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Mixed-type tremors pose a clinical diagnostic challenge. The aim of the study was to better characterize patients with combined postural and rest tremor. Patients were categorized into four groups: essential tremor (ET) ( n = 7), combined rest + postural tremor ( n = 17), PD ( n = 17), and control subjects ( n = 9). All underwent the University of Pennsylvania Smell Identification Test (UPSIT). The mixed-tremor group was also evaluated with SPECT imaging using the dopamine transporter (DaT) ligand 123I-labeled FP-CIT. There was no significant difference in olfaction scores between the mixed tremor and essential tremor groups (23.2 ± 6.6 vs 21.7 ± 4.9) or between these groups and controls (27.2 ± 5.0). The patients with PD had significantly lower scores than all the other groups (13.7 ± 5.4, p < 0.001). Of the 12 patients with mixed tremor evaluated by SPECT, 9 had normal findings. This study suggests that rest tremor is part of the spectrum of ET, even in patients with long-standing disease. However, in a minority of patients, there might be transformation of ET–PD. [ABSTRACT FROM AUTHOR]

Purpose: To assess the knowledge and confidence level regarding the basic first-aid for treating epistaxis among medical staff, including nurses and physicians across various medical disciplines. The study focused three aspects of first aid management: location of digital pressure, head position and duration of pressure., Methods: The study involved 597 participants, categorized into five groups according to their specialties: emergency medicine, internal medicine, surgery, pediatrics, and community-based healthcare. A paper-based multiple-choice questionnaire assessed knowledge of managing epistaxis. Correct answers were determined from literature review and expert consensus., Results: Most medical staff showed poor knowledge regarding the preferred site for applying digital pressure in epistaxis management. For head position, pediatricians and internal medicine physicians were most accurate (79.4% and 64.8%, respectively, p < 0.01), and nurses from the emergency department outperformed nurses from other disciplines; internal medicine, surgery, pediatrics, and community-based healthcare (61.1%, 41.5%, 43.5%, 60%, 45.6%, respectively, p < 0.05). While most medical staff were unfamiliar with the recommended duration for applying pressure on the nose, pediatricians and community clinic physicians were most accurate (47.1% and 46.0%, respectively, p < 0.01), while ER physicians were least accurate (14.9%, p < 0.01). Interestingly, a negative correlation was found between years of work experience and reported confidence level in managing epistaxis., Conclusions: Our findings indicate a significant lack of knowledge concerning epistaxis first-aid among medical staff, particularly physicians in emergency departments. This finding highlights the pressing need for education and training to enhance healthcare workers' knowledge in managing epistaxis., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: To evaluate the safety and outcomes of powered intracapsular tonsillotomy and adenoidectomy (PITA) for the treatment of sleep disordered breathing in infants up to 36 months of age compared to older children., Methods: This retrospective analysis included children who underwent PITA from 2013 to 2019 at a single tertiary care medical center. The patients were divided into 2 groups: up to 36 months, and 36 to 72 months. The data were collected from electronic medical records and from a telephone survey based on a modified version of the OSA-18 questionnaire. Post-operative complications, and short- and long-term outcomes were compared., Results: A total of 48 patients met the inclusion criteria for the main study group (up to 36 months of age). They were compared to 59 children 36 to 72 months of age. There were no differences in subjective outcomes between age groups ( P  = .65). There were no differences in the frequency of post-operative complications between age groups ( P  = .8) or in the number of hospitalization days ( P  = .91)., Conclusion: The short- and long-term outcomes and safety of PITA for the treatment of sleep disordered breathing in infants up to 36 months of age are similar to those of older children.

Objective: To investigate whether dysregulated thyroid hormone function is associated with Bell's palsy., Study Design: Cross-sectional., Setting: Electronic medical record database of Clalit Health Services (CHS). CHS is an Israeli payer-provider, integrated health care system, serving >4.5 million members (54% of the Israeli population)., Patients: Older than 18 years with Bell's palsy, during 2002 to 2019., Interventions: None., Methods: A total of 1,374 patients with Bell's palsy who had thyroid-stimulating hormone (TSH) blood levels measured up to 60 days before the palsy were matched (1:2) for age and sex with 2,748 controls who had TSH blood levels and no history of Bell's palsy., Results: Retrospective review of the CHS database, from 2002 to 2019 yielded 11,268 patients with Bell's palsy, of which, 1,374 met the inclusion criteria. Mean age was 57.9 years, and 61.4% were female. A higher percentage of patients in the Bell's palsy group had low TSH (≤0.55 mIU/L) compared with controls (5.7% vs. 3.6%, p < 0.001). Low TSH compared with TSH > 0.55 mIU/L, was independently associated with 1.45-fold increased odds for having Bell's palsy (95% CI 1.11-2.02, p < 0.001), when controlled for age, sex, body mass index, diabetes, hypertension, prior cerebrovascular accident, hemoglobin level, and purchasing thyroid hormone drugs. Among the patients with TSH ≤ 0.55 mIU/L, 95.5% had normal free thyroxin and 97.7% had normal free triiodothyronine levels (subclinical hyperthyroidism). For 47.1% of patients, TSH remained ≤0.55 mIU/L, 3 to 12 months after the Bell's palsy occurred and most patients had normal free thyroxin (95.4%) and normal free triiodothyronine (91.8%)., Conclusions: Subclinical hyperthyroidism is independently associated with Bell's palsy after controlling for multiple confounding factors., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2023, Otology & Neurotology, Inc.)

Introduction: Retraction pockets and marginal perforations of the pars tensa of the tympanic membrane (TM) are most commonly found at superior posterior quadrant (SPQ). The patulous Eustachian tube tends to manifest in the same quadrant. Variation in the structure of the TM may explain these observations., Material and Methods: A line defined by the manubrium was used to divide the pars tensa into anterior and posterior portions. A transverse line centered on the umbo divides the pars tensa into superior and inferior parts, resulting in four quadrants. Surface areas of each of the TM quadrants were measured in a sample of 23 human adult formalin-fixed temporal bones. The TMs were completely excised, faced medially, and placed against graph paper to maintain scale measurements, photoed, and measured.TM thickness was measured on a different set of 20 human temporal bones (TB) preparations with normal external and middle ears. Four random loci were chosen from each pars tensa's TM quadrant. The thickness was measured using high-magnification power microscopy., Results: The SPQ was the largest and thinnest of the four quadrants. It occupies 31% of the pars tensa area. It is 69 μm as compared to approximately 85 μm in the other quadrants. The radial lines between the umbo and the annulus are in descending order from superior posterior toward the anterior-superior radials., Conclusion: The SPQ has the largest vibratory area and is the thinnest of the four TM quadrants. Variation in the thickness of the middle, fibrous layer accounts for the variation in the thickness of the TM. These findings may explain the tendency of pathologies related to Eustachian tube dysfunction to preferentially manifest in or originate from the SPQ., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Background: Dysphagia is a common symptom with diverse etiologies and refers to disorders of the process of swallowing food or fluids. Many studies have reported the anatomical and functional differences between men and women in swallowing in healthy patients; however, sex discrepancies in symptomatic patients have not often been studied., Objectives: To compare the performance of men and women with dysphagia using videofluoroscopy., Methods: To compare the performance of men and women with dysphagia using videofluoroscopy., Results: A total of 203 patients met the inclusion criteria, 106 men (52%) and 97 women (48%). Men complained significantly more about choking on liquids (P = 0.002) and in swallowing pills (P = 0.004) compared to women. Men had more abnormalities in the pharyngeal phase (P = 0.015) and at the upper esophageal sphincter (P = 0.056). The prevalence of aspiration, penetration, and barium residue in the hypopharynx and in the vallecula were significantly greater in men as well., Conclusions: In patients with dysphagia, women had fewer subjective symptoms and performed better than men in videofluoroscopy especially in the pharyngeal phase. These differences are probably due to different anatomical and functional swallowing characteristics. A better understanding of these discrepancies can be useful in offering tailored treatment in clinical practice.

Introduction: This study aimed to identify the characteristics of cranial-base morphology in platybasic and nonplatybasic patients with palatal anomalies and velopharyngeal dysfunction (VPD) compared with control subjects to investigate structural factors related to craniofacial morphology that affect the nasopharyngeal space and may influence velopharyngeal function, and to develop precise treatments for specific patients with VPD., Methods: Three hundred eighty-six patients with VPD and various palatal anomalies were studied retrospectively. The control group included 126 healthy patients with normal speech. Lateral cephalometric images assessed craniofacial morphology., Results: Nonplatybasic patients and control subjects had larger SNA, S-Ba-Ptm, and N-Ba-PP angles (in the craniomaxillary complex), and platybasic patients had larger nasopharyngeal ANS-Ptm-Ve and Ba-S-Ptm angles and longer Ve-T and Ve-Ba distances than the nonplatybasic patients. All study patients had larger ANB, Gn-Go-Ar, and PP-MP angles (in the craniomandibular complex). Nonplatybasic patients had smaller Ba-SN angles than platybasic patients and controls because of more acute N-S-Ptm angle. Among the nonplatybasic patients, Ve-T length tended to be shorter (with no significant difference between groups) and located more inferiorly (because of the smallest ANS-Ptm-Ve angle) in relation to the maxilla. Thus, the nasopharynx was narrower horizontally but longer vertically than in patients with platybasia., Conclusions: Cranial-base flexure influences the shape of the skull base and facial-skeletal structure and may alter the pharyngeal space between them. This finding should help improve preoperative planning regarding the effect of the pharyngeal flap height relative to the nasopharynx and oropharynx ratio that affects surgical outcomes, such as resonance and residual VPD. In patients with Class III malocclusion and maxillary constriction, careful planning of presurgical orthodontic treatment is needed in maxillary advancement procedures. Orthodontic and surgical collaboration can help prevent postoperative VPD, especially in platybasic patients., (Copyright © 2022 American Association of Orthodontists. Published by Elsevier Inc. All rights reserved.)

Background: Nivolumab, an immune checkpoint inhibitor is used to treat advanced metastatic malignancies. Data showed that nivolumab can cause exacerbated response of T-Helper 2 cells and lead to airway inflammation., Objective: To present the upper airway findings of a 69-year-old woman after treatment with nivolumab., Methods: Case report., Results: A 69-year old woman with no history of chronic rhinosinusitis developed complaints of nasal congestion, rhinorrhea, sneezing, and anosmia. These symptoms started after one year of treatment with nivolumab. Pale polyps were observed on fiberoptic endoscopy examination. A gradual increase in eosinophil blood counts was noted. On histopathology, heavy infiltrates of eosinophils were seen in the tissue., Conclusions: Nivolumab is used to treat various advanced metastatic malignancies, with a good safety profile. Nevertheless, physicians must be alert to the possibility of evolving type II inflammation in patients, as appropriate therapy can be provided to improve their quality of life.

The study aimed at assessing the relationship between skull base morphology, represented by skull base and nasopharyngeal angles, and palatal anatomy among patients with 22q11DS and velopharyngeal dysfunction. Retrospective analysis of patients with 22q11DS and velopharyngeal dysfunction. Age, sex, severity of velopharyngeal dysfunction, type of cleft (overt cleft palate, submucous cleft palate, occult submucous cleft palate, or no-CP, and cephalometric skull base angles were reviewed. Correlations between type of palatal anomaly and the angles were assessed. Among 132 patients, 71 were male (53.8%) and 61 were female (46.2%), ages 3.3-40.0 years (mean 8.3 ± 6.10). No difference in the mean cranial-base angle (P = 0.353) or in the distribution of the three types of cranial base angle sizes was found among the palatal anomaly groups (P = 0.137). More men had normal cranial base angles and more women had acute angulation (P = 0.008). A positive correlation was found between the skull base and nasopharyngeal angles (P = 0.001, r = -0.590). No direct correlation was found between cranial base morphology and palatal anomalies in patients with 22q11DS, and velopharyngeal dysfunction. This is probably because skull base and palate morphology contribute independently to velopharyngeal dysfunction., Competing Interests: Declaration of competing interest The authors have no financial or other conflicts of interest to declare., (Copyright © 2021 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Superior Semicircular Canal Dehiscence (SSCD) may lead to vestibular and auditory impairments., Objective: To study the effects of power absorbance (PA), Distortion Product Otoacoustic emissions (DPOAE), and hearing thresholds in normal ears of fat sand rats, after a bullotomy, creation and patching., Methods: SSCD was performed unilaterally in eight normal hearing animals while the contra-lateral un-operated ear was used as a control. Measures included auditory brain stem responses thresholds for air and bone conduction stimuli, DPOAEs and PA at peak pressure., Results: The normal PA pattern of the animals grossly resembled that of human ears. A bullotomy generated specific, large and significant (p < 0.0001) changes in PA without altering hearing thresholds. SSCD significantly decreased PA at low (p < 0.02) and increased at high frequencies (p < 0.03), but on a smaller scale than the bullotomy. SSCD, induced a mean air-bone gaps of 24.3 for clicks, and 31.2 dB for 1 kHz TB. SSCD also increased the DPOAEs levels by mean of 10.1 dB SPL (p < 0.03). Patching the dehiscence, reversed partially the PA changes, the auditory threshold shifts, and the DPOAEs levels to pre-SSCD values., Conclusions: SSCD affects both incoming and emitting sounds from the ear, probably due to its effect on cochlear impedance and stiffness of the middle and inner ear. The presence of DPOAEs and ABGs indicated a "third window" disease, i.e., SSCD. Due to similar PA patterns after bullotomy and SCCD, PA alone has limited diagnostic yield for patients with SCCD., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2021, Otology & Neurotology, Inc.)

Objective: To compare Ostmann's fat pad (OFP) size between healthy ears and ears with chronic otitis media with cholesteatoma (COMwC) in children, to assess its role in the disease., Methods: MRI scans of 29 children with unilateral COMwC with conductive hearing loss were used to measure OFP, represented by the maximal diameter of the high intensity area medial to the tensor veli palatini muscle (TVP): M1. A reference diameter was defined from the medial border of OFP reaching the medial border of the medial pterygoid muscle: M2. Values of M1, M2 and the ratio of M1:M2 were compared between the healthy and pathological ear in each patient., Results: No difference in OFP size was observed between healthy (H) ears (mean M1H:M2H ratio 0.72 ± 2.28) compared to ears with COMwC pathology (P) (mean M1P:M2P ratio .68 ± 1.57; P = .943) in children, suggesting that OFP size abnormalities do not have a role in pediatric COMwC., Conclusion: OFP size was not correlated to the development of unilateral COMwC in children., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: To compare the size of Ostmann's fat pad (OFP) between healthy ears and ears with chronic otitis media with cholestatoma (COMwC) using magnetic resonance imaging (MRI)., Methods: Twenty-six patients with unilateral COMwC underwent mastoidectomy. Pre-operative MRI records were reviewed retrospectively. The healthy ears served as the control group. OFP is represented by the maximum diameter of the high intensity area medial to the tensor veli palatini muscle (TVP); M1. A reference diameter was defined from the medial border of OFP reaching the medial border of the medial pterygoid muscle; M2. Values of M1, M2 and the ratio of M1:M2 was compared between the healthy and pathological ear in each patient., Results: All 26 patients (16 females,10 males) had unilateral cholestatoma. Mean age was 37.6 years (range 19-83). In the healthy ( H ) ears group, mean M1 H was 2.04 ± 0.53 mm, mean M2 H was 9.57 ± 2.57 mm.In the pathological ( P ) ears group; mean M1 P was 2.03 ± 0.55 mm, mean M2 P was 9.86 ± 2.37 mm. A comparison of M1 and M2 values between the healthy and pathological ear groups was not statistically significant ( P  = .853 and P  = .509, respectively).Mean M1 H :M2 H ratio in the healthy ears group was 0.22 ± 0.05, mean M1 P :M2 P ratio in the pathological ear group was 0.21 ± 0.06. A comparison between these ratios found no significant statistical correlation ( P  = .607)., Conclusion: The size of Ostmann's fat pad does not affect the development of chronic otitis media with cholestatoma in adults.

Purpose: To evaluate the safety and outcomes of adenoidectomy for the treatment of sleep disordered breathing (SDB) in infants up to 12 months of age as compared to children ages 13-72 months METHODS: A retrospective analysis was performed by reviewing the medical records of children who underwent adenoidectomy from 2005 to 2018. The data of older age groups were also collected for comparison. The patients were divided into three groups: up to 12 months (infants), 13-36 months (toddlers) and 37-72 months (preschool). The data were collected from electronic medical records and from a telephone survey based on a modified version of the OSA-18 questionnaire. Postoperative complications, and short and long-term outcomes were compared., Results: Twenty-one patients met the inclusion criteria for the main study group (infants). They were compared with forty-four toddlers and thirty-two preschoolers. Among the infants, four (19%) needed additional surgical intervention, none of the toddlers and four (12.5%) preschoolers. There were no differences in subjective outcomes between age groups (p = 0.365) in the first year after surgery. One year after surgery, outcomes remained similar in all age groups (p = 0.302) with regard to SDB, but subjective improvements in mouth breathing and nasal discharge were better among the older children (p = 0.011 and p = 0.012), respectively., Conclusion: The outcomes of adenoidectomy for the treatment of SDB in infants up to 12 months of age is similar to children ages 13-72 months.

Laryngeal squamous cell carcinoma (LSCC) responds to 17β-estradiol via estrogen-receptor (ER, transcribed from ESR1) dependent mechanisms, but is not recognized as a hormonally responsive cancer. 17β-estradiol production by LSCC cell lines UM-SCC-11A and UM-SCC-12 was examined. Wild type (WT) and ESR1-silenced LSCC cultures and xenografts were examined for 17β-estradiol responsiveness in vivo. 14 LSCC and surrounding epithelial samples at various pathological stages were obtained from patients; ERα and ERβ expression were verified using data from the total cancer genome atlas. UM-SCC-11A and UM-SCC-12 both produce 17β-estradiol, but only UM-SCC-12, not UM-SCC-11A, xenograft tumors grow larger in vivo in response to systemic 17β-estradiol treatments. ERα66 and ERα36 expression inversely correlated with clinical cancer stage and tumor burden. LSCC ERα66 expression was higher compared to surrounding epithelia in indolent samples but lower in aggressive LSCC. ERβ expression was highly variable. High ESR1 expression correlated with improved survival in LSCC. Loss of ERα66 expression inversely correlated with prognosis in LSCC. ERα66 may be a histopathological marker of aggression in LSCC.

Introduction: The popularity of dental implants is continuously increasing. Displacement of implants into the maxillary sinus is a well-documented complication following this treatment., Aims: To characterize patients treated in our institution for uncontrolled penetration of dental implants into the maxillary sinus, and highlight the importance of the multidisciplinary approach in treating these cases., Methods: The charts of all patients treated in 2018 within the Sinuses and Dental Clinic at the Meir Medical Center were reviewed. Data concerning age, gender, timing and the type of treatment performed was retrospectively analyzed., Results: Fifteen patients were included in the study. Ten implants were found in the left sinus and five in the right side. Eight implants were seen in the lower medial alveolar recess. None of the patients presented with an oro-antral fistulae. Ten patients were treated endoscopically - eight through a nasal approach, and two through the mouth. All patients healed uneventfully., Conclusions: Different approaches can be used to remove implants from the maxillary sinus., Discussion: Most patients in this study were referred adjacent to the displacement of the dental implant. The medial alveolar recess is the most common area of implant displacement. While either a nasal or oral approach can be used to retrieve the implant in the absence of sinus disease, a nasal approach should be preferred in the presence of such pathology. The collaboration between the otorhinologist and the maxillofacial surgeon, enables both the dental and rhinosinus considerations to be considered. This cooperation allows practitioners to design better treatment plans for patients with dental implants involving the sinuses.

Introduction: Deafness is the most common sensory disability in humans affecting all aspects of life. Approximately 50% of congenital deafness is hereditary and about half of genetic deafness is still unsolved. To date, more than 150 genes are known to cause hearing loss worldwide, with specific genes contributing to deafness in distinct populations. Of these, more than 20 genes are involved in deafness among the Jewish Israeli hearing-impaired population. The most common gene in many worldwide populations, including Israel, is GJB2, which encodes the connexin 26 protein. The second most common gene among Jews is TMC1, with most pathogenic variants found only among Jews of Moroccan origin. Most other pathogenic variants found in the Jewish population are origin-specific and not found in other Jewish ethnic groups or in other worldwide populations. In patients where hereditary deafness is suspected, known variants in the specific ethnicity are routinely examined. In Israel, the GJB2 gene is screened in all cases of hereditary deafness and the TMC1 gene is screened in deaf persons of Jewish Moroccan origin. In cases where no variant is found in a known gene, more comprehensive diagnostic tests should be used. Since the beginning of the deep sequencing era, less than a decade ago, the number of deafness-related genes in the Jewish population has increased by threefold. Identifying the pathogenic variant makes it possible to study molecular pathogenesis, to anticipate and understand the prognosis, to calculate probability of concomitant morbidity, to offer prenatal diagnosis, prevent recurrence of deafness in the family and early rehabilitation. Currently, cochlear implant offers the greatest chance for rehabilitation. The hope is that understanding the molecular pathogenesis will in the future lead to personalized medical treatment. We review the genetics of deafness, with an emphasis on the Jewish population in Israel, new diagnostic methods and suggest a diagnostic algorithm and future treatment methods.

Objective: Imaging is important for the diagnosis and follow-up of necrotizing external otitis (NEO). The best imaging modality is controversy. To suggest 2-deoxy-2-[fluorine-18] fluoro-D-glucose-positron emission tomography/computed tomography (18F-FDG-PET/CT) as an alternative to technetium-99m and gallium-67 scans for diagnosis and assessment of response to treatment for patients with NEO., Study Design: Case series., Methods: Tertiary referral center. From 2013 through 2017, 12 patients were diagnosed with NEO based on clinical features and positive FDG uptake within the temporal bone on PET/CT. Mean age was 74 ± 11.5; 83% of the patients were male; and 83% had diabetes., Results: PET/CT scans were reviewed independently by two nuclear medicine specialists. Imaging located osteomyelitis in external ear canal, mastoid, temporomandibular joint, and nasopharyngeal region (100%, 50%, 16%, 8%, respectively). Mean follow-up was 16 months. Eight patients (67%) underwent a second PET/CT scan after active otitis resolved and after at least 6 weeks of antibiotic treatment. The scan demonstrated no or substantially reduced FDG uptake and treatment was stopped. The patients had no NEO symptoms at the end of follow-up. One patient had significant uptake, and antibiotic treatment was continued until a third scan demonstrated no FDG uptake. Two patients died before the second PET/CT, and two were lost to follow-up., Conclusion: 18F-FDG-PET/CT is a reliable imaging modality for diagnosis, disease localization, and decision making regarding treatment cessation. 18F-FDG-PET/CT should be considered as the imaging modality of choice for initial diagnosis and follow-up in NEO patients. Larger, controlled studies are warranted., Level of Evidence: 4 Laryngoscope, 129:961-966, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: Cephalometric evaluation of craniofacial and craniopharyngeal morphology is important for understanding the factors affecting velopharyngeal dysfunction (VPD) in patients with palatal anomalies., Materials and Methods: In this study, 366 patients with VPD were retrospectively stratified into cleft lip and palate (CLP), cleft palate (CP), submucous cleft palate (SMCP), occult submucous cleft palate (OSMCP), and non-CP groups. Lateral cephalometrics were used to assess craniofacial, craniopharyngeal, and velopharyngeal anatomy., Results: The average craniofacial morphology in patients with VPD differed significantly according to the type of palatal anomaly. The non-CP and OSMCP groups differed from the CLP, CP, and SMCP groups in nasopharyngeal size and shape as depicted by a larger ANS-Ptm-Ve angle, a smaller S-N-Ba and NBa-PP angles, and a shorter linear value of S-Ar in the non-CP group. The CLP and CP groups had shorter ANS-Ptm, shorter Ptm-P, and smaller SNA and SNB angles., Conclusion: VPD patients with overt clefts have different skeletal and nasopharyngeal shapes compared to non-CP and OSMCP. Velopharyngeal function assessment should include the size and shape of the nasopharyngeal space in addition to the size and the activity of the velum and posterior and lateral walls of the nasopharynx. This should enable a more precise understanding of VPD pathology, and lead to improvements in the posterior pharyngeal flap technique in order to obtain better postoperative speech outcomes after surgical management of velopharyngeal dysfunction., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: Malignant external otitis (MEO) is an aggressive infection, primarily affecting elderly diabetic patients. It begins in the external ear canal and spreads to adjacent structures. This study investigated the clinical characteristics of patients diagnosed and treated for MEO and analyzed factors affecting patient outcomes., Study Design: Historical cohort., Setting: Tertiary medical center., Methods: Medical records of all patients diagnosed and treated for MEO from 1990 to 2013, were retrospectively reviewed. Clinical features, laboratory, imaging and outcomes were analyzed., Results: 88 patients were included, mean age was 73±11.5years, 61 (69%) were male. Of these, 75% had diabetes. Mean follow-up was 60months. The most common presenting symptoms were otalgia (89%), external ear canal edema (86%) and otorrhea (84%). Pseudomonas aeruginosa was isolated in 61% of ear cultures. All patients were treated with antibiotics, 22% had surgery and 8% hyperbaric oxygen. Overall survival rate was 38% in 5years, with disease specific mortality 14%. DM, facial nerve palsy, positive CT scan and age above 70 were found to correlate and predict disease-specific mortality., Conclusions: MEO carries a grave prognosis. The presence of two or more of the following features, DM, facial nerve palsy, positive CT scan and age above 70, predicts poor outcome, and highlights the need for prolonged, vigorous treatment., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Cochlear implantation is associated with deterioration in hearing. Despite the fact that the damage is presumed to be of sensory origin, residual hearing is usually assessed by air-conduction thresholds alone. This study sought to determine if surgery may cause changes in air- and bone-conduction thresholds producing a mixed-type hearing loss. The sample included 18 patients (mean age 37 years) with an air-bone gap of 10 dB over three consecutive frequencies and measurable masked and reliable bone-conduction thresholds of operated and non-operated ears who underwent cochlear implant surgery. All underwent comprehensive audiologic and otologic assessment and imaging before and after surgery. The air-bone gap in the treated ears was 17-41 dB preoperatively and 13-59 dB postoperatively over 250-4,000 Hz. Air-conduction thresholds in the treated ears significantly deteriorated after surgery, by a mean of 10-21 dB. Bone-conduction levels deteriorated nonsignificantly by 0.8-7.5 dB. The findings indicate that the increase in air-conduction threshold after cochlear implantation accounts for most of the postoperative increase in the air-bone gap. Changes in the mechanics of the inner ear may play an important role. Further studies in larger samples including objective measures of inner ear mechanics may add information on the source of the air-bone gap.

Objectives: Currently available behavioral tools for the assessment of noise-induced hearing loss (NIHL) depend on the reliable cooperation of the subject. Furthermore, in workers' compensation cases, there is considerable financial gain to be had from exaggerating symptoms, such that accurate assessment of true hearing threshold levels is essential. An alternative objective physiologic tool for assessing NIHL is the auditory steady state response (ASSR) test, which combines frequency specificity with a high level of auditory stimulation, making it applicable for the evaluation of subjects with a moderate to severe deficit. The primary aim of the study was to assess the value of the multifrequency ASSR test in predicting the behavioral warble-tone audiogram in a large sample of young subjects with NIHL of varying severity or with normal hearing. The secondary goal was to assess suprathreshold ASSR growth functions in these two groups., Design: The study group included 157 subjects regularly exposed to high levels of occupational noise, who attended a university-associated audiological clinic for evaluation of NIHL from 2009 through 2011. All underwent a behavioral audiogram, and on the basis of the findings, were divided into those with NIHL (108 subjects, 216 ears) or normal hearing (49 subjects, 98 ears). The accuracy of the ASSR threshold estimations for frequencies of 500, 1000, 2000, and 4000 Hz was compared between groups, and the specificity and sensitivity of the ASSR test in differentiating ears with or without NIHL was calculated using receiver operating characteristic analysis. Linear regression analysis was used to formulate an equation to predict the behavioral warble-tone audiogram at each test frequency using ASSR thresholds. Multifrequency ASSR amplitude growth as a function of stimulus intensity was compared between the NIHL and normal-hearing groups for 1000 Hz and 4000 Hz carrier frequencies., Results: In the subjects with NIHL, ASSR thresholds to various frequencies were significantly and highly correlated with the behavioral warble-tone thresholds; Pearson correlation coefficients ranged from 0.6 to 0.8 over the four frequencies tested. Differences between thresholds ranged from 10 to 13 dB. The configuration of the ASSR waveforms closely approximated the behavioral audiogram. The sensitivity for screening hearing thresholds was 92%; by frequency, sensitivity ranged between 92.7 and 98.4%, but specificity was lower, especially at the low frequencies. ASSR accurately predicted moderate and severe NIHL. The mean ASSR growth amplitude to increasing stimulus level for 1000 and 4000 Hz was significantly steeper in the NIHL than in the normal-hearing group, with no significant difference between frequencies., Conclusions: The ASSR test has a high sensitivity to detect moderate to severe hearing loss in subjects with NIHL. Its use can facilitate the early identification of noise-exposed workers with NIHL. It may also serve an important medico-legal function in cases of workers' compensation. The ASSR test is not, by itself, an appropriate tool for hearing screening in the general population.

Background: The aim of this study was to present a novel anatomically comprehensive and clinically applicable system for the quantification of sleep endoscopy findings in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS)., Methods: Fifty-five adult patients with a polysomnographic diagnosis of OSAHS were referred for midazolam-induced sleep endoscopy following failure of continuous positive airway pressure. Five anatomical sites of possible obstruction along the upper airway were documented: nose/nasopharynx (N), uvulopalatine plane (P), tongue base (T), larynx (L), and hypopharynx (H). Each involved site was assigned a severity grade of 1 (partial obstruction) or 2 (complete obstruction). The digits representing the obstruction pattern at each level were then added to yield a severity index (SI). The SI for each patient was determined by two independent observers. Findings were correlated with the respiratory disturbance index (RDI) and body mass index (BMI)., Results: The SI was significantly correlated with the RDI (R=0.746, Pearson; P<0.0001) and predicted disease severity with 65% accuracy. There was no association with BMI. By site, the tongue base and hypopharynx were significantly correlated with obstruction severity; obstruction in the tongue base predicted disease severity with a sensitivity of 68.8 and sensitivity of 81.1., Conclusion: Our easy-to-use endoscopic grading system provides physicians with an accurate picture of the pattern of the upper-airway system obstruction in patients with obstructive sleep apnea/hypopnea syndrome. It is a promising tool for estimating the location and severity of upper airway disease and may have implications for treatment planning.

Background: The purpose of this study was to investigate the efficacy of the KTP/532 YAG laser to reduce nasal congestion and discharge in patients with allergic rhinitis., Methods: Forty-eight patients with symptoms of allergic rhinitis were treated with the KTP/532 laser. All had positive skin tests for common allergens. Treatments were provided on an ambulatory basis in one to three sessions under local anesthesia with lidocaine nose spray. Outcome was determined by daily symptom reports and regular endoscopy examination and interviews for 12 months., Results: Treatment was very well tolerated. There were no major side effects. At examination after 1 year, nasal obstruction was improved in 69% and nasal discharge in 40% of cases., Conclusion: The KTP/532 YAG laser is effective for the treatment of nasal obstruction and discharge. Comparison with other techniques showed it to be the most effective in reducing nasal discharge. It can be done as an office procedure and does not damage the nasal mucous membrane. The KTP/532 YAG laser is effective as an additional treatment for patients refractory to medication.

Objectives/hypothesis: The posterior commissure is an uncommon site of glottic carcinoma. The aim of the study was to compare the clinical and prognostic characteristics of glottic carcinoma of the posterior commissure and the vocal cords., Study Design: Retrospective case control study., Methods: The study group consisted of 40 patients aged 32 to 84 years (mean, 62.7 +/- 10.7) diagnosed with T1 glottic carcinoma involving the posterior commissure from 1960 to 2008. Data on clinical features and outcome were collected from the medical files and compared with the data for 42 patients aged 30 to 87 years (mean, 64.4 +/- 11.8) with T1 vocal cord carcinoma., Results: : There were no significant differences in clinical characteristics between the groups except for the higher rate of smokers among the patients with vocal cord carcinoma (95% vs. 65%, P = .01). All patients were treated primarily with radiotherapy. Disease-free survival in the posterior commissure carcinoma group was 76.1% after 5 years and 72.3% after 10 years, and in the vocal cord carcinoma group, 95% after 5 and 10 years (P = .012). The risk of recurrence was higher when the tumor involved the posterior commissure (hazard ratio, 8.78; 95% CI, 1.12-68.5, P = .038)., Conclusions: T1 glottic carcinoma involving the posterior commissure has a more aggressive biological behavior and a worse prognosis than T1 glottic carcinoma of the vocal cords. Smoking, which is an important pathogenetic factor in vocal cord carcinoma, plays a lesser role in posterior commissure carcinoma. Laryngoscope, 2009.

The objectives of our study were to demonstrate the patterns and sites of the upper airway (UA) collapse in obstructive sleep apnea/hypopnea syndrome (OSAHS) patients, utilizing the sleep endoscopy technique, and to describe the technique and summarize our experience in a large series of patients. UA findings during sleep endoscopy with midazolam were examined prospectively in 55 surgical candidates with OSAHS. The uvulopalantine was the most common site of obstruction (89%), followed by the tongue base, hypopharynx and larynx (33% each), and nose (21%); 72% of the patients had multiple obstructions. There was a significant correlation between the number of obstructions and the respiratory distress index (RDI). Laryngeal obstruction was typically supraglottic. Hypopharyngeal obstruction involved concentric UA narrowing. Our findings emphasize the considerable rate of laryngeal and hypopharyngeal obstructions in patients with OSAHS and suggest that their misdiagnosis may explain at least part of the high surgical failure rate of UPPP for OSAHS patients. The number of obstruction sites correlates with respiratory distress index. Sleep endoscopy is safe and simple to perform.

The aim of this study was to evaluate the efficacy of an intraoperative monitoring hearing preservation strategy that includes simultaneous recordings of an auditory brainstem response (ABR) and non-invasive electrocochleography (ECochG). The combined ABR and tympanic membrane (TM) ECochG testing was performed in 74 patients undergoing acoustic neuroma (AN) surgery. In addition, EMG recordings were conducted to monitor the facial nerve function. Hearing was preserved in 19 of the 30 patients with residual hearing prior to surgery (63%), and facial nerve function was maintained in 89% of the patients. In most cases, the presence of both auditory brainstem and TM-ECochG responses at the end of surgery was associated with preservation of postoperative functional hearing; however, eight patients had a TM-ECochG response with a complete loss of the ABR, pointing to deafferentation of the auditory nerve. Tumour size and preoperative hearing thresholds significantly affected the postoperative hearing. The TM-ECochG response yielded large reproducible responses, which, in some patients, was the only way to monitor the auditory function. This auditory monitoring approach offers a valuable auditory tool that helps to improve the hearing preservation during AN surgery.

Objective: Acute mastoiditis becomes clinically significant when infection spreads through the periosteum and induces periosteitis. This study describes an atypical complication of acute mastoiditis: osteomyelitis of the temporal bone., Patients and Methods: The study sample included all patients admitted for acute mastoiditis between September 2001 and December 2003 who had symptoms, signs and imaging findings of osteomyelitis of the temporal bone beyond the mastoid area. The files were reviewed for diagnosis, work-up, radiographic findings and treatment., Results: The study group included 6 of the 120 patients treated for acute mastoiditis. In four children (66%), the diagnoses of acute otitis media and acute mastoiditis were made simultaneously at admission. Ear cultures yielded coagulase-positive Staphylococcus in three patients, Bacteroides in two, multiple organisms in two, S. pneumoniae in one, and no growth in two. Complications were suspected if there was a lack of improvement in symptoms and signs, or in cases of skin involvement over the temporal bone beyond the area of the mastoid in accordance with imaging findings. Computerized tomography demonstrated temporal bone absorption beyond the mastoid area (squama and/or petrous bones) in all children, suspected sinus vein thrombosis in two, and suspected epidural abscess in one. All children were treated with at least cortical mastoidectomy and insertion of ventilation tubes. Revision mastoidectomy was performed in three children in whom no improvement was noted and imaging suggested other complications., Conclusion: The present study describes an unusual complication of acute mastoiditis-osteomyelitis of the temporal bone beyond the mastoid framework. The disorder is characterized by a failure to respond both locally and systemically to accepted medical and surgical therapy, persistent fever and high levels of inflammatory markers, and computerized tomography findings of temporal bone destruction. Treatment includes broad-spectrum antibiotics and at least cortical mastoidectomy. Prognosis is good.

The aim of the present study was to review our recent experience in the diagnosis and treatment of acute mastoiditis and its complications in a single tertiary-care, university-affiliated pediatric center. Ninety-eight children with 101 episodes of acute mastoiditis were included in the study. The mean interval from onset of illness to mastoiditis was 4.5 days. Ear cultures most often grew Streptococcus pneumoniae and Pseudomonas aeruginosa (23.7% each). Complications occurred in 15.8% of episodes. The only factor differentiating children with and without complications was white blood cell count. These findings indicate that acute mastoiditis not only is a complication of prolonged infection of the middle ear, but may also present as an acute infection of the mastoid bone that can progress within 48 hours. The complication rate remains high, and antibiotic treatment at the onset of symptoms does not prevent complications. A high white blood cell count on admission may serve as a predictive factor of complicated cases.

Squamous cell carcinomas of the head and neck (SCCHN) are excellent candidates for local immunotherapy owing to their accessibility and their infiltration by mononuclear cells that are susceptible to immunomodulation. A response rate of 25-60% has been reported for treatment with natural IL-2 or a mixture of natural lymphokines. In the present study, biopsies and posttreatment excision specimens from nine patients with operable SCCHN treated systemically with a variety of immunomodulators and locally with natural lymphokines (multikine, CelSci) were analyzed in an attempt to correlate clinical response to histopathological and immunohistochemical changes. Formalin-fixed, paraffin-embedded tissues were stained with antibodies against lymphocytes (CD45, CD3, CD4, CD8, CD20), macrophages (CD68) including dendritic cells (S-100), markers for lymphocyte activation (CD30, HLA-DR), natural killer cells (CD56 and CD57), beta-2-microglobulin and keratin. One patient showed a complete response to treatment and two a partial response. Tumor size was significantly smaller after therapy. Clinical and pathological regression were more prominent in the smaller tumors. Numerous macrophages, both mononucleated and multinucleated, were present along the tumor-stroma interface in the posttreatment specimens of seven patients, most prominently in the three patients with tumor regression. The increase in the number of CD68+ and S-100+ macrophages after treatment was statistically significant. Lymphocytic infiltrates, which showed some increase following treatment, were composed of a mixture of T and B lymphocytes, the former mostly in contact with the tumor and the latter placed more peripherally. CD8+ lymphocytes extended into the tumors, whereas CD4+ lymphocytes showed minimal extension. Intensity of beta-2-microglobulin staining in tumors was significantly higher following therapy and associated with a better outcome. The marked increase in macrophages following treatment may indicate that the macrophage plays a major role in tumor recognition, destruction and clearance. An increase in the number of macrophages in a posttreatment specimen may indicate immunoresponsiveness.

Background: Technetium-99m sestamibi scintigraphy has become one of the most popular techniques for localization of the parathyroid gland after failure of primary neck exploration., Objective: To examine the efficacy of sestamibi with the hand-held gamma ray detecting probe for the identification of parathyroid adenomas during revision parathyroidectomy., Methods: We reviewed six cases of probe-assisted neck exploration for parathyroid lesions following unsuccessful primary exploration., Results: In all cases the pathologic glands were successfully detected and removed., Conclusions: With careful planning, a gamma ray detecting probe can be used optimally 2-3 hours after technetium-99m sestamibi injection. The probe is efficient, easy and convenient to use.

Background: Basaloid squamous cell carcinoma (BSCC) is a distinct variant of squamous cell carcinoma that was first described by Wain et al in 1986. Since then, about 160 cases have been reported in the literature. Only 40 cases have been described in the larynx., Methods: Four cases of BSCC of the larynx treated in our department between 1986 and 2000 are presented. The clinical features, biological behavior, and histopathological and immunohistochemical characteristics of this uncommon tumor are described, and the relevant literature is reviewed., Results: The main clinical presentation did not differ from other histological types of laryngeal carcinoma. The clinical course, however, was much more aggressive. All the patients received aggressive therapy including radical surgery and radiation. Two patients received chemotherapy. Two of the 4 patients presented died of distant metastasis shortly after diagnosis and treatment., Conclusions: The finding of this study with a limited number of patients supports previous reports suggesting that BSCC is a highly aggressive tumor that presents in older population with male predominance. The frequency of associated regional as well as distant metastases suggests that aggressive treatment is indicated and that systemic chemotherapy should be contemplated.

Unlabelled: We reviewed the records of 38 patients aged 16 to 76 years with isolated sphenoid sinus disease who were treated by intranasal endoscopic sphenoidotomy at our hospital during the period 1992-1997. Diagnosis was made on the basis of history rigid nasal endoscopy and computed tomography (CT) scan of the sinuses. Headache was the main symptom in 29 (76%) patients. Other complaints were rhinitis, cough, nasal obstruction and nasal bleeding. Sphenoidotomy was performed endoscopically, directly through the area of the natural ostium. Acute or chronic sinusitis was found in 57% of the patients, cysts in 13%, polyps in 10%, mucocele in 8%, and fungal infection, pituitary adenoma, inverted papilloma and adenocarcinoma, in 3% each. Surgical results were excellent. The endoscopic approach proved to be both safe and effective., Conclusion: Sphenoid sinus disease is mostly inflammatory in origin. The endoscopic approach to the sphenoid sinus is currently the most appropriate method of surgery for an isolated sphenoid lesion.

Background: Otitis externa (OE) is a common disorder which can cause severe pain and discomfort with discharge and hearing loss. The majority of topical preparations for OE treatment contain a combination of steroids and antibiotics and are administered as ear drops. Otic powder preparations are less common. We found no studies which compared the efficacy of the two dosage forms., Objective: The purpose of the study was to compare the healing process of the external ear canal when treated locally either with otic powder (Auricularum), a preparation containing antibiotic, steroidal and antimycotic components, or with otic drops (Dex-Otic), a commercial ear drop preparation containing antibiotic and steroidal components., Methods: The study was designed as an open, randomised, comparative clinical trial. Ambulatory patients suffering from OE were examined by an ear specialist and randomly divided into an otic powder (Auricularum) treatment group and an ear drop (Dex-Otic) treatment group. Each treatment group was treated in accordance with the daily doses recommended by the manufacturers. Patients were treated for a period of 14 days and examined on days 0, 3, 7, 10 and 14. Clinical signs and symptoms recorded were pain, erythema, swelling and discharge., Results: A total of 67 patients entered the study. The probability of healing within 7 days was 74% in the otic powder group as opposed to 40% in the ear drops group (log rank test, p = 0.0013). The probability of total pain relief after 3 days of treatment was 60% in the otic powder group compared to 53% in the ear drops group (log rank test, p = 0.0001)., Conclusion: We conclude that treatment with an otic powder (Auricularum) may promote earlier healing and pain relief than does treatment with otic drops (Dex-Otic).

The effect of passive smoking on odor identification was studied in 10 children exposed to passive smoke at home. All had at least one parent who smoked at least one pack of cigarettes a day. The control group consisted of 10 children of nonsmoking parents. Ten odorants were tested: vinegar, ammonia, peppermint, roses, bleach, vanilla, cough drops, turpentine, licorice and mothballs. Each child was presented with five test trays containing all 10 odorants in random order. Of the total of 500 odors presented, the control group correctly identified 396 (79%) and the study group, 356 (71%) (p < 0.005). This work demonstrates that children exposed to passive smoke have difficulty identifying odors in comparison to children raised in relatively smoke-free environments. Since the study group tend to misidentify four of the 10 odorants tested--vanilla, roses, mothballs and cough drops--we suggest that these four odorants should suffice in testing odor identification in children.