Showing papers in "European Archives of Oto-rhino-laryngology in 2020"

Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study.

Abstract: To investigate the occurrence of olfactory and gustatory dysfunctions in patients with laboratory-confirmed COVID-19 infection. Patients with laboratory-confirmed COVID-19 infection were recruited from 12 European hospitals. The following epidemiological and clinical outcomes have been studied: age, sex, ethnicity, comorbidities, and general and otolaryngological symptoms. Patients completed olfactory and gustatory questionnaires based on the smell and taste component of the National Health and Nutrition Examination Survey, and the short version of the Questionnaire of Olfactory Disorders-Negative Statements (sQOD-NS). A total of 417 mild-to-moderate COVID-19 patients completed the study (263 females). The most prevalent general symptoms consisted of cough, myalgia, and loss of appetite. Face pain and nasal obstruction were the most disease-related otolaryngological symptoms. 85.6% and 88.0% of patients reported olfactory and gustatory dysfunctions, respectively. There was a significant association between both disorders (p < 0.001). Olfactory dysfunction (OD) appeared before the other symptoms in 11.8% of cases. The sQO-NS scores were significantly lower in patients with anosmia compared with normosmic or hyposmic individuals (p = 0.001). Among the 18.2% of patients without nasal obstruction or rhinorrhea, 79.7% were hyposmic or anosmic. The early olfactory recovery rate was 44.0%. Females were significantly more affected by olfactory and gustatory dysfunctions than males (p = 0.001). Olfactory and gustatory disorders are prevalent symptoms in European COVID-19 patients, who may not have nasal symptoms. The sudden anosmia or ageusia need to be recognized by the international scientific community as important symptoms of the COVID-19 infection.

COVID-19 in otolaryngologist practice: a review of current knowledge.

Abstract: Otorhinolaryngological manifestations are common symptoms of COVID-19. This study provides a brief and precise review of the current knowledge regarding COVID-19, including disease transmission, clinical characteristics, diagnosis, and potential treatment. The article focused on COVID-19-related information useful in otolaryngologist practice. The Medline and Web of Science databases were searched without a time limit using terms “COVID-19”, “SARS-CoV-2” in conjunction with “otorhinolaryngological manifestation”, “ENT”, and “olfaction”. The most common otolaryngological dysfunctions of COVID-19 were cough, sore throat, and dyspnea. Rhinorrhea, nasal congestion and dizziness were also present. COVID-19 could manifest as an isolated sudden hyposmia/anosmia. Upper respiratory tract (URT) symptoms were commonly observed in younger patients and usually appeared initially. They could be present even before the molecular confirmation of SARS-CoV-2. Otolaryngologists are of great risk of becoming infected with SARS-CoV-2 as they cope with URT. ENT surgeons could be easily infected by SARS-CoV-2 during performing surgery in COVID-19 patients. Ear, nose and throat (ENT) symptoms may precede the development of severe COVID-19. During COVID-19 pandemic, patients with cough, sore throat, dyspnea, hyposmia/anosmia and a history of travel to the region with confirmed COVID-19 patients, should be considered as potential COVID-19 cases. An otolaryngologist should wear FFP3/N95 mask, glasses, disposable and fluid resistant gloves and gown while examining such individuals. Not urgent ENT surgeries should be postponed. Additional studies analyzing why some patients develop ENT symptoms during COVID-19 and others do not are needed. Further research is needed to determine the mechanism leading to anosmia.

Recommendation of a practical guideline for safe tracheostomy during the COVID-19 pandemic.

Abstract: The COVID-19 pandemic is placing unprecedented demand upon critical care services for invasive mechanical ventilation. There is current uncertainty regarding the role of tracheostomy for weaning ventilated patients with COVID-19 pneumonia. This is due to a number of factors including prognosis, optimal healthcare resource utilisation, and safety of healthcare workers when performing such a high-risk aerosol-generating procedure. Literature review and proposed practical guideline based on the experience of a tertiary healthcare institution with 195 critical care admissions for COVID-19 up until 4th April 2020. A synthesis of the current international literature and reported experience is presented with respect to prognosis, viral load and staff safety, thus leading to a pragmatic recommendation that tracheostomy is not performed until at least 14 days after endotracheal intubation in COVID-19 patients. Practical steps to minimise aerosol generation in percutaneous tracheostomy are outlined and we describe the process and framework for setting up a dedicated tracheostomy team. In selected COVID-19 patients, there is a role for tracheostomy to aid in weaning and optimise healthcare resource utilisation. Both percutaneous and open techniques can be performed safely with careful modifications to technique and appropriate enhanced personal protective equipment. ORL-HNS surgeons can play a valuable role in forming tracheostomy teams to support critical care teams during this global pandemic.

The role of self-reported olfactory and gustatory dysfunction as a screening criterion for suspected COVID-19.

Abstract: We read with interest the paper written by Lechien et al. [1] describing a multi-centre cohort of COVID-19 patients, in which 85.6% had olfactory or taste disorders (OTD). If the association between COVID-19 and OTD is not recognized, the diagnosis may be missed. However, while a large proportion of COVID-19 patients had OTD, [1–3] the actual specificity as a criterion for screening suspected COVID-19 cases is unknown, as other viral infections may also cause OTD. Other studies have reported patients presenting with acute anosmia with or without upper respiratory tract symptoms, [4, 5] but not all patients were tested for COVID-19 [4]. Additionally, information on OTD in Asian cohorts is lacking [1]. In Singapore, the first case of COVID-19 was reported in end-January 2020. At our institution, the largest acute hospital in Singapore, from end-March 2020 all new admissions were screened for self-reported OTD at emergency department (ED) triage. All patients reporting new-onset OTD were admitted to exclude COVID-19. We report our experience using self-reported OTD as a screening criterion for suspected COVID-19. Over a 2-week period from 26 March–10 April 2020, given ongoing community transmission and the difficulty in distinguishing COVID-19 from ordinary viral infection, a questionnaire including respiratory symptoms, self-reported OTD, and travel and epidemiological risk factors was administered at ED triage to risk-stratify admissions. Suspect case criteria for COVID-19 were defined as the presence of respiratory symptoms and suspicious epidemiological links or travel history; or new-onset OTD. Testing was not limited to hospitalised inpatients; as part of the national strategy of containment, all patients who fulfilled suspect case criteria for COVID-19 were tested via real-time reverse transcription PCR (rRT-PCR) of oropharyngeal swabs, even if hospitalization was not otherwise required. Inpatient, if patients had respiratory symptoms and a viral prodrome, or OTD, oropharyngeal specimens were also tested for a routine panel of respiratory viruses. As this study was based on aggregated surveillance data, ethics approval was not required under our hospital’s Institutional Review Board guidelines. Over the study period, a total of 870 patients fulfilled suspect case criteria for COVID-19 at ED triage. A minority (5.05%, 44/870) presented with OTD. The majority of suspects (65.3%, 568/870) were well and discharged to selfisolate while awaiting results. Amongst suspected COVID19 cases, 154 patients (17.9%, 154/870) tested positive. Of those, roughly one-fifth (22.7%, 35/154) had OTD. The presence of OTD had high specificity as a screening criterion for COVID-19 (98.7%, 95% CI 97.6–99.4%), but lower sensitivity (22.7%, 95% CI 16.4–30.2%). This was roughly equivalent to the specificity and sensitivity of a history of close contact with a confirmed COVID-19 case (specificity: 94.8%, 95% CI 93.0–96.3%; sensitivity: 27.3%, 95% CI 20.4–35.0%), Supplementary Table 1. Amongst the 35 This comment refers to the article available online at https ://doi. org/10.1007/s0040 5-020-05965 -1.

Comment to the article "Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study".

Abstract: We read with interest the paper: “Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study” by Lechien et al. [1] published on your Journal. The involvement of the olfactory tract by viruses is well known and even preliminary reports on Chinese patients attested that around 10–15% of Covid-19 positive hospitalized patients presented olfactive and/or gustative disorders [2]. Lechien et al. [1] claim that a percentage as high as 85–88% of the patients affected by Sars-CoViD2 who underwent a validated questionnaire reported olfactory or gustative disorders. Authors used a short version of the Questionnaire of Olfactory Disorders-Negative Statements, a tool mostly focused to identify psychologic impairment due to olfactory dysfunction than the olfactory impairment itself; moreover, the social anxiety, annoyance, and eating questions are possibly severe confounding factors in patients hospitalized, isolated, and concerned about their health in a pandemic scenario. In our University Hospital, the anamnestic interview of patients transited in the Covid-19 inpatient wards revealed olfactory disorders in 25–30% of affected individuals. This figure is close to the data reported by Giacomelli et al. [3] in 60 patients. In this group, 39% reported olfactory or gustatory disorders in a questionnaire including olfactory and taste disorders [3]. Our convincement is that the use of a questionnaire focused on the psychologic and social burden of olfactory disorders, especially in the context of a pandemic scenario and the consequent restrictions in social life, might lead to overestimation. When the situation (risks and emergency contingencies) does not allow to investigate olfaction with validated and more objective tests, in our view, it is advisable to use a questionnaire directly focused on the symptoms, both nasal and olfactory ones.

Tracheostomy in the COVID-19 pandemic

Abstract: The role of tracheostomy in COVID-19-related ARDS is unknown. Nowadays, there is no clear indication regarding the timing of tracheostomy in these patients. We describe our synergic experience between ENT and ICU Departments at University Hospital of Modena underlining some controversial aspects that would be worth discussing tracheostomies in these patients. During the last 2 weeks, we performed 28 tracheostomies on patients with ARDS due to COVID-19 infection who were treated with IMV. No differences between percutaneous and surgical tracheostomy in terms of timing and no case of team virus infection. In our experience, tracheostomy should be performed only in selected patients within 7- and 14-day orotracheal intubation.

Olfactory and gustatory dysfunctions in 100 patients hospitalized for COVID-19: sex differences and recovery time in real-life.

Abstract: COVID-19 displays a variety of clinical manifestations; in pauci-symptomatic patients olfactory (OD) and gustatory dysfunctions (GD) may represent the first or only symptom. This topic is currently arousing great interest, and a growing number of papers are being published. Aim of this study is to investigate the timing of recovery from OD and GD in a real-life population hospitalized for COVID-19. We followed up by a phone interview the first 100 patients discharged a month earlier from three Italian non-intensive care wards. All 100 patients were Caucasian, mean age was 65 years, 60% were males. Forty-two patients (mean age 63 years) experienced subjective chemosensory dysfunctions (29 OD and 41 GD): the male/female ratio was 2:1; 83% reported a complete or near complete recovery at follow-up. The recovery rate was not significantly different between males and females. The mean duration of OD and GD was 18 and 16 days, respectively. The mean recovery time from OD or GD resulted significantly longer for females than for males (26 vs 14 days, P = 0.009). Among the 42 symptomatic, the mean age of males was significantly higher than that of females (66 vs 57 years, P = 0.04), while the opposite was observed in the 58 asymptomatic patients (60 vs 73 years, P = 0.0018). Recovery from OD or GD was rapid, occurring within 4 weeks in most patients. Chemosensory dysfunctions in women was less frequent, but longer lasting. The value of our study is its focus on a population of hospitalized patients significantly older than those previously described, and the additional data on gender differences.

The role of self-reported smell and taste disorders in suspected COVID­19.

Abstract: The sudden onset of smell and taste loss has been reported as a symptom related to COVID-19. There is urgent need to provide insight to the pandemic and evaluate anosmia as a potential screening symptom that might contribute to the decision to test suspected cases or guide quarantine instructions. Systematic review of the PubMed/Medline, Cochrane databases and preprints up to May 3, 2020. Combined search terms included: “COVID-19”, “SARS-CoV-2”, “coronavirus”, “nose”, “anosmia”, “hyposmia”, “olfactory loss”, “smell loss”, “taste loss”, and “hypogeusia”. Our search identified 18 reviewed articles and 6 manuscript preprints, including a large epidemiological study, four observational case series, five case–controlled studies, five cross-sectional studies, five case series of anosmic patients and four electronic surveys. Great methodological differences were noted. A significant prevalence of anosmia is reported in COVID-19 patients. Controlled studies indicate that anosmia is more common in COVID-19 patients than in patients suffering from other viral infections or controls. Most of the studies reported either smell loss or smell plus taste loss. Less severe COVID-19 disease is related to a greater prevalence of anosmia. A quick recovery of the smell loss may be expected in most COVID-19 cases. Anosmia is more prevalent in COVID-19 patients than in patients suffering from other respiratory infections or controls.

Deep neck space infections: an upward trend and changing characteristics

Abstract: This study reviews our experience with deep neck space infections (DNIs) requiring surgical intervention, including cervical necrotizing fasciitis. The aim of the study was to identify predisposing and aggravating factors of the disease and recognize the possible factors that can lead to life-threatening complications and slow down the healing process. We compare the results to previous data from 1985 to 2005 to find possible alterations and changing trends. The characteristics of four lethal cases are described. This retrospective analysis includes patient data from 2004 to 2015 in tertiary referral hospital and in total, 277 patients were found. Surgical drainage through a neck opening ± intraoral incision was made in 215 (77.6%) patients, an intraoral incision was only made in 62 patients (22.4%). ICU care was needed in 66 (23.8%) cases. Odontogenic etiology (44.8%) was the most common origin. The most common comorbidity was a psychiatric disorder and/or dementia and occurred in 55 (19.9%) patients. Patients with underlying illnesses were more likely to be admitted to the ICU (p = 0.020), required a longer ICU stay (p = 0.004) and repeated surgery (p = 0.009). Gas formation seemed to be predictive of a more severe course of infection. Early extraction of the odontogenic foci was related to a lower length of stay (LOS) (p = 0.039). The annual numbers have risen from 14 to 24 cases per year when compared to previous data. DNIs remain a cause of lethal complications; the mortality was 1.4% and overall complications occurred in 61 (22.0%) patients.

New onset of loss of smell or taste in household contacts of home-isolated SARS-CoV-2-positive subjects.

Abstract: To estimate the prevalence of smell or taste impairment in household contacts of mildly symptomatic home-isolated SARS-CoV-2-positive patients. Cross-sectional study based on ad hoc questions. Of 214 mildly symptomatic COVID-19 patients managed at home under self-isolation, 179 reported to have at least one household contact, with the total number of no study participants contacts being 296. Among 175 household contacts not tested for SARS-CoV-2 infection, 67 (38.3%) had SARS-CoV-2 compatible symptoms, 39 (22.3%) had loss of smell or taste with 7 (4.0%) having loss of smell or taste in the absence of other symptoms. The prevalence of smell or taste impairment was 1.5% in patients tested negative compared to 63.0% of those tested positive for SARS-CoV-2 (p < 0.001). Smell or taste impairment are quite common in not-tested household contacts of mildly symptomatic home-isolated SARS-CoV-2-positive patients. This should be taken into account when estimating the burden of loss of sense of smell and taste during COVID-19 pandemic, and further highlights the value of loss of sense of smell and taste as a marker of infection.

Olfactory and gustatory abnormalities in COVID-19 cases.

Abstract: At the time of writing, there is a pandemic affecting virtually every country on Earth There is considerable discussion amongst clinicians as well as lay people about anosmia and ageusia in COVID-19 sufferers We aimed to report the results from comprehensive olfactory and gustatory testing in a series of hospital in-patients The prospective study evaluated 81 individuals with a COVID-19 infection, as confirmed by 2019 n-cov Real-Time PCR laboratory testing The control group consisted of forty individuals with COVID-19 negative Olfactory and gustatory testings were carried out by an examiner utilizing stringent safety standards and wearing full personal protective equipment The results obtained in the case group were then compared with those obtained for the controls In the case group, 41(506%) of patients were male and 40 (494%) were female, mean age of 5416 ± 1698 years (18–95) In the control group, 21 (525%) of subjects were male and 19 (475%) were female, and mean age was 55 ± 1539 years (18–90) Fifty (617%) COVID-19-positive patients had complaints related to olfaction The distribution of olfactory symptoms in the case group differed at the level of statistical significance from the control group (p < 0001) Turning to gustatory abnormalities, within the case group, 22 individuals (272%) had taste malfunction A statistically significant difference was found in the distribution of gustatory abnormalities between cases and controls (p < 0001) Olfactory and gustatory dysfunctions are strongly associated with SARS-CoV-2 infection Hyposmia with or without hypogeusia is potentially a reliable indicator of latent COVID-19

Facial nerve electrodiagnostics for patients with facial palsy: a clinical practice guideline

Abstract: Facial nerve electrodiagnostics is a well-established and important tool for decision making in patients with facial nerve diseases. Nevertheless, many otorhinolaryngologist—head and neck surgeons do not routinely use facial nerve electrodiagnostics. This may be due to a current lack of agreement on methodology, interpretation, validity, and clinical application. Electrophysiological analyses of the facial nerve and the mimic muscles can assist in diagnosis, assess the lesion severity, and aid in decision making. With acute facial palsy, it is a valuable tool for predicting recovery. This paper presents a guideline prepared by members of the International Head and Neck Scientific Group and of the Multidisciplinary Salivary Gland Society for use in cases of peripheral facial nerve disorders based on a systematic literature search. Required equipment, practical implementation, and interpretation of the results of facial nerve electrodiagnostics are presented. The aim of this guideline is to inform all involved parties (i.e. otorhinolaryngologist—head and neck surgeons and other medical specialists, therapeutic professionals and the affected persons) and to provide practical recommendations for the diagnostic use of facial nerve electrodiagnostics.

Risk factors of pharyngocutaneous fistula after total laryngectomy: a systematic review and meta-analysis

Abstract: The purpose of this study was to systematically evaluate the risk factors of pharyngocutaneous fistula (PCF) after total laryngectomy. We systematically searched Pubmed, Web of Science, Cochrane Library, and Embase databases and included the literature according to the inclusion and exclusion criteria. A total of 52 studies with 8605 patients were included in the meta-analysis. The total incidence of PCF was 21% (1808/8605). Meta-analysis results indicated that age (OR = 1.29, 95% CI 1.06–1.58, P = 0.01), smoking (OR = 1.62, 95% CI 1.27–2.07, P < 0.01), COPD (chronic obstructive pulmonary disease) (OR = 1.62, 95% CI 1.19–2.22, P < 0.01), CAD (coronary atherosclerotic heart disease) (OR = 1.82, 95% CI 1.36–2.45, P < 0.01), T-stage (OR = 0.81, 95% CI 0.67–0.98, P = 0.03), previous radiotherapy (OR = 2.41, 95% CI 2.00–2.90, P < 0.01), preoperative albumin (OR = 2.95, 95% CI 1.47–5.91, P < 0.01), preoperative hemoglobin (OR = 1.97, 95% CI 1.28–3.03, P < 0.01), tumor site (OR = 0.28, 95% CI 0.22–0.36, P < 0.01), and treatment method (OR = 1.85, 95% CI 1.44–2.38, P < 0.01) were risk factors associated with PCF. In our study, age, smoking, COPD, CAD, T-stage, previous radiotherapy, preoperative albumin, preoperative hemoglobin, tumor site, and treatment method were risk factors of PCF.

Patients with acid, high-fat and low-protein diet have higher laryngopharyngeal reflux episodes at the impedance-pH monitoring

Abstract: To assess the impact of diet on the occurrence of proximal reflux episodes at the multichannel intraluminal impedance-pH monitoring (MII-pH) in patients with laryngopharyngeal reflux (LPR). Patients with LPR symptoms and findings were recruited from three European hospitals. The LPR diagnostic was confirmed through MII-pH and patients were benefited from gastrointestinal (GI) endoscopy. Regarding the types of reflux at the MII-pH (acid, nonacid, mixed), patients received a 3 month-therapy based on the association of alkaline, low-fat and high-protein diet, proton pump inhibitors, alginate or magaldrate. Reflux symptom score (RSS) and reflux sign assessment (RSA) were used to evaluate laryngeal and extra-laryngeal symptoms and findings from pretreatment to posttreatment. The Global Refluxogenic Score (GRES) was used to assess the refluxogenic potential of the diet of the patients at baseline and posttreatment. The relationship between GRES severity; the MII-pH findings; GI endoscopy; and the therapeutic response was explored through multiple linear regression. Eighty-five LPR patients were included. The mean GRES significantly improved from pretreatment (50.7 ± 23.8) to posttreatment (27.3 ± 23.2; P = 0.001). Similarly, RSS and RSA significantly improved from baseline to posttreatment. The baseline GRES was significantly associated with the occurrence of proximal reflux episodes at the MII-pH (P = 0.001). Trends were found regarding the association between GRES and the occurrence of esophagitis (P = 0.06) and between hiatal hernia and DeMeester score (P = 0.06). There was a significant and strong association between the concomitant respect of diet and medication and the improvement of RSS (P = 0.001). The consumption of high-fat, low-protein, high-sugar, acid foods, and beverages is associated with a higher number of proximal reflux episodes at the MII-pH, according to the global refluxogenic score of LPR patients.

Possible link between anosmia and COVID-19: sniffing out the truth.

Abstract: Coronavirus disease 2019 (COVID-19) is a new respiratory disease that is spreading widely and rapidly throughout the world [1]. The most common clinical presentations of COVID-19 are now well known and include fever, cough, fatigue, headache, gastrointestinal discomfort, dyspnoea and muscle ache [2]. However, we are increasingly observing two additional symptoms in infected patients: anosmia and ageusia. Numerous reports, telephone calls, emails and direct olfactory complaints from concerned collaborators have reached us during the last weeks and our clinical impression is that these symptoms seem to appear late in the course of disease (second–third week) and eventually coincide with healing in patients experiencing mild symptoms. A questionnaire study conducted in several European countries seems to confirm that both olfactory and gustatory dysfunctions are significant symptoms in COVID-19 [3]. Despite similarities between the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and SARS-CoV in sequence, pathogenesis, cellular entry and clinical features [4], anosmia has never been described in SARS. Anosmia, the inability to smell, is estimated to afflict 3–20% of the population [5, 6] and can result from many underlying diseases. Olfactory impairment after upper respiratory tract infection is well-known and a frequent cause of consultation in specialized smell and taste outpatient clinics [7]. However, the exact location of the damage in postupper respiratory infections remains unknown, even though biopsies have suggested a direct damage of the olfactory epithelium [8]. A recent study demonstrated that nasal epithelial cells display a very high angiotensin converting 2 (ACE2) expression in SARS-CoV-2 infection, thus allowing wide viral entry [9]. Consequently, peripheral nerve injury might occur causing anosmia, frequently observed in infected patients in our clinical practice.

Nasal, pharyngeal and laryngeal endoscopy procedures during COVID-19 pandemic: available recommendations from national and international societies.

Abstract: The Severe Acute Respiratory Syndrome-CoronaVirus-2 (SARS-CoV-2), also known as COVID-19, pandemic is engaging clinicians around the world in an unprecedented effort to limit the viral spread and treat affected patients; the rapid diffusion of the disease represents a risk for healthcare providers who have a close contact with the upper aerodigestive tract during medical, diagnostic and surgical procedures [1]. Available evidence from China, Iran, Italy and United States [2, 3] suggests that otolaryngology specialists have a considerably high risk of contracting COVID-19 infection due to diagnostic or surgical aerosol-generating procedures (e.g. laryngeal endoscopy), as well as during head and neck emergency or surgical procedures [4, 5]. Nasal, pharynx and laryngeal endoscopy represents a high-risk procedure for otolaryngologists as it is commonly used in routine diagnostics, requires a short physical distance between patients and personnel, and can induce sneezing and coughing with consequent potential virus transmission through droplets, contact transmission and aerosol transmission especially in cases of long exposure to high concentrations of aerosols in closed environments [2, 5]. For this reason, recommendations for nasal, pharynx and laryngeal endoscopy during COVID-19 pandemic have been published by national and international otolaryngology and head and neck surgery societies. We conducted a review of the recent literature on endoscopic otolaryngology procedures during COVID-19 pandemic and evaluated available data published until April 15, 2020. Sixty-six societies have been identified and 27 (40.9%) of them published information and recommendations regarding nasal, pharyngeal and laryngeal endoscopy procedures during COVID-19 pandemic (Table 1). The majority of societies (24 societies—88.9%) suggested to perform endoscopy procedures only if strictly necessary; one (3.7%) recommended to avoid flexible endoscopy in all cases. Among them, the ENT UK at The Royal College of Surgeons of England suggested to consider whether to use or avoid topical decongestant and local anesthetic solution to reduce chances of sneezing and coughing during examination [6]. There is a lack of consensus about whether flexible or rigid endoscope should be used, while all societies recommended performing endoscopy using a monitor without directly viewing through the eyepiece. All national and international societies recommended the rational use of personal protective equipment (PPE) during the diagnostic procedures such as disposable gowns, gloves, FFP2 or N95 respirators and surgical masks, and eye protection (goggles or face shield), based on the experience of health care systems in Asia and Europe [1]; endoscopy staff should be protected against infectious material during the endoscopic procedure as well as against direct contact with contaminated equipment or potentially harmful chemicals during the sterilization procedures [7]. Furthermore, * Pietro De Luca dr.dlp@hotmail.it

3D exoscopic surgery of lateral skull base.

Abstract: The aim of the study is to assess whether the 3D exoscopic surgery technique could be used in lateral skull base surgery and if it could ultimately replace the microscope in the future. This is a retrospective study in which were included 24 patients affected by lateral skull base pathologies, who underwent surgery using the 3D exoscope or the operative microscope at the Department of Otolaryngology—Head and Neck Surgery at the University Hospital of Verona. The exoscope and microscope groups each included 12 cases. The feasibility of all the surgical steps solely using the 3D exoscope was evaluated. The exoscope group and microscope group were compared taking into account the following factors: time of the surgery, facial and hearing functions outcomes, as well as the intraoperative and postoperative complications. No intraoperative complication occurred during all the procedures. Postoperatively, only one minor complication emerged. The average operative time was 289 in the exoscope group and 313 min in the microscope one. No significant statistical differences were identified between the two groups (p > 0.05). The facial and hearing function outcomes were fully comparable. Our experience demonstrated that the exclusive use of the 3D exoscope, as that of the traditional microscope during lateral skull base surgery, is feasible for all open approaches. The use of the 3D exoscopic technique is very promising for future lateral skull base surgeries.

Preservation of residual hearing after cochlear implant surgery with slim modiolar electrode.

Abstract: To evaluate the insertion results and hearing preservation of a novel slim modiolar electrode (SME) in patients with residual hearing. We retrospectively collected the data from the medical files of 17 patients (18 ears) implanted with a SME. All patients had functional low frequency hearing (PTA (0.125–0.5 kHz) ≤ 80 dB HL). The insertion results were re-examined from the postoperative cone-beam computed tomography scans. Postoperative thresholds were obtained at the time of switch-on of the sound processors (mean 43 days) and at latest follow-up (mean 582 days). The speech recognition in noise was measured with the Finnish matrix sentence test preoperatively and at follow-up. The mean insertion depth angle (IDA) was 395°. Neither scala dislocations nor tip fold over were detected. There were no total hearing losses. Functional low-frequency hearing was preserved in 15/18 (83%) ears at switch-on and in 14/17 (82%) ears at follow-up. According to HEARRING classification, 55% (10/18) had complete HP at switch-on and 41% (7/17) still at follow-up. Thirteen patients (14 ears) were initially fitted with electric–acoustic stimulation and seven patients (8 ears) continued to use it after follow-up. The preliminary hearing preservation results with the SME were more favorable than reported for other perimodiolar electrodes. The results show that the array may also be feasible for electro-acoustic stimulation; it is beneficial in that it provides adequate cochlear coverage for pure electrical stimulation in the event of postoperative or progressive hearing loss.

A review of the 8th edition of the AJCC staging system for oropharyngeal cancer according to HPV status.

Abstract: Background The incidence of oropharyngeal squamous cell carcinoma (OPSCC) has increased substantially in recent decades, particularly p16-positive human papillomavirus (HPV)-related OPSCC, which has risen by 50% in western countries. HPV-positivity is the most favourable non-anatomic predictor of oropharyngeal cancer outcomes, which underscores the importance of incorporating this variable into the cancer staging system. Methods In the present article, we review the differences between the 7th and 8th editions of the AJCC staging system, with particular focus on the role of HPV-positivity in patients with head and neck cancer. Results In the previous edition (7th edition) of the AJCC/UICC manual, HPV status and its correlation with nodal metastasis were not considered, thereby leading to incorrect lymph node (N) staging and, potentially, inadequate treatment and worse outcomes. The 8th edition of the AJCC manual addresses these issues, providing more accurate discrimination between groups and better risk stratification in patients with HPV-positive OPSCC. In the future, additional adjustments are likely to be needed, such as unification of the pathological and clinical staging models. Conclusions The new staging system is substantially more accurate than the previous system and should be widely adopted in routine clinical practice.

COVID-19: what happened to all of the otolaryngology emergencies?

Abstract: COVID-19 is a global pandemic caused by the novel coronavirus SARS-CoV-2, and Italy was the first European country to experience a large-scale outbreak. With this, every aspect of healthcare, the economy, and society has been deeply affected in Italy, so much so that fundamental changes are expected in the post-COVID-19 era. One aspect is that access to emergency care in Otolaryngology (ORL) patients has already changed in the month following the onset of the COVID-19 outbreak, and, seemingly, many non-COVID illnesses have been disappearing. Although the government did not enact any limitations or prohibitions to emergency access for patients afflicted by acute ORL pathologies, the number of daily urgent consultations to the ORL Departments in Bari and Foggia University Hospitals has significantly reduced and, on some days, was even zero. One possible reason for this change may be patients’ fear of acquiring a nosocomial COVID-19 infection. Even so, it is difficult to believe that some acute diseases, such as massive epistaxis, otitis, or pharyngotonsillitis, could have occurred so rarely or not at all or, alternately, could have been treated at home by patients or their families. Rather, most certainly, primary care physicians, who have been performing telehealth consultations in accordance with the guidelines from the Higher Institute of Health (ISS), have been providing an invaluable service [1]; it is posited that patients who received primary care services this way may have been able to delay or even forego specialist evaluation. This telehealth treatment has not only helped to keep patients at home but has provided other benefits and should be considered in the future. Table 1 shows data regarding the number of emergency department consultations by diagnosis in the 30 days preceding (from February 8th to March 8th, 2020) and 30 days following (from March 9th to April 9th, 2020) the onset of the COVID-19 outbreak at the two main tertiary referral centers in the Puglia region, as well as the percentage reduction for each diagnosis. The data revealed an overall decrease in the number of ORL emergency consultations by 80.8%. Of note, reductions were noted across all subspecialties. Although some illnesses, such as rhinitis, sinusitis, uvular edema, and tinnitus, do not usually require immediate attention, it is more difficult to explain the large reduction, ranging from 80.2% to 88.9%, of other diagnoses, such as vertigo, epistaxis, sudden hearing loss, otitis media, and peritonsillar abscesses, which often merit urgent ORL consultations. The reduction of some diagnoses may be the consequence of national lockdown orders. For example, the 84.6% reduction in the number of nasal bone fractures may be related to the near-absence of motor vehicle accidents reported during this time. In contrast, it is more difficult to explain the reduction of other acute diseases such as sudden hearing loss, whose frequency decreased 83.3%, especially when compared to non-disease conditions, such as cerumen impaction, whose reduction in presentation, interestingly, was slightly more modest at 73.7%. * Eleonora M. C. Trecca eleonoramc.trecca@gmail.com; eleonora.trecca@unifg.it

Indications and timing for tracheostomy in patients with SARS CoV2-related.

Abstract: Background The indications and timing for tracheostomy in patients with SARS CoV2-related are controversial. Purpose In a recent issue published in the European Archives of Otorhinolaryngology, Mattioli et al. published a short communication about tracheostomy timing in patients with COVID-19 (Coronavirus Disease 2019); they reported that the tracheostomy could allow early Intensive Care Units discharge and, in the context of prolonged Invasive Mechanical Ventilation, should be suggested within 7 and 14 days to avoid potential tracheal damages. In this Letter to the Editor we would like to present our experience with tracheostomy in a Hub Covid Hospital. Methods 8 patients underwent open tracheostomy in case of intubation prolonged over 14 days, bronchopulmonary overlap infections, and patients undergoing weaning. They were followed up and the number and timing of death were recorded. Results Two patients died after tracheostomy; the median time between tracheostomy and death was 3 days. A negative prognostic trend was observed for a shorter duration of intubation. Conclusion In our experience, tracheostomy does not seem to influence the clinical course and prognosis of the disease, in the face of possible risks of contagion for healthcare workers. The indication for tracheostomy in COVID-19 patients should be carefully evaluated and reserved for selected patients. Although it is not possible to define an optimal timing, it is our opinion that tracheostomy in a stable or clinically improved COVID-19 patient should not be proposed before the 20th day after orotracheal intubation.

Endoscopic stapedotomy: safety and audiological results in 150 patients

Abstract: The most widely accepted treatment for otosclerosis is currently microscopic stapes surgery under either local or general anesthesia. The aim of the study is to describe the surgical steps in endoscopic stapes surgery and to evaluate the audiologic and surgical outcomes. All patients who underwent exclusive endoscopic stapes surgery or revision surgery for previous stapedotomy between November 2014 and September 2018 were enrolled in this study. Demographic data, surgical information, preoperative and postoperative pure tone averages and air bone gaps, intraoperative and postoperative complications and follow-up data were summarized and gathered in a database for further consideration and analysis. In the period examined, 181 stapes surgical procedures were performed and out of these 150 met the inclusion criteria. There were no cases of major intraoperative complications. Sensorineural hearing loss was observed in one case. In one patient a gusher effect occurred during surgery. The postoperative air–bone gap improved significantly compared to the preoperative gap (8 vs 29 dB HL, respectively), and the mean air–bone gap closure was 20 dB HL. In 78.7% of cases, the observed postoperative air–bone gap was less than 10 dB HL and in 14% it was between 11 dB HL and 20 dB HL. An ABG closure lower than 20 dB HL was achieved in a total of 92.7% of patients. Endoscopic stapes surgery is a safe procedure with a low risk of peri- or postoperative complications and is a possible alternative to the traditional microscopic surgical procedure in the treatment of otosclerosis.

Surgery for necrotizing otitis externa-indications and surgical findings.

Abstract: Treatment for necrotizing otitis externa (NOE) includes long term antibiotic and surgery in selected cases. Indications and extent of surgery, however, are still not defined. The aims of this study were: (1) present our experience in surgery for NOE (2) compare high-resolution computer tomography and perioperative findings (3) suggest recommendations for indications and extent of surgery. A retrospective case series study was conducted in a tertiary referral center. Patients hospitalized due to NOE between the years 1990–2015 and underwent surgery were included. Twenty patients were included in the study. HRTBCT was performed in 17 patients. Most common radiological findings included mastoid fullness (n = 13, 76.4%) and edema of external ear canal (n = 12, 70.5%). Surgical indications included lack of response to treatment (n = 18) and facial nerve palsy (n = 2). Seven patients underwent local debridement. Most common operative findings included soft tissue necrosis (n = 4, 57.1%) and gross bony destruction of the external ear canal (n = 2, 28.5%). Thirteen patients underwent tympanomastoid surgery. Most common operative findings included granulation tissue in the mastoid (n = 7, 53.8%) and mastoid bony erosion (n = 4, 30.7%). Facial canal involvement was seen in four patients (30.7%). This is the first study to describe a large group of surgically treated NOE. Initial surgical approach should be based on clinical and HRTBCT findings. Minimal HRTBCT findings may be addressed with local debridement. Severe HRTBCT findings should be addressed with canal wall up mastoidectomy as the minimal surgical procedure. Further extent should be decided based on perioperative findings.

Effect of tonsillectomy on humeral and cellular immunity: a systematic review of published studies from 2009 to 2019.

Abstract: Although tonsillectomy is the most commonly performed surgical operation for children, its postoperative effect on the immune response was a source of debate among physicians. The aim of this systemic review was study the effect of tonsillectomy on children immune response. PubMed, Medline, Embase and Cochrane Library. All relevant articles published English language addressing the effect of tonsillectomy on the immune system were included. One investigators extracted data regarding: year of the study, sample size, study design, sample size, timing of analysis, studied immune factors, result and conclusion were identified. Another investigator independently reviewed data accuracy. Ten articles published between from January 2009 to January 2019 in about this issue that included 404 children were reviewed. All reviewed studies showed a non-significant difference between levels of indicators of the humeral immunity (IgA, IgG, IgM, C3 and C4) pre- and postoperatively. Studies that measured these indicators only after surgery, showed a non-significant difference in their levels between patients and healthy controls. Levels of indicators of cellular immunity (CD4+ , CD3+ , CD8+ , CD19+ , CD25+ , CD16+ , CD+ 56) showed slight reduction or increase in some studies but without a significant difference compared to their levels preoperatively, postoperatively at different intervals or with healthy controls. Other studies found no changes in these indicators postoperatively. There was enough evidence to conclude that tonsillectomy has no negative affect on both humeral and cellular immunity of children

Olfactory training ball improves adherence and olfactory outcomes in post-infectious olfactory dysfunction

Abstract: In an effort to make olfactory training (OT) simpler, we designed an ‘olfactory training ball’ (OTB)—a baseball-size ball with four odor-containing tubes to use in OT. The study aimed to investigate the effects of OT with the OTB in comparison to classical OT with special attention to the effects of adherence to OT on olfactory outcome measures. Sixty patients with olfactory dysfunction following infections of the upper respiratory tract received OT either with classical methods—sniffing odors from jars (COT)—or the OTB for 12 weeks. Patients exposed themselves to the odors for 5 min twice daily. Adherence was measured with a modified version of the Morisky scale. Before and after OT, all patients underwent extensive olfactory testing using the Sniffin’ Sticks test. At the end of the 12 weeks of OT, TDI composite score (22.1 ± 2.8 vs. 19.9 ± 4.7, P = 0.044) and odor discrimination subtest scores (9.1 ± 1.8 vs.7.6 ± 2.5, P = 0.013) of the OTB group were significantly higher than that of the COT group. Adequate adherence to OT was significantly higher in patients receiving OTB when compared to those receiving COT (63% vs. 30%, P = 0.019). The present study shows that a novel OT device, the OTB, provides better adherence to the training process compared to COT. Moreover, findings of the current study show that better adherence to the OT process is associated with better olfactory outcomes.

Rehabilitation of dynamic visual acuity in patients with unilateral vestibular hypofunction: earlier is better.

Abstract: Patients with acute peripheral unilateral hypofunction (UVH) complain of vertigo and dizziness and show posture imbalance and gaze instability. Vestibular rehabilitation therapy (VR) enhances the functional recovery and it has been shown that gaze stabilization exercises improved the dynamic visual acuity (DVA). Whether the effects of VR depend or not on the moment when it is applied remains however unknown, and investigation on how the recovery mechanisms could depend or not on the timing of VR has not yet been tested. Our study investigated the recovery of DVA in 28 UVH patients whose unilateral deficit was attested by clinical history and video head impulse test (vHIT). Patients were tested under passive conditions before (pre-tests) and after (post-tests) being subjected to an active DVA rehabilitation protocol. The DVA protocol consisted in active gaze stabilization exercises with two training sessions per week, each lasting 30 min, during four weeks. Patients were sub-divided into three groups depending on the time delay between onset of acute UVH and beginning of VR. The early DVA group (N = 10) was composed of patients receiving the DVA protocol during the first 2 weeks after onset (mean = 8.9 days), the late group 1 (N = 9) between the 3rd and the 4th week (mean = 27.5 days after) and the late group 2 (N = 9) after the 1st month (mean: 82.5 days). We evaluated the DVA score, the angular aVOR gain, the directional preponderance and the percentage of compensatory saccades during the HIT, and the subjective perception of dizziness with the Dizziness Handicap Inventory (DHI). The pre- and post-VR tests were performed with passive head rotations done by the physiotherapist in the plane of the horizontal and vertical canals. The results showed that patients submitted to an early DVA rehab improved significantly their DVA score by increasing their passive aVOR gain and decreasing the percentage of compensatory saccades, while the late 1 and late 2 DVA groups 1 and 2 showed less DVA improvement and an inverse pattern, with no change in the aVOR gain and an increase in the percentage of compensatory saccades. All groups of patients exhibited significant reductions of the DHI score, with higher improvement in subjective perception of dizziness handicap in the patients receiving the DVA rehab protocol in the first month. Our data provide the first demonstration in UVH patients that earlier is better to improve DVA and passive aVOR gain. Gaze stabilization exercises would benefit from the plastic events occurring in brain structures during a sensitive period or opportunity time window to elaborate optimal functional reorganizations. This result is potentially very important for the VR programs to restore the aVOR gain instead of recruiting compensatory saccades assisting gaze stability.

Ultra-high-fidelity virtual reality mastoidectomy simulation training: a randomized, controlled trial.

Abstract: Ultra-high-fidelity (UHF) graphics in virtual reality (VR) simulation might improve surgical skill acquisition in temporal bone training. This study aims to compare UHF VR simulation training with conventional, screen-based VR simulation training (cVR) with respect to performance and cognitive load (CL). In a randomized trial with a cross-over design, 24 students completed a total of four mastoidectomies in a VR temporal bone surgical simulator: two performances under UHF conditions using a digital microscope and two performances under conventional conditions using screen-based VR simulation. Performances were assessed by two blinded raters using an established assessment tool. In addition, CL was estimated as the relative change in secondary-task reaction time during simulation when compared with individual baseline measurements. Data were analyzed using linear mixed model analysis for repeated measurements. The mean final-product performance score was significantly lower in UHF VR simulation compared to cVR simulation [mean difference 1.0 points out of 17 points, 95% CI (0.2–1.7), p = 0.02]. The most important factor for performance during UHF simulation was the ability to achieve stereovision (mean difference = 3.4 points, p < 0.001). Under the UHF VR condition, CL was significantly higher than during cVR (28% vs. 18%, respectively, p < 0.001). UHF graphics in VR simulation training reduced performance and induced a higher CL in novices than conventional, screen-based VR simulation training. Consequently, UHF VR simulation training should be preceded by cVR training and might be better suited for the training of intermediates or experienced surgeons.

Cochlear implantation in adults with single-sided deafness: generic and disease-specific long-term quality of life

Abstract: To determine the 2-year outcome of health-related quality of life (HRQoL) in adults who received a cochlear implant (CI) for single-sided deafness (SSD). Twenty adults (mean age at implantation: 47 ± 11 years) with SSD (PTA worse ear: 113 dB HL, PTA better ear: 14 dB HL) were administered the Nijmegen Cochlear Implant Questionnaire (NCIQ), and the Health Utility Index 3 (HUI 3). Questionnaire administration occurred before cochlear implantation and 3, 6, 12, and 24 months after implant activation. Of the 20 patients, 2 discontinued CI use within the observation period due to poor benefit. The NCIQ total score of the sample increased significantly over time (p = 0.003). The largest increase occurred within the first 3 months of CI use. Also, the HUI 3 multi-attribute utility score increased significantly (p = 0.03). The post-treatment increase of this score (+ 0.11 points) indicated that the gain in HRQoL was clinically relevant. Patients with a duration of deafness > 10 years had in all measures an equal HRQoL improvement than had patients with a duration of deafness < 10 years. Cochlear implantation led to significant improvement of hearing-specific and generic HRQoL in our patients. The improvement was seen after 3 or 6 months but did not increase further at later intervals. Patients with long-lasting SSD may be at higher risk of discontinuing CI use. However, if they adapt to the CI, they can experience an equal increase of HRQoL as patients with a short duration of SSD.

Video head impulse test and caloric test in definite Ménière's disease.

Abstract: The objective of the study was to compare the results of caloric reflex tests and video head impulse tests (vHITs) of lateral semicircular canals (SCCs). Patients aged over 18 years diagnosed with definite Meniere’s disease (MD) according to the AAO–HNS 1995 criteria were recruited. Audiological tests, caloric tests and vHITs were conducted on all participants. A caloric weakness (canal paresis) of > 25% was considered significant. A VOR gain of < 0.8 in lateral or 0.7 in vertical SCCs was defined as significant. Patients were classified into active (having symptoms during the preceding 3 months) and inactive groups (free of symptoms for over 3 months). 51 patients (13 males and 38 females) participated. Caloric weakness was found in 39 patients (76.5%), while abnormal VOR gain was found in 24 (47.1%). The active group had 40 patients, and the inactive group had 11. There was statistical significance (p, 0.002) for disease duration but not for the caloric weakness and vHIT results of the two groups. Moreover, caloric weakness with an abnormal vHIT was not statistically significant, and there was no correlation between the two tests (r, 0.207) in lateral SCCs. The most common abnormal VOR gain in patients with caloric weakness was found in anterior SCCs. The caloric test can detect abnormalities of the vestibular function better than vHIT in all stages of MD. However, the vHIT showed more specificity for the detection of abnormal SCC function. The vHIT test can be used as a screening tool and the caloric test should be considered if a vHIT result is normal.

Lateral pharyngoplasty techniques for obstructive sleep apnea syndrome: a comparative experimental stress test of two different techniques.

Abstract: To show the different effects of expansion sphincter pharyngoplasty (ESP) and barbed reposition pharyngoplasty (BRP) on muscle tension and muscle fiber tearing using a comparative experimental stress test with a frog thigh muscle model. Frog thigh muscle was used for this experimental study. A Barbed suture was used to simulate the BRP pharyngoplasty whereas a Vicryl 3-0 suture was used to simulate the ESP technique. The other extremity of the suture was attached to traction scales. The traction scales were used to measure the weight relative to the amount of force required to obtain muscle breaking. Both surgical techniques were simulated on the frog muscle. Traction was performed until muscle breaking was observed, measuring the value of force needed to obtain muscle rupture. Specimen muscle breakdown in the ESP simulation occurred with an average value of 0.7 kg of traction force. Contrarily, specimen muscle breakdown in the BRP simulation with Barbed suture occurred with an average value of 1.5 kg of traction force During simulation of the ESP technique, specimen muscle breakdown occurred with an average value of traction force lower than in the BRP technique. During traction the multiple lateral sustaining suture loops of BRP could ensure greater stability then the single pulling tip suture of ESP with minor risk of muscle fiber damage.