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Abstract Introduction Wegener's Granulomatosis is a vasculitis of uncertain aetiology. Affected patients usually present with disease of the respiratory and renal tracts. Classic symptoms and clinical findings, together with serology titres positive for anti-neutrophil cytolplasmic antibody against proteinase 3 confirm the diagnosis. Wegener's Granulomatosis can occasionally involve other organs, but solitary parotid gland disease is uncommon; patients generally also have systemic disease. Case Presentation We report a case of Wegener's Granulomatosis in a 69-year-old Caucasian female presenting initially with an isolated parotid abscess and only subsequently developing nasal, paranasal sinus and respiratory symptoms. We describe the clinical course, diagnostic difficulties, imaging and histopathology of this case. Conclusion Major salivary gland infection is not an uncommon ENT disorder, but the clinician should be wary of the patient who fails to respond appropriately to adequate therapy. In such cases a differential diagnosis of Wegener's Granulomatosis should be considered, as early recognition and treatment of this potentially fatal disease is paramount.

Background and Purpose: The aim of this study was to describe the variations in the speech range profile (SRP) of patients affected by cognitive decline., Methods: We collected the data of patients managed for suspected voice and speech disorders, and suspected cognitive impairment. Patients underwent an Ear Nose and Throat evaluation and Mini-Mental State Examination (MMSE). To obtain SRP, we asked the patients to read 18 sentences twice, at their most comfortable pitch and loudness as they would do in daily conversation, and recorded their voice on to computer software., Results: The study included 61 patients. The relationship between the MMSE score and SRP parameters was established. Increased severity of the MMSE score resulted in a statistically significant reduction in the average values of the semitones to the phonetogram, and the medium and maximum sound pressure levels ( p <0.001). The maximum predictivity of MMSE was based on the highly significant values of semitones ( p <0.001) and the maximum sound pressure levels ( p =0.010)., Conclusions: The differences in SRP between the various groups were analyzed. Specifically, the SRP value decreased with increasing severity of cognitive decline. SRP was useful in highlighting the relationship between all cognitive declines tested and speech., Competing Interests: Conflict of Interest: The authors have no financial conflicts of interest., (© 2021 Korean Dementia Association.)

Purpose: This study aims to understand the factors contributing to the severity of oropharyngeal dysphagia and its persistence in the sub-acute phase of stroke., Methods: We retrospectively collected the data of all the patients suffering from a stroke in the last year. The severity of stroke was reported according to the NIHSS score. All the patients were evaluated with the Dysphagia Risk Score and with a FEES. We classified the Dysphagia Risk Score and FEES results using the PAS score and ASHA-NOMS levels. The data were analysed statistically with ANOVA test, Student's t test and Pearson's correlation coefficient., Results: A series of 54 patients were evaluated. The ANOVA test did not find any difference in the mean score of Dysphagia Risk Score, PAS and ASHA-NOMS when compared with the brain area of stroke. An NIHSS at hospital admission (stroke unit) of more than 12 was predictive of ASHA-NOMS score 1-4 after 60 days (p < 0.05). A PAS score between 6 and 8 at first FEES evaluation was predictive of poor (1-4) ASHA-NOMS score after 60 days (p < 0.01). A moderate positive linear correlation was found between NIHSS score and both PAS (r 0.65) and Dysphagia Risk Score (r 0.50); a moderate negative linear correlation was recorded between NIHSS and ASHA-NOMS (r  - 0.66) scores., Conclusion: In the sub-acute phase of stroke, the predictive factors of persistent dysphagia are not linked to the damaged neuroanatomical region and others factors such as NIHSS value and high PAS score seem more useful.

Purpose: To evaluate the prevalence of oropharyngeal dysphagia in elderly patients suffering from minimal or mild cognitive decline., Patients and Methods: We retrospectively collected the data of patients suffering from mild cognitive impairment or mild dementia and were undergoing management for suspected oropharyngeal dysphagia, in our department. All our patients were subjected to Mini Mental State Examination test, MD Anderson dysphagia inventory and caregiver mealtime and dysphagia questionnaire. We performed a mealtime observation study and endoscopic evaluation of swallowing in all our patients. Following evaluation, we then analysed the data statistically., Results: Out of 708 patients who visited us for cognitive decline and suspected oropharyngeal dysphagia in the last two years, 52 patients were confirming to the inclusion criteria of this study. Classification of oropharyngeal dysphagia patients according to ASHA-NOMS scale showed that 32.7% of patients presented with grade 4 of dysphagia followed by another 32.7% with grade 5 and 30.8% presented with grade 6. Only 3.8% of our patients were considered normal (grade 7 of ASHA-NOMS scale). MD Anderson dysphagia inventory could collected swallowing alterations in only 23.1% of the cases. The caregiver mealtime and dysphagia questionnaire showed acceptable caregivers patient management in 53.8% of patients., Conclusion: Our study underscores the fact that oropharyngeal dysphagia is present in many cases of mild cognitive decline. While patients understate their swallowing problems, the caregivers are not competent enough to manage this situation in a great percentage of cases. Only a mealtime observation by a speech-language pathologist along with FEES is able to identify the true prevalence of the condition., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Primary objective of this study was to find a statistical link between the most worldwide comorbidities affecting the elderly population (hypertension, diabetes, osteoarthrosis, osteoporosis and depression) and recurrent episodes of BPPV. Secondary objective was defining possible "groups of risk" for people suffering recurrent positional vertigo related to the presence of a well documented comorbidity., Methods: This was an observational, cross-sectional, multicenter, spontaneous, non-pharmacological study. The data of 1092 patients suffering BPPV evaluated in 11 different Departments of Otolaryngology, Otoneurology and Neurology, referring Centers for positional vertigo evaluation, were retrospectively collected., Results: Regarding evaluated comorbidities (hypertension, diabetes, osteoarthrosis, osteoporosis and depression), data analysis showed the presence of at least one comorbid disorder in 216 subjects (19.8%) and 2 or more in 408 subjects (37.4%). Moreover there was a statistical significant difference between the number of comorbidities and the number of recurrences, otherwise said as comorbidity disorders increased the number of relapses increased too., Conclusion: The presence of a systemic disease may worsen the status of the posterior labyrinth causing a more frequent otolith detachment. This condition increases the risk for patients suffering BPPV to have recurrent episodes, even if correctly managed by repositioning maneuvers. The combination of two or more of aforementioned comorbidities further increases the risk of relapsing BPPV, worsened by the presence of osteoporosis. On the basis of this results it was possible to define "groups of risk" useful for predicting BPPV recurrence in patients with one or more comorbidity., (Copyright © 2013. Published by Elsevier Ireland Ltd.)

Background: Insulin resistance (IR) is associated with hepatic fibrosis and cirrhosis, regardless of its etiology but the mechanism of hyperinsulinemia in cirrhosis is still unclear. The current study was designed to assess hyperinsulinemia and pancreatic β-cell function in euglycemic cirrhosis of varied etiology., Methods: A cross sectional case control study of 100 subjects. IR was assessed by the Homeostasis Model Assessment (HOMA) and quantitative insulin sensitivity check index in euglycemic cirrhosis of varied etiology and in different stages of cirrhosis. HOMA-β was calculated for insulin secretion ability of pancreatic β-cells in different stages of cirrhosis., Results: Overall IR in euglycemic cirrhosis was seen in 68.5%. IR was seen in the order hepatitis C (100%), non-alcoholic fatty liver disease (100%), autoimmune hepatitis (100%), hepatocellular carcinoma (80%), alcoholic liver disease (72%) and hepatitis B (45%). HOMA-IR value was raised in Child Turcotte Pugh (CTP) score >9 (P value 0.0004) and model of end stage liver disease (MELD) score >15 (P value 0.02). HOMA-β was raised in CTP score >9 (P value 0.02) and MELD score >15 (P value 0.0003). HOMA-β level among diabetic controls was 27.1±7.7 compared to 154.6±80.7 in euglycemic cases (P value <0.0001)., Conclusion: IR is common in euglycemic cirrhosis and with advancement of liver disease; there is a compensatory increase in pancreatic β-cell insulin secretion to overcome the IR. However, over a period of time with fall in β-cell function development of hepatogenous diabetes may occur.

Background: Alteration of cardiovascular functions in patients with liver cirrhosis has been described and it correlates with severity of hepatic failure. But cardiac functions by conventional 2-dimensional (2-D) echocardiography has limitations. The aim of the study was to evaluate cardiac systolic and diastolic functions in liver cirrhosis patients with or without ascites by tissue Doppler imaging and conventional 2-D- echocardiography., Methods: A cross sectional case control study of sixty patients. Twenty subjects grouped as healthy controls, pre-ascitic cirrhosis and cirrhosis with ascites were enrolled. Cardiac evaluation was done by both conventional Doppler and tissue Doppler echocardiography., Results: Cirrhosis with portal hypertension is associated with increased heart rate, ejection fraction and mean peak systolic velocity, while mean arterial pressure is decreased. All cardiac chamber dilation occurs and is mostly seen in the left atrium. Ratio of early diastolic annular velocity to peak early diastolic annular wave velocity (E/e') was the most significant marker for diastolic dysfunction. E/e' ratio was 7.76±0.40, 12.55±1.73 and 11.4±1.19 in healthy controls, pre ascitic cirrhosis and ascitic cirrhosis respectively (P<0.0001). Overall Type I and II Left ventricular diastolic dysfunction was present in 70% cirrhotic patient with or without ascites, while there were no cases of Type III (Severe) diastolic dysfunction., Conclusion: Left ventricular diastolic dysfunction is commonly associated with advancement of hepatic dysfunction while systolic function is maintained till advanced hepatic failure. Peak early diastolic wave velocity, deceleration time and E/e' ratio for left ventricular diastolic dysfunction are accurately assessed by pulsed tissue Doppler imaging.

Problems/objectives: Malignant peripheral nerve sheath tumours are uncommon soft tissue tumours originating from Schwann cells or nerve sheath cells. Malignant epithelioid schwannoma is an aggressive variant of malignant peripheral nerve sheath tumour, and unfortunately is related with a high rate of recurrence and poor prognosis., Methodology: In this study we present a rare case of malignant epithelioid schwannoma of the parotid gland and we discuss its origin, unusual presentation, and possible treatments options., Results: Patient underwent total parotidectomy without neck dissection. Postoperative radiotherapy and chemotherapy management were not necessary., Conclusion: Patients with malignant epithelioid schwannomas typically present with pain and/or rapid enlargement of a pre-existing lesion but the diagnosis of these tumours remains difficult as it is based primarily on clinical suspicion. There is no recognized management for this tumour yet while the prognosis seems to correlate best with the extent of surgical resection (Fig. 4, Ref. 16).

Unlabelled: Primary malignant lymphomas in the salivary glands are relatively rare. Clinical presentation is not characteristic and the disease is often overlooked resulting in diagnosis and treatment delays., Aim: To stress the importance of the diagnostic process and combined management, we present a series of eight patients with malignant lymphoma of the parotid who were diagnosed only after surgery and managed with radiation and chemotherapy., Methods: Retrospective series of patients with primary malignant lymphoma of the parotid gland managed with radiotherapy and diagnostic surgical partial resection., Results: After treatment completion we achieved a loco-regional control rate of 87.5%. Toxicity was charted according to the Common Toxicity Criteria and it was seen in six patients (75%). Six patients are still alive without evidence of recurrent disease in their last follow-up., Conclusion: Our study confirms that primary early stage Non-Hodgkin Lymphoma of the parotid gland is a disease with an excellent prognosis and a good local control rate, with minimal morbidity.

Objectives: An important component of management of benign paroxysmal positional vertigo (BPPV) has been the application of postural restrictions after use of a canalith repositioning maneuver (CRM) to prevent the return of otolithic debris into the posterior semicircular canal (PSC). This study was designed to explore the effectiveness of postural restrictions in patients with BPPV caused by otolithic debris in the PSC., Methods: Seventy-four adult patients with unilateral PSC BPPV were enrolled into this study. All patients were managed with a CRM--either the modified Epley maneuver or the Semont maneuver. The patients were divided randomly into 2 groups: group A, with postural restrictions, and group B, without postural restrictions. The statistical analysis was performed with X2 tests and t-tests., Results: No patients in either group showed positional nystagmus in the posttreatment evaluation under infrared videonystagmoscopy. No patients had symptoms of vertigo after the therapy. The results of follow-up vestibular tests were normal in both groups., Conclusions: In our experience, postural restrictions do not enhance the beneficial effect of the CRMs. They do not seem to have any protective role and therefore should not be recommended as an adjunct to the treatment of PSC BPPV.

The intermediate nerve (IN), also called the nerve of Wrisberg, is a relatively small nerve with a variable anatomical course. Currently, this nerve is not addressed well in the pertinent literature. Pre-operative diagnosis of IN tumours is clinically challenging due to the lack of related symptoms. Symptoms are typically caused by the functional deterioration of neighbouring anatomical structures. In this report, we describe a patient with a schwannoma that arose at the porus acusticus of the internal auditory canal; during surgery, this proved to originate from the IN. We discuss our findings in the context of previously reported cases of IN schwannomas and analyse the vague characteristics and symptoms of this rare tumour.

Objective: The classical teaching advocates a conservative approach for children presenting with various naso-septal deformities. It may not be appropriate especially when it causes nasal obstruction to the growing child. This study has two main purposes: to contribute in identifying the correct selection criteria for surgical management of pediatric patients and in selecting the most appropriate surgical technique., Material and Method: We reviewed a series of 46 cases of post-traumatic septal and naso-septal deformity not managed promptly or with recurrence of nasal deviation, following bones fracture correction alone. The mean follow-up was 10 years., Results: Patients with naso-septal deformity managed only by septoplasty had accentuation of nasal pyramid deformity; those treated by septorhinoplasty showed a good aesthetic and functional result after long-term follow-up., Conclusion: Our series results demonstrated that the best results were obtained when we correct all evident alterations of nasal septum and pyramid at a single stage. Unsuccessful results seen in our first group suggest that immediate correction of septum alone with delayed management of nasal pyramid deformity leads to a poorer outcome.

The main problem arising from tinnitus is the disturbance it causes in day-to-day life and disturbance in sleep leading to fatigue and general discomfort. We attempted to study the effect of melatonin in conjunction with Sulodexide as a treatment method for tinnitus and evaluate its effectiveness. We studied 102 patients suffering from tinnitus with a Prospective Randomised Controlled Study conducted in a tertiary care ENT department. After randomisation, 34 patients were treated with melatonin and Sulodexide, another 34 were treated with melatonin alone, and the remaining 34 (control group) were managed without therapy in order to evaluate spontaneous variations in quality of tinnitus. Patients were assessed prospectively with Tinnitus Handicap Inventory and Acufenometry both pre-treatment and post-treatment. Among the patients we studied, we found better results with both Tinnitus Handicap Inventory and Acufenometry in the group who received melatonin and Sulodexide as against melatonin alone. Any improvement was noted in the control group. In conclusion, our opinion is that melatonin in combination with Sulodexide is a viable treatment option for patients suffering from central or sensorineural tinnitus.

Since very little is understood about the exact aetiology of tinnitus, this has made treatment of the condition difficult. Even though approximately 10-15% of the general population suffer from tinnitus, only 2% consider it serious enough to warrant any treatment. The main problem arising from tinnitus is the disturbance it causes not only in day to day life but also in sleep, leading to fatigue and general discomfort. The present study focused on the effect of Melatonin in conjunction with Sulodexide as a treatment method for tinnitus. Overall, 102 patients suffering from tinnitus were evaluated in a prospective randomised controlled study conducted in a tertiary care ENT department. After randomisation, 34 patients were treated with Melatonin and Sulodexide, another 34 were treated with Melatonin alone, while the remaining 34 (control group) were managed without treatment in order to evaluate spontaneous variations in the quality of tinnitus. Patients were assessed prospectively with the Tinnitus Handicap Inventory and Acufenometry, both pre- and post-treatment. Among the patients studied, better results with both Tinnitus Handicap Inventory and Acufenometry were found in the group who received Melatonin and Sulodexide compared to those receiving Melatonin alone. No improvement was observed in the control group. In conclusion, Melatonin in combination with Sulodexide is, in our opinion, a viable treatment option for patients suffering from central or sensorineural tinnitus.

Unlabelled: Benign paroxysmal positional vertigo (BPPV) of lateral semicircular canal (LSC) is one of the rarer forms of BPPV as compared to posterior semicircular canal BPPV. Various particle repositioning manoeuvres have been described in the literature as a mode of treating this condition., Purpose: Evaluation and discussion of the procedure of the Gufoni's manoeuvre and its advantages in the treatment of BPPV of LSC., Material and Methods: Prospective study of 58 patients affected by LSC BPPV who were office-treated with Gufoni's manoeuvre., Results: Seventy-nine percent of the patients so treated had complete resolution of symptoms, and 6.9% did not show any improvement in their symptoms. The remaining 13.8% had a conversion into posterior semicircular canal BPPV during treatment and were successfully treated with Epley's or Semont's manoeuvre., Conclusions: Gufoni's manoeuvre is effective in treating patients suffering from BPPV of LSC; it is simple to perform; there are not many movements to execute, it needs low time of positioning, and positions are comfortable to the patient.

Unlabelled: Delayed facial nerve paralysis post middle ear surgery: herpes simplex virus activation., Problem: Facial nerve paralysis following middle ear surgery is a nightmare for the otology surgeon. Usually this is caused by surgical trauma or local anaesthetic use. It is uncommon to see onset of facial nerve palsy more than 72 hours following the surgery., Methodology: We report a case of facial nerve paralysis appearing 11 days following a successful canal wall-down mastoidectomy., Results: Viral screening for Herpes Virus type 1 confirmed the viral aetiology of the delayed facial paralysis., Conclusion: When an ipsilateral facial nerve palsy appears more than 72 hours after an uneventful middle ear procedure, without symptoms of any infection, suspect a viral reactivation.

Objective: To establish the efficacy of uvulopalatopharyngoplasty with tonsillectomy for treating selected patients with severe obstructive sleep apnea syndrome., Methodology: Retrospective study of patients who underwent clinical/instrumental evaluation and surgical treatment., Setting: University ENT division with a tertiary snoring referral center., Participants: Twenty-two patients with normal body mass index affected by severe obstructive sleep apnea syndrome., Main Outcome Measures: Pre- and post-operative cardiopulmonary monitoring during sleep, daytime sleepiness evaluation, post-treatment complication recording., Results: Complete response to therapy was obtained in 78% of patients. Four patients had relief of symptoms but retained apnea/hypopnea index scores greater than 5., Conclusions: Uvulopalatopharyngoplasty associated with tonsillectomy can beemployed safely to treat patients with normal body mass index who suffer from severe obstructive sleep apnea.

Pleomorphic adenoma is the most common tumour of the salivary glands. However, it is extremely rare for these to originate in the nose and even when they do so, it is most commonly in the nasal septum. It is important to be aware of the paucity of presenting symptoms (nasal obstruction and epistaxis), as the lesion may not be recognized immediately. Growth is generally restricted locally and the tumour is not known to spread to the neighbouring structures. Surgical resection is the treatment of choice. Recurrences and evolution to malignancy are not frequent, but long-term follow-up is recommended. The case is presented of pleomorphic adenoma arising from the lateral wall of the right nasal cavity, in a 34-year-old male, which was resected completely, endoscopically. Histological and immunohistochemical evaluation revealed the presence of a pleomorphic adenoma.

Problem: It is common to see nasal polyps arising from the lateral wall of the nose; however, polyps arising from the nasal septum are rare. Diagnosis of such lesions is usually made by nasal endoscopy and confirmed by computer tomography., Methodology: Two cases of isolated nasal septum polyps were diagnosed from 150 consecutive functional endoscopic sinus surgeries. Both patients had septal deviation; only one had a history of allergy. The polyps were completely excised in both cases; the septal deviations were not corrected., Results: Both patients remain disease-free after two and three years of follow-up., Conclusions: Nasal septal deviation does not seem to play an important role in septal polyp development, whereas local nasal inflammatory factors appear to be important for the genesis of septal polyps. Limited resection using a functional endoscopic surgical approach is the best choice of treatment to prevent recurrence of polyps.

Background: Fine-needle aspiration cytology (FNAC) is useful in the diagnosis of many conditions of the head and neck. No reported studies have investigated the optimal needle gauge in the head and neck region., Methods: This was a prospective randomized trial of 100 patients who required FNAC performed with either a 21G or 23G needle. Discomfort was scored by patients using a visual analogue scale. Sample accuracy was assessed in patients who subsequently had excision biopsy., Results: FNAC performed with a 23G needle was less painful (mean +/- SE, 1.6 +/- 1.01) than FNAC with a 21G needle (3.3 +/- 1.94; p < .001). There was no difference in sample adequacy between the 2 needle sizes (p = .59). The sensitivities and specificities of both needles were similar., Conclusion: Head and neck FNAC should routinely be performed with a 23G needle, resulting in less patient discomfort, and giving sample adequacy comparable to a conventional 21G needle.

Chordoma is a rare tumor, arising from notochord remnants, which usually occurs in the axial skeleton and rarely metastasizes. Although there have been 3 previous reports of metastatic disease to the facial bones from sacrococcygeal chordoma, this is the first to describe spread to the mandible from a vertebral primary chordoma.