Showing papers in "International Archives of Otorhinolaryngology in 2020"

High risk of covid-19 infection for head and neck surgeons

Abstract: The epidemic of a serious respiratory disease caused by a new coronavirus virus that started in Wuhan (Hubei province), China, was first reported to the local World Health Organization (WHO) office on December 31, 2019. The virus and disease were labeled as Severe Acute Respiratory Syndrome (SARS-CoV-2) coronavirus 2. The disease caused by this virus was later called COVID-19.1 It was declared an international health emergency by WHO on January 30, 2020.2On February 26, 2020, the BrazilianMinistry of Health confirmed the first case in Brazil.3 In less than 4 weeks, more than 1,100 cases and 18 deaths were registered in the country.4 More than 80% of the patients with COVID-19 are asymptomatic or oligosymptomatic. Approximately 15% require hospitalization and 3% to 5% evolve to severe clinical conditions requiring ventilatory support in an intensive care unit (ICU). The mortality rate varies from 0.3 to 8%, with a higher risk for the elderly, hypertensive and diabetic patients.3,5,6 On March 20, 2020, we have an accelerated pandemic that puts almost the entire world population at risk, with more than 330,000 cases and more than 14,000 registered deaths.7 The first death of a doctor whowas a victim of COVID-19 in Wuhan was an otolaryngologist on January 20, 2020.5 The death from the disease of the ophthalmologist Li Wenliang, who sinceDecember 2019 tried to alert theauthorities about a serious disease similar to SARS (another serious coronavirus) and was exonerated by the Chinese government, occurred on February 6 and revolted theworld.8,9Thefirst recorded case in Wuhan of contamination by a surgical team is frightening. All 14 participants in an endonasal video-assisted hypophysectomywere contaminated.10Given the high exposure to aerosols duringdiagnostic endoscopicprocedures or surgeries,manyof the doctors who died in China are otorhinolaryngologists or ophthalmologists.11 According to Patel et al,12 many Italian and Iranian otorhinolaryngologists are infected and in isolation. Fatalities have been reported not only among elderly doctors, but also young people, including an Iranian resident doctor of undisclosed age. A significant viral load is concentrated in the upper airways, being a probable cause of the high rate of infection and many deaths among otolaryngologists, head and neck surgeons, ophthalmologists and Chinese endoscopists in these 3 months of the epidemic.11–14 The same high risk has been recorded in Europe. Due to the contamination of this group of doctors, it can be observed that, in addition to the symptoms previously described, anosmia is a frequent finding.15,16 Thus, it is mandatory to alert all professionals who need to doheadandneckexams(includingeyeexams)ofpatients,with or without access to upper aerodigestive pathways (videolaryngoscopy, for example), rehabilitation procedures or even hygiene of this region (tracheostomies, dressings). Given the high professional risk, the Regional Council of Medicine of the State of São Paulo recommends that surgery and elective consultations be suspended, except for those of an oncological nature, in addition to urgencies and emergencies.17 In cancer cases, especially in patients with carcinomas of the upper aerodigestive tract, where the treatment of choice is surgical, it is important to investigate the contagion of COVID 19. The Stanford University team suggests that an examination be performed 2 days before the operation.12Not all surgeries can be rescheduled. During this period, special attention should be given to tracheostomies and other emergencies such as abscesses and cervicofacial trauma. Meticulous protective measures must be taken for all team members as well as the operating room, with the execution of the procedure in a negative pressure room and highefficiency particulate air (HEPA) filter in the anesthesia respirator car and the use of personal protective equipment.18

Lemierre Syndrome: A Meta-analysis.

Abstract: Introduction Lemierre syndrome, or postpharyngitis anaerobic sepsis, is an infrequent but life-threatening infection that often involves thrombosis of the internal jugular vein. The role of anticoagulation in addition to antibiotics and surgical treatment remains uncertain. Objectives 1) To perform a meta-analysis on outcomes and treatment of Lemierre syndrome; and 2) to evaluate the effect of anticoagulation in Lemierre syndrome on vessel recanalization and on mortality. Data Synthesis A Pubmed database search was conducted using the keywords Lemierre syndrome. A total of 427 studies were identified and reviewed. Data were extracted on patient demographics, treatment type including use and type of anticoagulation, type of antibiotics, presence and location of vessel thrombosis, presence of cranial neuropathies, recanalization of thrombosed vessels on follow-up imaging, organisms isolated on wound or blood cultures, and mortality. The primary outcome variables examined were the effect of anticoagulation on vessel recanalization and mortality. After the review, 359 studies totaling 394 patients between 1990 and 2017 had partial or complete data that could be analyzed. In total, 50 patients had sufficient data on the effect of anticoagulation on vessel recanalization, and 194 had sufficient data on the effect of anticoagulation on mortality. The odds ratio for anticoagulation and vessel recanalization was 1.6 (95% confidence interval = 0.3 to 9.4; p = 0.6). The odds ratio for anticoagulation and death was 0.6 (95% confidence interval = 0.1 to 2.9; p = 0.5). Conclusion The present meta-analysis did not demonstrate a statistically significant effect on vessel recanalization or mortality for patients treated with anticoagulation versus patients not anticoagulated in the Lemierre syndrome literature.

Otorhinolaryngologists and coronavirus disease 2019 (COVID-19)

Abstract: In December 2019,Wuhan City, the capital of Hubei province in China, became the center of an outbreak of pneumonia of unknown etiology. By January 7, 2020, Chinese scientists had isolated a novel coronavirus: severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; previously known as 2019-nCoV), from patients with viral pneumonia (COVID19).1,2 Due to the Public Health Emergency of International Importance declared by the World Health Organization (WHO) on January 30, 2020, caused by SARS-CoV-2 and the confirmation of the first cases of COVID-19 in Brazil (2 confirmed cases in the state of São Paulo by February 29, 2020), the Brazilian Association of Otorhinolaryngology and Cervico-Facial Surgery (Associação Brasileira de Otorrinolaringologia e Cirurgia Cervico-Facial, ABORL, in Portuguese) made a public announcement to guide otorhinolaryngologists in care protocols in their offices.3 Coronaviruses are a relatively common family of respiratory viruses and the second most frequent cause of common cold after rhinoviruses. In the recent decades, they have been related to more serious outbreaks, such as severe acute respiratory syndrome (SARS) in 2002 and Middle East respiratory syndrome (MERS) in 2012.3 There are seven identified coronaviruses that affect humans. The most common are α coronavirus 229E and NL63 and β coronavirus OC43 and HKU1, the viruses responsible for the SARS-CoV and MERS-CoV outbreaks respectively. Recently, a novel coronavirus has been identified, which was initially named 2019-nCoV and then SARS-CoV-2 on February 11, 2020, as it was found to be genetically related to SARS-CoV. The disease caused by the new coronavirus was named COVID-19.3 In practice, the healthcare system cannot sustain an uncontrolled outbreak, and stronger containment measures are now the only realistic option to avoid the total collapse of the intensive care unit (ICU) system. Hence, over the last 2 weeks, clinicians have continuously advised authorities to augment containment measures.4 While regional resources are currently at capacity, the central Italian government is providing additional resources, such as transfer of critically ill patients to other regions, emergency funding, personnel, and ICU equipment. The goal is to ensure that an ICU bed is available for every patient who requires one. Other healthcare systems should prepare for a massive increase in ICU demand during an uncontained outbreak of COVID-19.4 Vaccine development and research into medical treatment for COVID-19 are under way, but results are many months away. Meanwhile, the pressure on the global healthcare work force continues to intensify. This pressure takes two forms: the first is the potentially overwhelming burden of illnesses that stresses the capacity of health systems, and the second is the adverse effects on healthcare workers, including the risk of infection.5 Many healthcare workers have conditions that elevate the risk of severe infection or death if they become infected with SARS-CoV-2; hence, organizations will need to decide whether such workers, including physicians, should be redeployed away from the highest risk sites. It is not possible to entirely eliminate the risk, but prudent adjustments may be warranted. New sites may need physician and nurse expertise, including telemedicine services, patient advice lines, and augmented telephone triage systems.5

Prevalence of Mild Hearing Loss in Schoolchildren and its Association with their School Performance.

Abstract: Introduction Hearing is important for the proper development of every child, especially for those younger than 5 years of age, because it helps in the development of language and speech. Emotional and social problems, as well as issues with academic performance, can result from hearing loss even of mild degree. Early diagnosis and management can overcome those negative impacts. Objective To determine the prevalence of mild hearing loss in primary-school children and its association with their school performance. Methods A comparative cross-sectional study was conducted at a regular school. The study included the random selection of 120 apparently normal students (aged 6-9 years) who were considered as having normal hearing by their parents. A total of 20 students were excluded from the study due to the presence of wax in their ears. Finally, the study was conducted with 100 students. All participants were subjected to a basic audiological evaluation, and the Screening Instrument for Targeting Educational Risk (SIFTER) questionnaire was given to their teachers to evaluate their school performance. Results From a total of 100 students, we confirmed that 23 (23%) had mild hearing loss, 17 (17%) had bilateral conductive hearing loss, and 6 (6%) had bilateral sensorineural hearing loss. The students who had low attention and communication performance were significantly associated with mild hearing loss. Conclusion The prevalence of mild hearing loss was of 23% (23 cases). This problem had an effect on the communication and attention in school; and it might affect academic performance later in life. A hearing assessment is highly recommended for every child, especially those who have a low rate of academic performance.

Recurrence of Cholesteatoma - A Retrospective Study Including 1,006 Patients for More than 33 Years

Abstract: Introduction Cholesteatomas are benign tumors consisting of skin, and growing inside a retraction pocket in the tympanic membrane. Cholesteatomas can occupy the entirety of the middle ear, and are known for their osteolytic capabilities. Surgery is the only curative treatment for cholesteatomas. Objective To describe the risk of recurrence after first-time surgically-treated middle-ear cholesteatoma (STMEC1) on the island of Funen from 1983 to 2015. Methods Cases of STMEC1 were identified in the Danish National Hospital Register. The medical records were reviewed. Time-to-event analyses were applied. The ears were followed from STMEC1 to a secondary cholesteatoma, emigration, death, or end of follow-up. Results Records from 1,006 patients with STMEC1 were reviewed. A total of 54 patients were submitted to surgery on both ears. The total sample consisted of 1,060 ears with STMEC1; 300 were children's ( The overall estimated proportion with recurrence 5 years after surgery was of 37% in children and of 15% in adults. The older the child was at the first surgery, the risk decreased by 7% per year. In children, canal wall up (CWU) mastoidectomy without obliteration was associated with a hazard ratio for recurrence of 1.9 (95% confidence interval [95%CI]: 1.2–3.0) compared with CWU with obliteration. Conclusion Compared with adults, children were had 2.6 times more risk of recurrence. Procedures performed without mastoidectomy had the lowest risk of recurrence. In children, obliteration was associated with a significantly lower risk of recurrence. However, patients were not randomized regarding the surgical approach; thus, the association between approach and risk of recurrence was likely influenced by confounding factors.

The Frontal Sinus and Frontal Recess: Anatomical, Radiological and Surgical Concepts

Abstract: Introduction The frontal sinus (FS) is the most complex of the paranasal sinuses due to its location, anatomical variations and multiple clinical presentations. The surgical management of the FS and of the frontal recess (FR) is technically challenging, and a complete understanding of its anatomy, radiology, main diseases and surgical techniques is crucial to achieve therapeutic success. Objectives To review the FS and FR anatomy, radiology, and surgical techniques. Data Synthesis The FS features a variety of anatomical, volumetric and dimensional characteristics. From the endoscopic point of view, the FR is the point of greatest narrowing and, to have access to this region, one must know the anatomical limits and the ethmoid cells that are located around the FR and very often block the sinus drainage. Benign diseases such as chronic rhinosinusitis (CRS), mucocele and osteomas are the main pathologies found in the FS; however, there is a wide variety of malignant tumors that can also affect this region and represent a major technical challenge to the surgeon. With the advances in the endoscopic technique, the vast majority of diseases that affect the FS can be treated according to Wolfgang Draf, who systemized the approaches into four types (I, IIa, IIb, III). Conclusion Both benign and malignant diseases that affect the FS and FR can be successfully managed if one has a thorough understanding of the FS and FR anatomy, an individualized approach of the best surgical technique in each case, and the appropriate tools to operate in this region.

The Impact of Olfactory Dysfunction on the Psychological Status and Quality of Life of Patients with Nasal Obstruction and Septal Deviation.

Abstract: Introduction Olfactory dysfunction may be present in patients with nasal obstruction and septal deviation. The impact of olfactory dysfunction on the psychological profile and quality of life (QoL) of these patients remains unexplored. Objective The present study aimed to investigate the emotional status and QoL of patients with olfactory dysfunction and septal deviation and to identify predictors associated with clinically significant improvement of psychological status and QoL, focusing mainly on the role of olfactory recovery after septoplasty. Methods The olfactory function was quantitatively assessed using the ‘‘Sniffin’ sticks'' test (Burghart Messtechnik GmbH, Wedel, Germany) in 60 patients and 25 controls enrolled in this prospective study. The participants completed validated questionnaires specific for general health (Short Form-36), nasal-symptom related QoL (SinoNasal Outcome Test-22), olfaction-associated QoL (Questionnaire of Olfactory Deficits) and for assessing their psychological state (Short Anxiety Screening Test and Beck Depression Inventory) preoperatively and 6 months postoperatively. The patients used the Glasgow Benefit Inventory to evaluate their personal benefit after septoplasty with. Results Septoplasty led to significantly improved olfactory function. Patients with olfactory impairment had significantly lower nasal-symptom related QoL, higher stress levels, and more depressive mood compared with normosmics and controls before and after septoplasty. Postoperatively, personal benefit from surgery was higher in normosmic patients. Improvement of nasal-symptom related QoL was significantly associated with higher likelihood of clinically significant improvement of patients' psychological profile and more personal benefit from surgery. Olfactory dysfunction was negatively correlated with the emotional status of the patients. Conclusion Olfactory dysfunction appears to significantly affect the psychological status of patients with nasal obstruction, and olfactory recovery improves the patients' perception of personal benefit from septoplasty.

A Comparative Study of Endoscopic versus Microscopic Cartilage Type I Tympanoplasty.

Abstract: Introduction The use of endoscope is rapidly increasing in otological and neuro-otological surgery in the last 2 decades. Middle ear surgeries, including tympanoplasty, have increasingly utilized endoscopes as an adjunct to or as a replacement for the operative microscope. Superior visualization and transcanal access to diseases normally managed with a transmastoid approach are touted as advantages with the endoscope. Objectives The present study aimed to compare the outcomes of endoscopic and microscopic cartilage tympanoplasty (Type I) Methods This was a retrospective comparative study of 70 patients (25 males and 45 females) who underwent type I tympanoplasty between March 2015 and April 2016. The subjects were classified into 2 groups: endoscopic tympanoplasty (ET, n = 35), and microscopic tympanoplasty (MT, n = 35). Tragal cartilage was used as a graft and technique used was cartilage shield tympanoplasty in both groups. Demographic data, perforation size of the tympanic membrane at the preoperative state, operation time, hearing outcome, and graft success rate were evaluated. Results The epidemiological profiles, the preoperative hearing status, and the perforation size were similar in both groups. The mean operation time of the MT group (52.63 ± 8.68 minutes) was longer than that of the ET group (48.20 ± 10.37 minutes), but the difference was not statistically significant. The graft success rates 12 weeks postoperatively were 91.42% both in the ET and MT groups, that is, 32/35; and these values were not statistically significantly different. There was a statistically significant improvement in hearing within the groups, both pre- and postoperatively, but there was no difference between the groups. Conclusion Endoscopic tympanoplasty is a minimally invasive surgery with similar graft success rate, comparable hearing outcomes and shorter operative time period as compared to microscopic use.

A Five-Year Review on Pediatric Foreign Body Aspiration.

Abstract: Introduction Foreign body aspiration is a leading cause of accidental death in children Clinical presentation varies from non-specific respiratory symptoms to respiratory failure making diagnosis challenging Objective To review pediatric patients who underwent bronchoscopy due to suspicion of foreign body aspiration at a tertiary center in Malaysia Methods We retrospectively studied patients Results Over the 10-year period, 20 patients underwent bronchoscopy, and 16 were found to have foreign body aspiration with equal gender distribution The most common age group was Conclusion Clinical presentation and chest radiograph findings were comparable across all age groups The most difficulties encountered during foreign body removal were via flexible bronchoscope, in children

Vocal Tract Discomfort Scale (VTDS) and Voice Symptom Scale (VoiSS) in the Early Identification of Italian Teachers with Voice Disorders

Abstract: Introduction The current Italian law does not include any guidance regarding voice education, prevention of voice disorders and screening in subjects with high vocal loading such as teachers. Objectives We aimed to check the correlation between the Vocal Tract Discomfort Scale (VTDS) with the Voice Symptom Scale (VoiSS) for the evaluation of Italian teachers. In addition, we aimed to investigate whether there are differences in the frequency and intensity of discomfort symptoms in teachers with disabilities comparing vocal tract discomfort symptoms in teachers with high risk (HRVD) and low risk (LRVD) of vocal disorders according to the VoiSS cutoff (> 15.5). Methods We analyzed 160 Italian teachers (111 women and 49 men) that completed the VTDS and VoiSS at vocal evaluation. The Spearman correlation test was applied to all variables. The Mann-Whitney U test was used to compare the average number of discomfort symptoms among HRVD and LRVD teachers. Results A moderate positive correlation was observed between the average number, frequency, and intensity of discomfort symptom and the total score, physical domain score, and limitation domain score of the VoiSS. Only the emotional domain score of the VoiSS showed a weak positive correlation (p Conclusion There is correlation between the VTDS and VoiSS scales. Like the VoiSS, the VTDS is a questionnaire that detects HRVD teachers. Therefore, the results suggest that both questionnaires could be useful for a preventive voice program for Italian teachers

Masking Level Difference and Electrophysiological Evaluation in Adults with Normal Hearing.

Abstract: Introduction The auditory structures of the brainstem are involved in binaural interaction, which contributes to sound location and auditory figure-background perception. Objective To investigate the performance of young adults in the masking level difference (MLD) test, brainstem auditory-evoked potentials (BAEPs) with click stimulus, and frequency-following response (FFR), as well as to verify the correlation between the findings, considering the topographic origin of the components of these procedures. Methods A total of 20 female subjects between 18 and 30 years of age, with normal hearing and no complaints concerning central auditory processing underwent a basic audiological evaluation, as well as the MLD test, BAEP and FFR. Results The mean result on the MLD test was of 10.70 dB. There was a statistically significant difference in the absolute latencies of waves I, III and V in the BAEPs of the ears. A change in the FFR characterized by the absence of the C, E and F waves was noticed. There was a statistically significant difference in the positive correlation of wave V in the BAEPs with the MLD. There was a statistically significant difference in the positive correlation of the mean MLD and the V, A and F components of the FFR. Conclusion The mean MLD was adequate. In the BAEPs, we observed that the click stimulus transmission occurred faster in the right ear. The FFR showed absence of some components. The mean MLD correlated positively with the BAEPs and FFR.

Effect of the COVID-19 Pandemic on the Activity of Physicians Working in the Areas of Head and Neck Surgery and Otorhinolaryngology

Abstract: Introduction Coronavirus disease 2019 (COVID-19) is an acute infection caused by the new coronavirus (SARS-CoV-2) and it is highly transmissible, especially through respiratory droplets. To prepare the health system for the care of these patients also led to a restriction in the activity of several medical specialties. Physicians who work with patients affected by diseases of the head and neck region constitute one of the populations most vulnerable to COVID-19 and also most affected by the interruption of their professional activities. Objective The aim of the present study was to assess the impact of the COVID-19 pandemic on the practice of head and neck surgeons and otorhinolaryngologists in Brazil. Methods An anonymous online survey of voluntary participation was applied, containing 30 questions regarding demographic aspects, availability of personal protective equipment (PPE), and impact on the routine of head and neck surgeons and otorhinolaryngologists, as well as clinical oncologists and radiation oncologists who work with head and neck diseases. Results Seven hundred and twenty-nine answers were received in a period of 4 days, ∼ 40 days after the 1st confirmed case in Brazil. With professionals working in public and private services, there was a high level of concerns with the disease and its consequences, limited availability of PPE and a significant decrease in the volume of specialized medical care. Conclusion The study demonstrated a direct impact of the COVID-19 pandemic on the clinical practice of specialties related to the treatment of patients with diseases of the head and neck region already in the beginning of the illness management in Brazil.

Salivary Gland Disorders in Children and Adolescents: A 15-year Experience.

Abstract: Introduction Diseases of the salivary glands are rare in children and adolescents, with the exception of viral-induced infections. Objective To determine the clinical course of the disease, the diagnostic procedures, the treatment and the outcome of all children and adolescents affected with salivary gland diseases at our clinic over a period of 15 years. Methods A retrospective chart review including a long-term follow-up was conducted among 146 children and adolescents treated for salivary gland disorders from 2002 to 2016. Results Diagnosing acute sialadenitis was easily managed by all doctors regardless of their specialty. The diagnosis of sialolithiasis was rapidly made only by otorhinolaryngologists, whereas diagnosing juvenile recurrent parotitis imposed difficulties to doctors of all specialties – resulting in a significant delay between the first occurrence of symptoms and the correct diagnosis. The severity-adjusted treatment yielded improvements in all cases, and a full recovery of 75% of the cases of sialolithiasis, 73% of the cases of juvenile recurrent parotitis, and 100% of the cases of acute sialadenitis. Conclusions Due to their low prevalence and the lack of pathognomonic symptoms, salivary gland diseases in children and adolescents are often misdiagnosed, resulting in an unnecessarily long period of suffering despite a favorable outcome following the correct treatment.

Tracheoesophageal Voice Prosthesis Use and Maintenance in Laryngectomees

Abstract: Tracheoesophageal speech is the most common voicing method used by laryngectomees. This method requires the installation of tracheoesophageal prosthesis (TEP), which requires continuous maintenance to achieve optimal speaking abilities and prevent fluid leakage from the esophagus to the trachea. The present manuscript describes the available types of TEPs, the procedures used to maintain them, the causes for their failure due to fluid leakage, and the methods used for their prevention. Knowledge and understanding of these issues can assist the otolaryngologist in caring for laryngectomees who use tracheoesophageal speech.

In Vivo Computed Tomography Direct Volume Rendering of the Anterior Ethmoidal Artery: A Descriptive Anatomical Study.

Abstract: Introduction The clinical relevance of the anatomy and variations of the anterior ethmoidal artery (AEA) is outstanding, considering its role as a landmark in endoscopic surgery, its importance in the therapy of epistaxis, and the high risks related to iatrogenic injuries. Objective To provide an anatomical description of the course and relationships of the AEA, based on direct computed-tomography (CT)-based 3D volume rendering. Methods Direct volume rendering was performed on 18 subjects who underwent (CT) with contrast medium for suspected cerebral aneurism. Results The topographical location of 36 AEAs was assessed as shown: 10 dehiscent (27.8%), 20 intracanal (55.5%), 6 incomplete canals (16.7%). Distances from important topographic landmarks are reported. Conclusion This work demonstrates that direct 3D volume rendering is a valid imaging technique for a detailed description of the anterior ethmoidal artery thus representing a useful tool for head pre-operatory assessments.

Application of Cervical Vestibular-Evoked Myogenic Potentials in Adults with Moderate to Profound Sensorineural Hearing Loss: A Preliminary Study.

Abstract: Introduction The cochlea and the vestibular receptors are closely related in terms of anatomy and phylogeny. Patients with moderate to profound sensorineural hearing loss (MPSHL) should have their vestibular organ functions tested. Objective To evaluate the incidence of vestibular abnormalities in patients with MPSHL and to study the correlation between the etiology of hearing loss (HL) and a possible damage to the labyrinth. Methods A case-control retrospective study was performed. In the case group, 20 adults with MPSHL of known etiology were included. The control group was composed of 15 adults with normal hearing. The case group was divided into 4 subgroups based on the etiology (bacterial meningitis, virus, vascular disease, congenital). Cervical vestibular-evoked myogenic potentials (cVEMPs) were used to rate the saccular function and lower vestibular nerve. Results The study was performed in 70 ears, and it highlighted the presence of early biphasic P1-N1 complex in 29 (71.5%) out of 40 ears in the study group, and in all of the 30 ears in the control group ( p = 0.001). Regarding the presence or absence of cVEMPs among the four subgroups of patients with MPSHL, the data were statistically significant ( p < 0.001). The comparison between the latencies and amplitude of P1-N1 in case and control groups from other studies and in the four subgroups of cases in the present study did not detect statistically significant differences. Conclusion The present study demonstrates that patients with MPSHL have a high incidence of damage to the labyrinthine organs, and it increases the current knowledge about the etiopathogenesis of sensorineural HL, which is often of unknown nature.

Malignancy Rate in Thyroid Nodules with Atypia or Follicular Lesion of Undetermined Significance.

Abstract: Introduction Atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS) is one of the six diagnostic categories of the Bethesda System for Reporting Thyroid Cytopathology. The prevalence of malignancy among Bethesda category III cytology is variable, ranging from 5% to 37% in the literature. Objective To determine the rate of malignancy in thyroid nodules reported as Bethesda category III. Methods A total of 495 patients underwent surgical intervention for thyroid nodules from January 2015 to December 2017. The present study included 81 cases reported as Bethesda category III, and their medical records were reviewed. Results Out of 495 fine-needle aspiration cytology samples, 81 (16.4%) samples were labeled as AUS/FLUS. Among these 81 patients, the mean age was 43.0 years (± 13.9), with only 11 (14%) patients older than 55 years of age. Most of our patients were female (n = 69; 85.2%), and the rest were male. The rate of malignancy based on the final histology was of 33.3% (n = 27). The majority were 17 cases (21%) of papillary carcinoma, followed by follicular carcinoma (n = 6) (7.4%). Conclusion The risk of malignancy can be higher than it is commonly believed, and guidelines should be based on the data from the institutions themselves for a better assessment of the outcomes.

Role of Fine Needle Aspiration Cytology in the Diagnosis of Parotid Gland Tumors: Analysis of 193 Cases.

Abstract: Introduction Parotid gland tumors include a wide variety of inflammatory and neoplastic diseases. The majority of these tumors are benign (80%), which usually require superficial parotidectomy, while the incidence of malignant tumors is lower (20%), requiring more radical surgery with or without neck dissection. The diagnosis cannot be established on the basis of clinical history and simple physical examination and requires complementary diagnostic methods. Fine needle aspiration cytology (FNAC) guided by ultrasound is a widely used diagnostic tool to evaluate parotid swellings. Objective To determine the sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of FNAC in the diagnosis of parotid gland tumors. Methods A retrospective chart review of 193 patients who underwent preoperative FNAC and parotidectomy at the Aga Khan University Hospital, Karachi, Pakistan, from the period of January 2000 to December 2015 was performed. Results Out of 193 patients undergoing parotidectomy, 110 (57%) were males and 83 (43%) were females, the mean age being 48.21 and 43.76 years old, respectively. The mean duration of the symptoms was 41.33 months, and the most common symptom was preauricular swelling present in all patients, followed by pain, which was present in 29 patients (15%) and facial nerve weakness in 6 patients (3.1%). Fine needle aspiration cytology was performed preoperatively and the results were compared with the final histopathology, which showed sensitivity of 88.9%, specificity of 97.9%, positive predictive value of 93%, negative predictive value of 96.7% and diagnostic accuracy of 95.8%. Conclusion Our results suggest that FNAC is relatively an accurate method for preoperative diagnosis of parotid swelling and can prove to be a valuable tool for preoperative counseling of the nature of the disease and prognosis.

Facial Clinimetric Evaluation Scale and Synkinesis Assessment Questionnaire Translation into Brazilian Portuguese: A Validation Study

Abstract: Introduction Facial nerve palsy results in both functional disability and psychological morbidity. There are several well-established grading scales to quantify the quality of life of these patients. Objective Translate and validate the Facial Clinimetric Evaluation (FaCE) scale and Synkinesis Assessment Questionnaire (SAQ) to Brazilian Portuguese. Methods This study adopted a forward-backward translation method and performed cross-cultural adaptation. A pilot study was conducted to correct any confusing language and to evaluate content validity. A validation study was then performed. Internal consistency of the Brazilian Portuguese version of the FaCE and SAQ items was evaluated by Cronbach's alpha coefficient. Construct validity was assessed by Spearman's Rank Correlation Coefficient between FaCE and SAQ scores to eFACE, House-Brackmann, Short Form 12 (SF-12) and Facial Disability Index (FDI) (sub)scores. Results A total of 90 patients were included. Cronbach's alpha for total domain scored 0.881 for FaCE and 0.809 for SAQ. FaCE total score correlation to eFACE total and House-Brackmann showed Spearman's r value of 0.537 and -0.538, respectively ( p < 0.001). SAQ correlation to eFACE synkinesis subdomain was -0.449 ( p < 0.001). No correlation was found between SAQ and HB score. FaCE total score correlations were of 0.301 and 0.547 for SF-12 PCS and MCS, respectively ( p < 0.001). Correlation between FaCE total and FDI Physical and Social/well-being functions were 0.498 and 0.567 ( p < 0.001). Conclusion Brazilian Portuguese FaCE scale and SAQ versions achieved high validity and reliability in the present study. These translated instruments demonstrated good psychometric properties, being proper to use in clinical practice in Brazil and with Brazilian Portuguese speakers.

Head and Neck Practice in the COVID-19 Pandemics Today: A Rapid Systematic Review

Abstract: Introduction Head and neck specialists and otorhinolaryngologists are greatly exposed to coronavirus disease 2019 (COVID-19) transmission in their everyday praxis. Many articles are being published regarding medical staff protection and patient management during the pandemic. Objective To provide an easy access to and a trustful review of the main aspects that have changed in the head and neck surgery and otorhinolaryngology practice due to the COVID-19 pandemic. Data Synthesis The search terms used were: (head and neck or otorhinolaryngology or ORL or thyroid) AND (severe acute respiratory syndrome coronavirus 2 [SARS-COV-2] or COVID-19 or CORONAVIRUS). The results were limited to the year of 2020. Articles were read in English, Portuguese, French, German, and Spanish or translated from Chinese. All included articles were read by at least two authors. Thirty-five articles were included. Most articles suggest postponing elective surgeries, with exception to cancer surgeries, which should be evaluated separately. Twenty-five articles recommended some kind of screening prior to surgery, using polymerase chain reaction (PCR) tests and epidemiological data. Extra precautions, such as use of personal protective equipment (PPE), are suggested for both tracheostomies and endoscopies. Fifteen articles give recommendation on how to use telemedicine. Conclusion The use of PPE (N95 or powered air-purifying respirator [PAPR]) during procedures should be mandatory. Patients should be evaluated about their COVID-19 status before hospital admission. Cancer should be treated. Tracheostomy tube cuff should be inflated inside the tracheal incision. All COVID-19 precautions should be kept until there is a validated antiviral treatment or an available vaccine.

The Difference in Thyroid Stimulating Hormone Levels between Differentiated Carcinoma and Benign Enlargement.

Abstract: Introduction Papillary and follicular thyroid carcinoma are common head and neck cancers. This cancer expresses a thyroid stimulating hormone (TSH) receptor that plays a role as a cancer stimulant substance. This hormone has a diagnostic value in the management of thyroid carcinoma. Objective The present study aimed to determine the difference in TSH levels between differentiated thyroid carcinoma and benign thyroid enlargement. Methods The present research design was a case-control study. The subjects were patients with thyroid enlargement who underwent thyroidectomies at the Dr. Sardjito General Hospital, Yogyakarta, Indonesia. Thyroid stimulating hormone levels were measured before the thyroidectomies. The inclusion criteria for the case group were: 1) differentiated thyroid carcinoma, and 2) complete data; while the inclusion criteria for the control group were: 1) benign thyroid enlargement, and 2) complete data. The exclusion criteria for both groups were: 1) patients suffering from thyroid hormone disorders requiring therapy before thyroidectomy surgery, 2) patients receiving thyroid suppression therapy before the thyroidectomy was performed, and 3) patients suffering from severe chronic diseases such as renal insufficiency, and severe liver disease. Results There were 40 post-thyroidectomy case group patients and 40 post-thyroidectomy control group patients. There were statistically significant differences in TSH levels between the groups with differentiated thyroid carcinoma and benign thyroid enlargement (p = 0.001; odds ratio [OR] = 8.42; 95% confidence interval [CI]: 3.19–36.50). Conclusion Based on these results, it can be concluded that there were significant differences in TSH levels between the groups with differentiated thyroid carcinoma and benign thyroid enlargement.

Mitomycin C in the Endoscopic Treatment of Laryngotracheal Stenosis: Systematic Review and Proportional Meta-Analysis.

Abstract: Introduction Mitomycin C is a natural antibiotic that has been used to inhibit the proliferation of fibroblasts in scar tissue. Objective To evaluate the effectiveness and safety of topical Mitomycin C as an adjuvant in the endoscopic treatment of laryngotracheal stenoses. Data synthesis A systematic review of experimental or observational studies that have evaluated the treatment of laryngotracheal stenoses with the use of topical Mitomycin C was performed. Databases researched: LILACS, PubMed, Embase, Cochrane and Web of Science. Outcomes: resolution (symptom-free time ≥ one year), number of procedures required, and complications resulting from the procedure. A total of 15 studies (involving 387 patients) were selected. Mitomycin C was administered to every patient in 11 studies, and in 4 other studies, the patients were separated into 2 groups, 1 receiving mitomycin C, and the other not. The resolution of the stenosis evaluated in 12 studies in which the patients received mitomycin C was of 69% (95% confidence interval [95%CI]: 61–76%; I2 = 17.3%). A total of 52% of the patients (95%CI: 39–64%, 11 studies; I2 = 64.7%) were submitted to a single endoscopic procedure, and 48% (95%CI: 36–61%, 11 studies; I2 = 64.7%) were submitted to more than 1 procedure. Complications (mediastinal and subcutaneous emphysema, dysphonia, laceration or vocal fold paralysis and acute light obstruction) were reported in 9% of the patients (95%CI: 3–18%, 9 studies; I2 = 79.8%). Conclusions The evidence suggests that mitomycin C is an effective and safe option in the endoscopic treatment of laryngotracheal stenosis.

Vestibular Syndromes in Childhood and Adolescence

Abstract: Introduction The prevalence of vestibular disorders in childhood ranges from 0.4% to 15%; they may be the result of several factors, but most of the time it's an episodic vestibular syndrome related to migraine equivalents. Objective To evaluate the diagnostic and therapeutic aspects of children with vestibular signs and symptoms. Methods The present cross-sectional study evaluated data from the records of patients treated in an outpatient pediatric neurotology clinic over a 10-year period. These data included sociodemographic and clinical variables, results of complementary examinations, the treatment provided, and the clinical evolution. Results The sample was composed of 117 patients, with 54.7% of female subjects with a mean age of 10 years. The most prevalent diagnosis was benign paroxysmal vertigo of childhood (BPVC) (41.9%), followed by vestibular migraine (16.2%). The most prevalent complaint was vertigo (53.9% of the cases). Most patients (66.7%) had inadequate eating habits. Improvement of symptoms was observed in 40.4% of the patients treated with dietary guidance alone. In 80% of the cases, dietary counseling in combination with vestibular rehabilitation therapy achieved therapeutic success without the need of a drug treatment. Conclusion The predominant diagnosis was of BPVC, and its close relationship with the personal and family history of migraine, its benign evolution, and the importance of dietary guidance and vestibular rehabilitation for therapeutic success were observed.

Intraoperative Use of Analgesics in Tonsillar Fossa and Postoperative Evaluation with Visual analogue Scale Scores-A Prospective, Randomized, Placebo-Controlled, Double-Blind Clinical Trial.

Abstract: Introduction Posttonsillectomy pain results in significant morbidity to the patients. There is a disagreement in the literature regarding the use of local anesthetics during tonsillectomy. The aim of this placebo-controlled, double-blind study is to evaluate the effect of peritonsillar administration of local anesthetics. Objective To evaluate the role of intraoperative use of analgesics in tonsillar fossa and postoperative evaluation with visual analogue scale (VAS) scores in achieving pain relief after tonsillectomy procedure Methods In this study, 180 patients were randomized to 1 of the 6 groups: bupivacaine infiltration, lidocaine infiltration, normal saline infiltration, bupivacaine packing, lidocaine packing, and normal saline packing. Pain caused by speaking, swallowing, and on rest was assessed using VAS at 4, 8, 12, 16 hours, and at discharge. Results Significant analgesia was obtained in patients who received bupivacaine infiltration and packing compared with placebo (p Conclusion We advocate the use of bupivacaine infiltration or packing immediately following the procedure to achieve adequate postoperative analgesia.

Functional Impact of Tinnitus in Patients with Hearing Loss

Abstract: Introduction Tinnitus, which is considered the third worst symptom for humans, is a common complaint among people living with hearing loss and may negatively affect the quality of life of those who have it. Objective To analyze the perception of the handicap in patients with tinnitus and hearing loss as well as the possible associations between the variables hearing loss, loudness, onset, frequency and annoyance by tinnitus, and the correlation between the visual analogue scale (VAS) and the Tinnitus Handicap Inventory (THI). Methods A total of 30 patients with complaints of tinnitus and the presence of sensorineural hearing impairment were selected for this cross-sectional, observational, and descriptive study. The loudness of the tinnitus was measured by a VAS and classified as mild, moderate, or severe. The THI was classified as slight, mild, moderate, severe, and catastrophic. Data were submitted to statistical analysis using the Fisher exact test and Spearman correlation coefficient. Results Eleven male (36.7%) and 19 female (63.3%) subjects with a mean age of 56.5 years old were evaluated. There was no significant association between loudness, annoyance, time and frequency of tinnitus, nor between hearing loss and tinnitus. There was a significant association between the variables hearing loss and loudness, and a weak correlation between VAS and THI. Conclusion Tinnitus has a practical impact in the lives of patients with hearing loss in terms of catastrophic, functional, and emotional aspects, regardless of loudness, frequency, or time of onset. Hearing loss was a factor that had an impact on the loudness of tinnitus. There was no statistically significant correlation between VAS and THI.

Imaging Analysis of Onodi Cells on Cone-Beam Computed Tomography

Abstract: Introduction Onodi cells are the most posterior ethmoid air cells, and extend superolaterally to the sphenoid sinus. The identification of Onodi cells is essential to because they can have some significant anatomic variations and relationships to vital adjacent structures, like the optic canal, the sphenoid sinus, and the internal carotid artery. Objective The present study aimed to assess the prevalence of Onodi cells and their position with respect to sphenoid sinus. To the authors' best knowledge, this is the first study that uses cone-beam computed tomography (CBCT) to assess the prevalence and position of Onodi cells. Methods We collected CBCT scan records from November 1st, 2016, to July 31st, 2017; the patients who fulfilled the eligibility criteria were included in the present study. The CBCT scans were reviewed by two independent observers. The descriptive statistics was performed using the Statistical Package for the Social Sciences (SPSS, SPSS, Inc., Chicago IL, US) software, version 17.0. A cross-tabulation of gender with the presence and position of Onodi cells was evaluated using the Chi-squared (χ2) test. The inter- and intraobserver agreements were evaluated using Kappa (κ) statistics. Results Onodi cells were identified in 86 (42.8%) out of 201 patients. A subgroup analysis revealed that Onodi cells were present in 45 (43.3%) female and 41 (42.3%) male patients. The position of the Onodi cells was superior with respect to the sphenoid sinus in 43 (50%) of the patients, superolateral in 36 (41.9%), and lateral to the sphenoid sinus in 7 (8.1%) of the patients. Conclusion The present study indicated a high prevalence of Onodi cells, with approximately equal distribution among males and females, and mostly superior in position in relation to the sphenoid sinus.

Olfactory and Taste Disorders in Patients with SARS-CoV-2 Infection

Abstract: Dear Editor, Since December 2019, a pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread globally.1,2 A spectrum of disease severity has been reported for the infection, with the main symptoms being fever, fatigue, dry cough, myalgia, and dyspnea.3 Previous strains of coronavirus have been demonstrated to invade the central nervous system through the olfactory neuroepithelium and propagate from within the olfactory bulb.4 Furthermore, nasal epithelial cells display the highest expression of the SARS-CoV-2 receptor, angiotensin-converting enzyme 2, in the respiratory tree.5 It has been observed that SARS-CoV-2 does not appear to generate clinically significant nasal congestion or rhinorrhea —that is, a red, runny, stuffy, itchy nose. This observation suggests a neurotropic virus that is site-specific for the olfactory system. Although labeled as a virus that affects the respiratory system, coronaviruses are known to be neurotropic and neuroinvasive.6–9 Olfactory and taste disorders are well known to be related with a wide range of viral infections.10,11 In a mice model, SARS-CoV has demonstrated a transneural penetration through the olfactory bulb.12Moreover, angiotensin converting enzyme 2 receptor, which is used by SARS-CoV-2 to bind and penetrate into the cell, is widely expressed on the epithelial cells of the mucosa of the oral cavity.13 These findings could explain the underlying pathogenetic mechanism of taste and olfactory disorders in SARS-CoV-2 infection.

Sound Generator: Analysis of the Effectiveness of Noise in the Habituation of Tinnitus.

Abstract: Introduction Tinnitus is a disorder that affects 10 to 15% of de world's population Sound therapy performed through hearing aids (HAs) with integrated sound generator (SG) is one of the forms of tinnitus treatment Objective To analyze the effectiveness of four masking noises in relieving tinnitus in individuals with mild and moderate bilateral sensorineural hearing loss and their influence in speech perception Methods The participants were 35 individuals with tinnitus and mild and moderate bilateral sensorineural hearing loss, divided into four groups All groups underwent HA and SG adaptation, being regulated in the combined mode (HA and SG) In group 1 (G1), the white noise stimulus was applied, in group 2 (G2), pink noise was applied, in group 3 (G3), speech noise, and in group 4 (G4), the high tone was applied All patients were subjected to the following procedures: audiological diagnosis, acuphenometry, tinnitus handicap inventory (THI), visual analogue scale (VAS), and hearing in noise test (HINT) The procedures were performed prior to and after hearing intervention, and after 3 months of use of HA and SG Results All groups presented a statistically significant difference for the THI, VAS, and HINT pre and postintervention In the case of the HINT, only pink noise presented a significant difference However, in the comparation among groups there was no significant difference Conclusion The present study made it possible to conclude that the four noises were equally effective in relieving tinnitus, with no statistically significant differences between the analyzed groups

A Three Point Assessment Protocol for Tympanoplasty Outcomes: A Retrospective Analysis.

Abstract: Introduction The surgical outcome of chronic otitis media (COM) of the mucosal type in the pediatric population with high rates of recurrent tympanic membrane perforation is indeed a concern for the attending surgeon. Objective The present study was done to evaluate the outcome of tympanoplasty in children with chronic otitis media mucosal type. Methods A retrospective analysis of the medical records of all children, aged Results A total of 90 children underwent type 1 tympanoplasty; 7 were lost to follow-up and 10 had incomplete audiometric results. In the 73 tympanoplasties analyzed, graft uptake was seen in 91.7% of the patients. Children with longer duration of ear discharge (> 8 years) had greater hearing loss. Children aged > 8 years old showed statistically significant higher chance of graft uptake (p = 0.021). Five of the six children who had graft rejection had bilateral disease. Conclusion A three-point assessment in the management of pediatric COM of the mucosal type offers good outcomes with post-tympanoplasty graft uptake rates > 90%.