant.

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Abstract Introduction The Eustachian Tube Dysfunction Patient Questionnaire (ETDQ-7) scale is used to assess the effectiveness of the treatment and to determine the severity of the eustachian tube dysfunction (ETD). There is currently no validated Arabic version of the ETDQ-7. Objectives The aim of the present study is to test the validity and the reliability of a translated Arabic version of the ETDQ-7. Methods A multicenter prospective validation study was conducted in Riyadh, Saudi Arabia. The ETDQ-7 was adapted and translated into Arabic using a standard validation methodology. Fifty-one patients diagnosed with Eustachian tube dysfunction and 45 healthy individuals were enrolled in the study. The known-groups method was used in the validity analysis. The test-retest method, item-total score correlation, and internal consistency analysis were used for the reliability analyses. Result The overall internal consistency of the Arabic ETDQ items was measured using Cronbach α (Cronbach α = 0.803). The average and total ETDQ scores were significantly higher in the ETD group (17.6) than in the control group (9.87) (p < 0.001). The results indicate a good to excellent correlation (> 0.7). The area under the curve for the total ETDQ score was 88.6% (95% confidence interval [CI]: 80.3–96.8%) Conclusion The Arabic version of the ETDQ-7 scale is a valid instrument for evaluating ETD. It can also be used as an important tool for diagnosis, patient follow-up, and treatment management.

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Abstract Introduction Cholesteatoma is a disease with significant clinical impact but is incompletely understood. The challenge of performing studies with long-term follow-up in humans is a factor that has restricted the advance of knowledge in this field. Thus, the use of animal models is highly pertinent, and the Mongolian gerbil model has emerged as one of the most useful. Objective The present study aims to evaluate, through serial otoendoscopies, the development and characteristics of pars flaccida retraction pocket and cholesteatoma in Mongolian gerbils after obliteration of the eustachian tube and compare it with the control group. Methods Forty Mongolian gerbils were divided into two groups of 20 animals each. In the intervention group, the animals were followed with serial otoendoscopies after eustachian tube obliteration. In the control group, the animals were only followed through serial otoendoscopies. Results At the end of the 16-week follow-up, cholesteatoma was present in 13 of 38 (34.2%) ears in the intervention group, and in 7 of 34 (20.6%) in the control group (p = 0.197). When we considered cholesteatoma and its potential precursor, pars flaccida retraction pocket, in a combined way, we verified it in 23 of 38 (60.8%) in the intervention group and in 11 of 34 (32.3%) in the control group (p = 0.016). Conclusions Over the 16 weeks of follow-up, serial otoendoscopies enabled us to evaluate the formation and development of pars flaccida retraction pockets and cholesteatomas in Mongolian gerbils and proved to be an excellent diagnostic tool.

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Abstract Introduction The bone-anchored hearing implant system (BAHS) is an effective amplification system that transmits the sounds received by an external operating system to the inner ear by bypassing the middle ear placed in the temporal bone. Objective This study compares the results of patients who underwent bone-anchored hearing implant system (BAHS) surgery using two different surgical methods in terms of preoperative and postoperative complications, surgical time, audiological findings, and patient satisfaction. Methods The results of 22 patients who underwent BAHS were evaluated retrospectively from video records and audiological results, The Turkish Version of the Glasgow Benefit Inventory (GBI) questionnaire were evaluated. Two different surgical approaches were used for implantation: the linear incision technique (n = 9) and the punch technique (n = 13). Results Mean surgical durations were 9.67 ± 2.85 and 47.65 ± 6.13 minutes for Groups A and B, respectively, and these were significantly different (p < 0.001). There were no significant differences between the groups’ speech recognition scores for a signal-to-noise ratio (SNR) of +5 (p = 0.173), SNR of 0 (p = 0.315), or SNR of -5 (p = 0.360) and results of the GBI scores. Conclusion The punch technique has a significant advantage due to a shorter surgery duration without increased surgical complications. Additionally, the punch technique showed no significant difference in hearing performance or satisfaction compared with linear incision.

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Abstract Introduction Acute upper respiratory infection (AURI) is the most common cause of postinfectious olfactory dysfunction (PIOD). Objective We investigated the prevalence of PIOD in a large group of patients reporting persistent smell impairment perception after the AURI resolution. Methods Olfactometry was performed within 1 month after the common cold resolution and after 1 year in 467 (299 males, mean age 41.7 years) outpatients. The Sniffin’ Sticks olfactory test (Burghart instruments, Wedel, Germany) was used. Results Anosmia was documented in 28 (6%) patients, hyposmia in 33 (7%), and cacosmia in 55 (11.7%). After 1 year, PIOD improved in 82 (79.6%) patients re-tested. Conclusion The current study demonstrated that persistent olfactory dysfunction is a relevant symptom in patients with AURI, even though many patients had normal olfactometry. Thus, smell impairment deserves careful attention and requires objective documentation.

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Abstract Introduction The endoscopic anatomy of the middle ear (ME) and of the external acoustic meatus (EAM) has been described in cadavers, in fresh temporal bones, or in vivo using conventional video recording, but not in dry bones or using an alternative inspection and recording technique. Objective To study the anatomy of the ME and of the EAM in dry temporal bones using a smartphone-endoscope system. Methods The EAM and the ME were studied in dry temporal bones using an endoscopic transcanal approach with a telescope connected to a smartphone (M-scope mobile endoscope app and adaptador, GBEF Telefonia, São Paulo, SP, Brazil). Results Out of 50 specimens, 2 had exostosis of the EAM and 3 contained remains of the tympanic membrane. The anterior wall of the EAM was prominent in 10/48 specimens (20.8%). Ossicles were seen in 13/45 (28.8%), stapes at the oval window were seen in 12/45 (26.6%), and the incus was seen in 1/45 (2.2%) specimens. The facial canal was open and protruding in 15/45 (33.3%) and in 7/45 (15.5%) specimens, respectively. Of the 45 MEs evaluated, type A was predominant for finiculus (93.3%), subiculum (100%), and ponticulus (95.6%). The rest were type B. None was classified as type C. According to its position in relation to the round window, the fustis was classified into type A (68.9%) or B (31.1%). The pyramidal eminence, the bony portion of the Eustachian tube, the semicanal of the tensor tympani muscle, and the cochleariform process were visualized completely or partially in all cases. Conclusion The use of a smartphone-based endoscopic transcanal procedure in dry temporal bones allowed the evaluation of anatomical variations in the EAM and in the ME.

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Abstract Introduction Benign paroxysmal positional vertigo (BPPV) appears during the same age group in which vitamin D and calcium deficiencies are evident. Vitamin D deficiency could predispose to BPPV, since these two entities share a demineralization process. Objective To establish the otological impact of vitamin D supplementation in patients with its deficiency who suffer from BPPV. Methods This was a randomized clinical trial. A total of 35 patients with vitamin D deficiency (< 30ng/ml) and BPPV were divided into 2 groups: Group 1 (control group): treatment with repositioning maneuvers; and Group 2: treatment with repositioning maneuvers and vitamin D supplementation. Results A follow-up of between 6 and 13 months and a log rank test revealed that the probability of recurrence between the experimental groups was significantly different, with group 2 having a decreased recurrence of vertigo (p = 0.17). Scores in the Dizziness Handicap inventory (DHI) in patients treated with vitamin D supplementation were smaller (10 ± 9) when compared with a score of 36 ± 9 in the control group. Conclusion Plasmatic values of 25-hydroxyvitamin D have an impact in patients with BPPV, who present an improvement in their quality of life when their vitamin D levels are replaced with supplementation. Benign paroxysmal positional vertigo could stop being perceived as a purely otologic disease.

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Abstract Introduction The aging process in the elderly can change the condition of the oral cavity, regarding both clinical appearance and function. The oral mucosa becomes more susceptible to mechanical damage and irritant agents. Any changes in the oral mucosa, including normal variance, should be examined. This is especially true for the elderly, to improve oral health and prevent any abnormalities. Objective To describe the prevalence of oral normal variance in healthy elderly patients. Methods An observational descriptive study with a cross-sectional design with total sampling conducted from March to April 2020. Results Among the 117 elderly patients who participated in this study, 58 were described as healthy without any comorbidities. From those subjects, there were 117 cases of normal variance in the oral mucosa. The three most prevalent issues were fissured tongue (93.1%), coated tongue (58.62%), and crenated tongue (27.59%). Conclusion Fissured tongue is a normal variance of the oral mucosa that is commonly found in healthy elderly patients.

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Abstract Introduction Several studies have shown that efferent pathways of the auditory system improve perception of speech-in-noise. But, the majority of investigations assessing the role of efferent pathways on speech perception have used contralateral suppression of otoacoustic emissions as a measure of efferent activity. By studying the effect of efferent activity on the speech-evoked auditory brainstem response (ABR), some more light could be shed on the effect of efferent pathways on the encoding of speech in the auditory pathway. Objectives To investigate the relationship between contralateral suppression of transient evoked otoacoustic emission (CSTEOAE) and unmasking of speech ABR. Methods A total of 23 young adults participated in the study. The CSTEOAE was measured using linear clicks at 60 dB peSPL and white noise at 60 dB sound pressure level (SPL). The speech ABR was recorded using the syllable /da/ at 80 dB SPL in quiet, ipsilateral noise, and binaural noise conditions. In the ipsilateral noise condition, white noise was presented to the test ear at 60 dB SPL, and, in the binaural noise condition, two separate white noises were presented to both ears. Results The F0 amplitude of speech ABR was higher in quiet condition; however, the mean amplitude of F0 was not significantly different across conditions. Correlation analysis showed a significant positive correlation between the CSTEOAE and the magnitude of unmasking of F0 amplitude of speech ABR. Conclusions The findings of the present study suggests that the efferent pathways are involved in speech-in-noise processing.

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Abstract Introduction Choanal polyps are benign lesions arising from the sinonasal mucosa, extending through the choana into the nasopharynx. Though polyps arising from the maxillary sinus and extending to the choana are common, polyps arising from the sphenoid sinus ostium, posterior part of middle turbinate, and inferior and middle meatus are quite uncommon. Objective To document the site of origin of choanal polyps arising from unusual sites; their clinical, radiological, and histopathological characteristics, as well as diagnostic challenges and management. Methods This retrospective, single-center study included 14 patients aged 16 to 75-years-old with choanal polyps. After obtaining informed consent, their clinical, radiological and surgical details and histopathology reports were reviewed. Patients were followed for at least 6 months after surgery. Results The predominant symptoms were unilateral nasal obstruction (n = 9), snoring, rhinorrhea, and epistaxis. Though anterior rhinoscopy was unremarkable, a mass could be visualized during posterior rhinoscopy in the nasopharynx in 11 patients, and a mass could be directly visualized in the oropharynx in 2 patients. After diagnostic by nasal endoscopy, these polyps were noted to arise from the posterior aspect of the middle meatus (n = 6), middle turbinate (n = 3), posterior septum (n = 3), sphenoid sinus ostium (n = 1), and inferior meatus (n = 1). All patients were managed surgically. The histopathological examination revealed inflammatory polyp (n = 12), actinomycosis (n = 1), and rhinosporidiosis (n = 1). Patients were followed up for 6 to 22 months. We observed no complications or recurrence. Conclusion Diagnostic nasal endoscopy should be performed in all patients presenting with nasal obstruction, to rule out choanal polyps arising from unusual sites. Complete polyp removal and appropriate treatment based on histopathology prevents recurrence.

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Abstract Introduction Vestibular pathologies cause physical and psychological symptoms, as well as cognitive problems. Objective To evaluate the deterioration in sleep quality associated with vestibular pathologies. Methods The Dizziness Handicap Inventory (DHI), the Beck Depression Inventory (BDI), the Pittsburgh Sleep Quality Index (PSQI), and the Limits of Stability test (LOS) were applied to the participants. Results We included 25 patients with Meniere’s disease (MD), 22 patients with benign paroxysmal positional vertigo (BPPV), 21 patients with unilateral peripheral vestibular loss (UPVL), 23 patients with vestibular migraine (VM), and 43 controls. The total PSQI scores of the controls were better than those of the MD (p = 0.014), VM (p < 0.001), BPPV (p = 0.003), and UPVL (p = 0.001) groups. The proportion of poor sleepers in the MD (p = 0.005), BPPV (p = 0.018), and UPVL (p < 0.001) groups was significantly higher than that of the controls. The highest total DHI score (45.68 ± 25.76) was found among the MD group, and it was significantly higher than the scores of the BPPV (p = 0.007) and control (p < 0.001) groups. The highest BDI score was obtained in the VM group, and it was significantly higher than the scores of the BPPV (p = 0.046) and control (p < 0.001) groups. Moreover, the BDI scores of the MD (p = 0.001) and UPVL groups were also significantly worse than the score of the controls (p = 0.001). Conclusion The present study showed that presents with vestibular symptoms have physical and functional complaints, as well as increased psychosocial stress and decreased sleep quality. Evaluating multiple parameters of quality of life may contribute to a better understanding of vestibular physiology and symptoms, and may help establish a more effective therapeutic approach.

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Abstract Introduction Chronic suppurative otitis media is one of the most common causes of reversible conductive hearing loss which can lead to necrosis of the ossicles. The incus, especially its long process, is the most common ossicle affected. Objectives The present study aims to assess the use of glass ionomer cement for the reconstruction of the long process of the incus. Methods The present study was conducted on 27 patients with chronic suppurative otitis media with central perforation with dry and quiescent ears with an eroded long process of the incus submitted to tympanoplasty. The audiological evaluations were done on all patients, including preoperative and postoperative evaluation of the airbone gap; the average pure tone threshold was done 6 months postoperatively. Results The average air pure tone threshold was 42.8 dB preoperatively and 22.5 dB postoperatively. The postoperative air pure tone thresholds were significantly smaller than the preoperative values (p < 0.01). The air-bone gap was 30.5 dB at 500 Hz, 31.6 dB at 1 KHz, and 24.1 dB at 2 kHz preoperatively, and 7.7 dB at 500 Hz, 7.2 dB at 1 KHz, and 7.1 dB at 2 kHz postoperatively at the end of 6 months of follow-up. There were significant hearing gains in the air-bone gap (p < 0.001). Conclusion Glass ionomer cement is a useful and effective material for bridging the defect of the long process of the incus.

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Abstract Introduction Psychoeducational counselling and residual inhibition therapy (RIT) are traditional approaches used in many clinics to manage tinnitus. However, neurophysiological studies to evaluate posttreatment perceptual and functional cortical changes in humans are scarce. Objectives The present study aims to explore whether cortical auditory-evoked potentials (CAEPs; N1 and P3) reflect the effect of modified RIT and psychoeducational counselling, and whether there is a correlation between the behavioral and electrophysiological measures. Methods Ten participants with continuous and bothersome tinnitus underwent a session of psychoeducational counselling and modified RIT. Perceptual measures and CAEPs were recorded pre- and posttreatment. Further, the posttreatment measures were compared with age and gender-matched historical control groups. Results Subjectively, 80% of the participants reported a reduction in the loudness of their tinnitus. Objectively, there wasasignificant reductioninthe posttreatment amplitude of N1 and P3, with no alterations in latency. There was no correlation between the perceived difference in tinnitus loudness and the difference in P3 amplitude (at Pz). Conclusion The perceptual and functional (as evidenced by sensory, N1, and cognitive, P3 reduction) changes after a single session of RIT and psychoeducational counselling are suggestive of plastic changes at the cortical level. The current study serves as preliminary evidence that event-related potentials (ERPs) can be used to quantify the physiological changes that occur after the intervention for tinnitus.

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Abstract Introduction Perinatal hypothyroidism has a negative repercussion on the development and maturation of auditory system function. However, its long-term effect on auditory function remains unsettled. Objective To evaluate the effect of prenatal hypothyroidism on the auditory function of adult offspring in rats. Methods Pregnant Wistar rats were given the antithyroid drug methimazole (0.02%-1-methylimidazole-2-thiol– MMI) in drinking water, ad libitum, from gestational day (GD) 9 to postnatal day 15 (PND15). Anesthetized offspring from MMI-treated dams (OMTD) and control rats were evaluated by tympanometry, distortion product otoacoustic emission (DPOAE), and auditory brainstem response (ABR) at PNDs 30, 60, 90, and 120. Results Our data demonstrated no middle ear dysfunction, with the OMTD compliance lower than that of the control group. The DPOAE revealed the absence of outer hair cells function, and the ABR showed normal integrity of neural auditory pathways up to brainstem level in the central nervous system. Furthermore, in the OMTD group, hearing loss was characterized by a higher electrophysiological threshold. Conclusion Our data suggest that perinatal hypothyroidism leads to irreversible damage to cochlear function in offspring.

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Abstract Introduction The technology regarding bone-anchored hearing devices has been advancing. Nevertheless, complications are still often reported, which can impair treatment adherence and lead to discontinuation of use. There is a lack of studies conducted in tropical countries, where complications can be even greater, as well as standardized protocols for selection, indication and evaluation. Objective To characterize implanted patients from a Brazilian public institution and describe the medical and audiological assessment protocols to which they were submitted during the selection process and in the follow-up after surgery. Method An observational, cross-sectional study evaluating the medical records of patients with hearing loss and ear malformations and describing the care protocol through which they were treated. Results The medical records of 15 patients were reviewed: 6 received transcutaneous implants, and 9, percutaneous implants; 9 patients reported some type of skin lesion, 2 reported pain on the follow-up visit, and 3 had osseointegration failure. The time between surgery and activation ranged from 2 to 9 months. The median scores on the sentences, Sentences in Noise and Monosyllable tests were 100%, 60% and 80%, respectively. Conclusion It was possible to characterize the patients who received implants at the institution. The patients performed well in silence and had greater difficulty in noise. Even patients who had complications did not complain about the audibility and sound quality. It is essential to develop a model and to standardize the assessment and follow-up methods aimed at the benefit of users of bone-anchored hearing devices, as well as to enable the technico-scientific development in this field.

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Abstract Introduction Septoplasty is one of the most common surgical procedures in rhinology practice. Two major problems encountered after septoplasty are pain and bleeding. Preoperative administration of analgesics before the surgical stimulus, which is the main concept of preemptive analgesia, decreases postoperative pain. Objective The present study was designed to investigate whether preincisional lidocaine infiltration to the subperichondrial area during septoplasty surgery reduced or not postoperative pain and analgesic use. Methods The present prospective, randomized, placebo controlled, double-blind trial was conducted on 64 consecutive patients with nasal septum deviation. Patients were randomly divided into 2 groups; the study group received 2% 20 mg lidocaine/cc (n = 31), and the control group received 6 cc 0.9% NaCl (n = 33). A standard questionnaire was given to each patient to mark his or her pain score between 0 and 10 at the 1st, 3rd, 6th, 12th, and 24th hours. Results The mean and the range of visual analogue scale (VAS) scores of the patients in the study group at the 1st, 3rd, 12th, and 24th hours were 4.03 ± 3.08 (0–10); 3.42 ± 2.39 (0–8); 2.97 ± 2.22 (0–8); 2.87 ± 2.61 (0–9); and 1.94 ± 2.06 (0–9) respectively. The mean and the range of VAS scores of the patients in the control group at the 1st, 3rd, 12th, and 24th hours were 4.12 ± 2.7 (0–10); 3.45 ± 2.4 (0–10); 2.94 ± 2.7 (0–10); 2.79 ± 2.34 (0–10); and 1.5 ± 1.8 (0–6), respectively. The statistical analysis revealed no significant difference among the groups. Conclusion The preemptive local anesthetic administration to the incision area and under the mucoperichondrial flap before septoplasty does not decrease the level of postoperative pain.

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Abstract Introduction Otosclerosis is characterized by the fixation of the stapes to the oval window, thereby impairing acoustic signal absorbance. A commonly used surgical technique for improving hearing in cases of otosclerosis is stapedotomy. However, it is unclear whether this surgery restores all the physical characteristics of the tympano-ossicular system. Objective To evaluate the tympano-ossicular system in individuals with fenestral otosclerosis pre and poststapedotomy using wideband tympanometry. Method A total of 47 individuals and 71 ears were assessed. The subjects were divided into three groups: presurgery otosclerosis; postsurgery; and a control group of normal-hearing adults. A handheld tympanometer with a wideband module (226–8,000 Hz) was used to take measurements at ambient pressure and under pressurized conditions. The level of statistical significance adopted was p ≤ 0.05. Results Acoustic absorbance at 226 Hz was low for all groups. At frequencies in the range 630 to 5,040 Hz, each group had a characteristic absorbance curve, allowing them to be distinguished from one another. In the presurgery group, absorbance values were below normal levels, with energy absorbance below 10%. Low energy absorbance was most evident at 1,000 Hz in the presurgery group, but this was not observed in the postsurgery group. Although there was an improvement in hearing, the surgery failed to restore the tympano-ossicular system to normal. Conclusion Wideband acoustic absorbance proved able to differentiate normal ears and otosclerotic ears pre and postsurgery, under both ambient pressure and pressurized conditions.

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Abstract Introduction The sinus fungus ball is an agglomeration of debris and hyphae, mainly caused by Aspergillus fumigatus, within the paranasal sinus, commonly affecting a single sinus, and it only rarely affects the frontal sinus. Objective To identify the state of the art of fungus ball in paranasal sinuses, especially related to the epidemiology of the disease in the frontal sinus. Additionally, this article reports a rare case of fungus ball in the frontal sinus in an adult male, and discusses the variables of this condition related to the patient. Data Synthesis All of the 8 cases of fungus ball in the frontal sinus reported in this study affected male patients: 40% had unilateral disease, and 60%, bilateral disease, contrary to the incidence data of fungus ball in the other paranasal sinuses, which reports unilateral prevalence. However, in the present study, this index changes, with 50% of unilateral and 50% of bilateral incidence regarding frontal sinus involvement. The average age of the patients was 65.36 years (range: 60-74 years). The etiologic agent was Aspergillus spp., and the endonasal endoscopic therapeutic approach corresponded to 80% of cases, while frontal osteoplasty accounted for 20% of cases, reaffirming the prevalence data from other studies. Conclusion Despite being a low-incidence entity, frontal sinus fungus ball should be considered in patients with pain in the frontal region refractory to the usual clinical treatments.

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Abstract Introduction Allergic rhinitis (AR) is estimated to affect up to 30% of the world population. With the rise in cases, newer treatment modalities have been explored. Probiotics have shown to reduce symptoms of AR and improve quality of life. A few systematic reviews have been published aiming to assess the role of probiotics in AR. Objectives To consolidate the recent evidence with an overview of systematic reviews by extracting data regarding subjective outcomes (from quality of life questionnaires, the Total Nasal Symptom Score, the Total Ocular Symptom Score, the Daily Total Symptom Score, the incidence of AR, and the Rhinitis Total Symptom Score) and objective outcomes (levels of antigen-specific immunoglobulin E [IgE], total IgE, interleukin 10 [IL-10], interferon gamma [IFNG], eosinophil, and the T helper 1/T helper 2 [Th1/Th2] ratio). Data Synthesis We conducted a literature search on the PubMed, EBSCO CINAHL, EBSCO Dentistry & Oral Sciences Source, and Cochrane Library up to April 14, 2020. The qualitative assessment was performed using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR-2) tool. A total of 419 titles were screened, and 3 systematic reviews met our eligibility criteria. Probiotics in the treatment of AR have been shown to improve quality of life, the total nasal and ocular symptom scores, the daily total symptom scores and Th1/Th2 ratio. No difference was ascertained for rhinitis total symptom score, and the rates of antigen-specific IgE, total IgE, IL-10, INFG and eosinophil. Conclusion The present review showed that there is considerable evidence that probiotics are useful in the treatment of AR. Further randomized trials targeting the limitations of the currently-available evidence can help ascertain the usefulness of probiotics in cases of AR.