Scielo RSS <![CDATA[International Archives of Otorhinolaryngology]]> vol. 22 num. 4 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[Award-Winning Research— IAO 2018]]> <![CDATA[A Comparative Study between Universal Eclectic Septoplasty and Cottle]]> <![CDATA[Probable Association of Hearing Loss, Hypertension and Diabetes Mellitus in the Elderly]]> Abstract Introduction The aging process causes changes in body structure in a continuous manner, and contributes to clinical disorders. Life expectancy is increasing, especially in developing countries. Objective To assess the prevalence of hearing loss and its possible association with hypertension and diabetes mellitus (DM) in the elderly. Methods A cross-sectional study with 519 elderly individuals aged over 60 years who underwent an audiological evaluation (pure tone audiometry), and answered a comorbidity questionnaire that included questions about age, gender, tinnitus and medical history, with data concerning DM. The dependent variable was the presence of hearing loss. The independent variables were age, gender, DM and hypertension. The variables were presented in absolute numbers and proportions, and enabled us to estimate the prevalence. The statistical analysis was performed through multiple logistic regression with 95% confidence intervals and values of p&lt; 0.05 for the hearing loss and its associated factors. Results A total of 519 subjects of both genders with a median age of 69 years were evaluated, and the individuals who did not attend the audiometric test were excluded from the study, so the final sample was composed of 498 subjects. Sensorineural hearing loss was more prevalent (66.26%) of most frequently with bilateral hearing loss of 91.56% and 26.50% with mild degree. The statistical analysis showed that the variable DM was associated with the high frequency of hearing loss in the elderly, and according to the multiple logistic regression, the risk factors are independent of the hearing loss only for age and exposure to occupational noise. Conclusions There was a statistically significant difference between hearing loss at high frequencies and the risk factors, that is, age and DM. <![CDATA[Outcomes of Automated Auditory Evoked Potential Performed in Different Settings and the Factors Associated with Referred Cases]]> Abstract Introduction For the population with risk factors for hearing loss, the first option to assess the hearing status is the performance of the automated brainstem auditory evoked potential (BAEP) test because of its efficacy in identifying retrocochlear hearing loss. Objective To verify the outcomes of automated BAEP performed in different settings as well as the factors associated with the prevalence of hearing impairment. Methods Cross-sectional study conducted from October of 2014 to May of 2015. The sample consisted of 161 infants with at least one risk factor for hearing loss who underwent automated BAEP during the hospital stay or at the outpatient clinic. After 30 days, the altered cases were referred for BAEP diagnosis. Results One hundred and thirty-eight infants (86%) had a result of “pass” and 23 (14%) of “failure” in the automated BAEP. There was no statistically significant difference in the rate of “referred” results between examinations performed in different settings. The infants' ages did not influence the number of abnormal cases. All of the 23 infants who presented a “referred” result in the automated BAEP, unilateral or bilateral, were sent for BAEP diagnosis, and out of these, 9 (39%) remained with at least some degree of alteration. The average age of diagnosis was 2.7 months. Conclusion The results of the automated BAEP were similar when performed during hospitalization or after discharge. Neither the age at the examination nor the gender of the patient influenced the prevalence of hearing loss. <![CDATA[The Contribution of Surface Electromyographic Assessment for Defining the Stage of Peripheral Facial Paralysis: Flaccid or Sequelae Stage]]> Abstract Introduction Surface electromyographic activity may not be symmetric, even in subjects with no facial paralysis history. Objective To evaluate the contribution of the index of electromyographic (IEMG) activity in the identification of the two extremes of the facial paralysis course. Methods Thirty-four subjects with unilateral peripheral facial paralysis were selected. A control group was composed of volunteers without a history of facial paralysis. The electromyographic assessment of the facial muscle was performed by placing surface electrodes during movements of the forehead, eyes and lips using MIOTEC equipment, such as the MIOTOOL (Miotec, Porto Alegre, Brazil) software. The electromyographic activity was also recorded in other channels during the primary activity to identify the presence of synkinesis. The statistical analysis was performed using the Statistical Package for Social Sciences for Macintosh (SPSS Inc, Chicago, IL, USA). The IEMG activity was obtained from the division of the electromyographic activity root mean square (RMS) values on both sides. Results There was a statistically significant difference among the groups in all the analyzed indexes. The ocular-oral synkinesis in all patients must be correctly identified (with 100% sensitivity and specificity) using an IEMG activity of 1.62 as a cutoff point. The oral-ocular synkinesis must be correctly identified (93.3% sensitivity and 95.9% specificity) using the IEMG activity of 1.79 as a cutoff point. Conclusion The IEMG activity is below the normal scores in patients in the flaccid stage, whereas patients in the sequelae stage can either show normal values or values above or below the normal scores. The IEMG activity was shown to have high sensitivity and specificity in the identification of synkinesis. <![CDATA[Headphone Evaluation for App-Based Automated Mobile Hearing Screening]]> Abstract Introduction With the need for hearing screenings increasing across multiple populations, a need for automated options has been identified. This research seeks to evaluate the hardware requirements for automated hearing screenings using a mobile application. Objective Evaluation of headphone hardware for use with an app-based mobile screening application. Methods For the purposes of this study, hEAR, a Bekesy-based mobile application designed by the research team, was compared with pure tone audiometric tests administered by an audiologist. Both hEAR and the audiologist's test used 7 frequencies (125 Hz, 250 Hz, 500 Hz, 1,000 Hz, 2000 Hz, 4,000 Hz and 8,000 Hz) adopting four different sets of commercially available headphones. The frequencies were regarded as the independent variable, whereas the sound pressure level (in decibels) was the dependent variable. Thirty participants from a university in Texas were recruited and randomly assigned to one of two groups, whose only difference was the order in which the tests were performed. Data were analyzed using a generalized estimating equation model at α = 0.05. Results Findings showed that, when used to collect data with the mobile app, both the Pioneer HDJ-2000 (Pioneer, Bunkyo, Tokyo, Japan) (p&gt; 0.05) and the Sennheiser HD280 Pro (Sennheiser, Wedemark, Hanover, Germany) (p&gt; 0.05) headphones presented results that were not statistically different from the audiologist's data across all test frequencies. Analyses indicated that both headphones had decreased detection probability at 4kHz and 8kHz, but the differences were not statistically significant. Conclusion Data indicate that a mobile application, when paired with appropriate headphones, is capable of reproducing audiologist-quality data. <![CDATA[Effect of Blood Group on Ultrahigh Frequency Auditory Sensitivity]]> Abstract Introduction Individuals with blood group O are reported to have reduced otoacoustic emissions (OAEs) compared with individuals with different blood groups. Objective The present study attempted to determine if the blood group has any effect on high-frequency auditory sensitivity using ultrahigh-frequency audiometry and ultrahigh-frequency distortion product otoacoustic emissions (DPOAEs). Methods High-frequency thresholds and high-frequency DPOAEs were measured in 60 individuals with normal hearing and different blood groups. Results The results of the study showed that there was a significant reduction in DPOAE amplitude for individuals with blood group O compared with individuals with other blood groups. However, there was no significant difference in ultrahigh-frequency thresholds across the blood groups. Conclusion This reduction in OAE amplitude may be attributed to a lower number of healthy outer hair cells in individuals with blood group O. Further studies on larger groups of individuals are essential for a better generalization of the results. <![CDATA[A Comparison of the Operative Techniques and the Postoperative Complications for Bone-Anchored Hearing Aid Implantation]]> Abstract Introduction Bone anchored hearing aids (BAHA) represent a useful surgical option for patients with single sided deafness. Objectives To compare multiple techniques for BAHA implantation regarding postoperative complications, operative time, and duration between the surgery and the first use of the BAHA. Methods A retrospective study was conducted of all patients receiving implantation of a BAHA from August of 2008 to October of 2014. Data collected included: patient age, gender, side operated, abutment length, operative time, duration until first use of the BAHA, operative technique, and postoperative complications. The statistical analysis was performed using analysis of variance (ANOVA), Tukey pairwise comparison, chi-square, and paired t-test. Statistical significance was determined using a level of p&lt; 0.05. Results A total of 88 patients (43 female and 45 male) were included in the data analysis. A total of 80 complications were documented, and these complications were classified according to the Holgers criteria. A significant difference in the total postoperative complications existed between the six techniques used (ANOVA; p&lt; 0.01). In addition, there was also a significant difference among the six techniques employed regarding the operative time (ANOVA; p&lt; 0.01). The average time duration until fitting of the BAHA processor among the various techniques trended toward but did not reach statistical significance (ANOVA; p= 0.16). Conclusions Significant differences in the operative outcomes exist among the various techniques for BAHA implantation. Based on the statistical analysis of our data, the BAHA Attract system (Cochlear Ltd., Sidney, Australia) requires greater operative time, but it is associated with less postoperative complications than percutaneous techniques and its processor may be fitted significantly sooner. <![CDATA[Periosteal Graft Myringoplasty: Our Experience]]> Abstract Introduction Different types of autologous graft materials are used for myringoplasty, with the temporalis fascia and cartilage being the most frequently used tissues. Periosteal tissue has been used for a long time in our department, and many advantages support its use in myringoplasty. To the best of our knowledge, this issue is scarcely discussed in the previously published literature. Objective To present our experience with periosteal graft myringoplasty, describing the technique and the anatomical and functional outcomes. Methods A prospective clinical study involving 88 patients (72 females and 16 males) with a mean age 26.9 years. The patients underwent myringoplasty using the mastoid cortex periosteum; they were all operated using the postauricular approach, and the graft was applied using the underlay technique. The patients performed pre- and postoperative pure tone audiometry for tested frequencies (0.5 kHz, 1 kHz, 2 kHz, and 4 kHz). All patients were followed-up for at least 12 months after the operation. Results The anatomical success rate among all patients was of 93%, which is comparable to the rate of success in procedures using other usual grafting materials. In addition, there was a highly significant postoperative improvement in pure tone audiometry results as compared with the preoperative ones (the main hearing gain was of ∼ 11 dB; p&lt; 0.001). Conclusion The periosteal graft is easily harvested, easy to apply, with excellent anatomical and functional success. <![CDATA[Effect of HIV and Antiretroviral Treatment on Auditory Functions]]> Abstract Introduction Numerous studies have evaluated auditory functions in human immunodeficiency virus (HIV) patients; however, these studies had a few major limitations in terms of methodology as they used mainly evoked audiometry although this method is expensive, time consuming and not widely available. Therefore, we conducted a study in naïve HIV subjects with routine audiometry. Objective To determine the effect of HIV and of the drugs used to treat it on the auditory functions. Methods A prospective observational study was conducted in a medical college with 25 naive HIV-seropositive patients for over a year. Pure tone audiometry (250–8,000 Hz) and CD4 T-lymphocyte count were performed at the time of enrollment and 6 months after commencement of highly active antiretroviral treatment. Results The subjects had increased hearing thresholds at high frequencies (4 KHz and 8KHz) in both ears at the time of enrollment that persisted at the same level (p &gt; 0.05) on follow-up at 6 months. None of the subjects had any other otological symptom during the 6 months of observation. Seven subjects had sensorineural hearing loss in one or both ears at 0 and 6 months. These observations did not show any significant difference on Wilcoxon-signed-rank test. Spearman correlation did not find a significant correlation (p &gt; 0.05) between CD4 T-lymphocyte counts and pure tone audiometry during the study. Conclusion We found high-frequency hearing loss in all subjects with no relation with highly active antiretroviral therapy (HAART) and severity of the disease. This study advocates hearing assessment with pure tone audiometry in HIV subjects so that intervention can be initiated in a timely manner. <![CDATA[Disparity between Preoperative and Pre-Excisional Intraoperative Parathyroid Hormone in Parathyroid Surgery]]> Abstract Introduction Intraoperative parathyroid hormone (ioPTH) testing is a widely accepted standard for assessing the parathyroid gland function. A decline of preoperative parathyroid hormone (PTH) levels by more than 50% is one accepted measure of parathyroid surgery adequacy. However, there may be a variation between preoperative PTH levels obtained at a clinic visit and pre-excisional ioPTH. Objective Our study explores the differences between preoperative PTH and pre-excisional ioPTH levels, and the potential impact this difference has on determining the adequacy of parathyroid surgery. Methods A retrospective study that consisted of 33 patients that had undergone parathyroid resection between September 2009 and March 2016 at a tertiary academic center was performed. Each subject's preoperative PTH levels were obtained from clinic visits and pre-excisional ioPTH levels were recorded along with the time interval between the measurements. Results There was a significant difference between the mean preoperative PTH and the pre-excisional ioPTH levels of 147 pg/mL (95% confidence interval [CI] 11.43 to 284.47; p= 0.0396). The exclusion of four outliers revealed a further significant difference with a mean of 35.09 pg/mL (95% CI 20.27 to 49.92; p&lt; 0.0001). The average time interval between blood draws was 48 days + 32 days. A weak correlation between the change in PTH values and the time interval between preoperative and pre-excision blood draws was noted (r2 = 0.15). Conclusion Our study reveals a significant difference between the preoperative PTH levels obtained at clinic visits and the pre-excisional intraoperative PTH levels. We recommend routine pre-excisional intraoperative PTH levels, despite evidence of elevated preoperative PTH levels, in order to more accurately assess the adequacy of surgical resection. <![CDATA[Effect of Fractal Tones on the Improvement of Tinnitus Handicap Inventory Functional Scores among Chronic Tinnitus Patients: An Open-label Pilot Study]]> Abstract Introduction Music-based sound therapies become recently a trend in the treatment of tinnitus. Few publications have studied the therapeutic use of fractal tones to treat chronic tinnitus. Objective The aim of this study was to determine the benefits of using fractal tones as a unique sound therapy for chronic tinnitus sufferers. Methods Twelve participants were recruited; however, six could not be assigned. At baseline and at 1, 3 and 6 months, the participants were provided with the Tinnitus Handicap Inventory (THI) and Hearing Handicap Inventory for Adults (HHIA) questionnaires, and their visual analog scale score was recorded. Tinnitus pitch and loudness matching was performed before fitting and after 6 months of use. Results The visual analog scale (VAS) score, pitch and loudness matching and minimal masking levels did not result in significant improvement at the end of the treatment. The mean THI measured at baseline was 45, and the final one was 25. A paired sample t-test showed that this 20-point difference was statistically significant. Conclusions We measured the benefits of using fractal tone therapy for the treatment of chronic tinnitus and found that most of the benefits were in the THI functional domain, which includes concentration, reading, attention, consciousness, sleep, social activities, and household tasks. For all patients with bothersome chronic tinnitus and high scores on the THI functional scale, fractal tones should be considered a promising initial sound therapy strategy. The findings from this open-label pilot study are preliminary, and further trials are needed before these results can be generalized to a larger tinnitus population. <![CDATA[Determination of Factors Associated with Critical Weight Loss in Oral Cavity Carcinoma Patients: A Retrospective Cohort Study]]> Abstract Introduction Critical weight loss is defined as an unintentional weight loss of ≥ 5% at 1 month or ≥ 10% at 6 months from the start of treatment. Critical weight loss leads to deterioration of the immune function and reduced tolerance to treatment (surgery ± radiochemotherapy) as well as increased complication rates. Objective Critical weight loss, defined as a weight loss of ≥ 5% after 1 month or ≥ 10% after 6 months from the start of treatment, is not uncommon in head and neck cancer patients. We aimed to assess the factors associated with critical weight loss during the treatment of oral cavity squamous cell carcinoma patients. Methods A retrospective cohort study was performed at the Aga Khan University Hospital, in Karachi, Pakistan, on 125 patients. Patients receiving adjuvant therapy were considered exposed, and the outcome was critical weight loss. Results The mean age of presentation was 46.9 ± 12.8 years in patients undergoing surgery and adjuvant therapy, with 119 (79.3%) of them being male and 31 (20.7%) female. One hundred and twelve patients (81.3%) developed critical weight loss at 6 months from the start of treatment, and the only significant variable associated with critical weight loss was the stage of the disease (p= 0.03). Conclusion A large proportion of patients with oral cancer developed critical weight loss requiring a need for intervention. The overall stage of the disease is a significant predictor of critical weight loss in patients undergoing treatment. <![CDATA[Identification of Fungal Pathogens in Otomycosis and Their Drug Sensitivity: Our Experience]]> Abstract Introduction Otomycosis is a common problem in otolaryngology practice. However, we usually encounter some difficulties in its treatment because many patients show resistance to antifungal agents, and present high recurrence rate. Objectives To determine the fungal pathogens that cause otomycosis as well as their susceptibility to the commonly used antifungal agents. Additionally, to discover the main reasons for antifungal resistance. Methods We conducted an experimental descriptive study on 122 patients clinically diagnosed with otomycosis from April 2016 to April 2017. Aural discharge specimens were collected for direct microscopic examination and fungal culture. In vitro antifungal susceptibility testing was performed against the commonly used antifungal drugs. We tested the isolated fungi for their enzymatic activity. Results Positive fungal infection was found in 102 samples. The most common fungal pathogens were Aspergillus and Candida species, with Aspergillus niger being the predominant isolate (51%). The antifungal susceptibility testing showed that mold isolates had the highest sensitivity to voriconazole (93.48%), while the highest resistance was to fluconazole (100%). For yeast, the highest sensitivity was to nystatin (88.24%), followed by amphotericin B (82.35%), and the highest resistance was to terbinafine (100%), followed by Itraconazole (94.12%). Filamentous fungi expressed a high enzymatic ability, making them more virulent. Conclusion The Aspergillus and Candida species are the most common fungal isolates in otomycosis. Voriconazole and Nystatin are the medications of choice for the treatment of otomycosis in our community. The high virulence of fungal pathogens is owed to their high enzymatic activity. Empirical use of antifungals should be discouraged. <![CDATA[Do Otolaryngology Patients Show Gender Preference When Choosing a Surgeon? — A Quantitative and Qualitative Analysis]]> Abstract Introduction Otorhinolaryngology has always been considered a gender-neutral specialty, whereas in several other specialties, such as obstetrics, gynecology and urology, gender preference has been consistently shown by patients when choosing their treating surgeon. To date, no study has been performed to analyze whether this practice of gender preference is prevalent in otorhinolaryngology patients too. Objectives To identify if gender preference exists in the field of otorhinolaryngology, specifically in its four subspecialties, namely otology, pediatric otolaryngology, laryngology and head and neck surgery. Methods Patients attending our outpatient department were asked to complete a preformed proforma. The pro forma consisted of two parts, demographic details of the subjects and gender preference in the following subspecialties: otology, pediatric otolaryngology, laryngology and head and neck oncosurgery. Results A total of 1,112 subjects took part in the study, out of which 1,089 subjects were included in the final analysis. Female gender preference was highest in the field of pediatric otolaryngology, while male preference was highest for head and neck oncosurgery. Conclusion Though otorhinolaryngology and head and neck surgery has been considered a gender-neutral field, subspecialties of this field show considerable gender preference. <![CDATA[P3 Cognitive Potential in Cochlear Implant Users]]> Abstract Introduction The P3 cognitive evoked potential is recorded when a subject correctly identifies, evaluates and processes two different auditory stimuli. Objective to evaluate the latency and amplitude of the P3 evoked potential in 26 cochlear implant users with post-lingual deafness with good or poor speech recognition scores as compared with normal hearing subjects matched for age and educational level. Methods In this prospective cohort study, auditory cortical responses were recorded from 26 post-lingual deaf adult cochlear implant users (19 with good and 7 with poor speech recognition scores) and 26 control subjects. Results There was a significant difference in the P3 latency between cochlear implant users with poor speech recognition scores (G-) and their control group (CG) (p= 0.04), and between G- and cochlear implant users with good speech discrimination (G+) (p= 0.01). We found no significant difference in the P3 latency between the CG and G+. In this study, all G- patients had deafness due to meningitis, which suggests that higher auditory function was impaired too. Conclusion Post-lingual deaf adult cochlear implant users in the G- group had prolonged P3 latencies as compared with the CG and the cochlear implant users in the G+ group. The amplitudes were similar between patients and controls. All G- subjects were deaf due to meningitis. These findings suggest that meningitis may have deleterious effects not only on the peripheral auditory system but on the central auditory processing as well. <![CDATA[Benefit of Cochlear Implantation in Children with Multiple-handicaps: Parent's Perspective]]> Abstract Introduction The cochlear implants centers in the world are studying the cochlear implantation in children with multiple handicaps. Objective To develop a questionnaire to analyze the subjective benefits of the cochlear implantation in multiple handicapped children according to their parent's perspective. Methods A questionnaire was applied to 14 families of multiple handicapped children, aging from 2–12 years old and having from 11 months to 11 years of implant use. Results The social-emotional abilities were improved because of many factors, such as: auditory exposure, which happened in 84% of the children; recognition of their own names, which increased in 56%; and development of eye contact, in 28% of the subjects. Other benefits appeared to be: music appreciation and more attention and adherence to other therapies and school activities. Besides, some children became interested in objects, playing with other children, and more adapted to daily routines. Thirty-five percent of the children acquired oral language, mainly the bilaterally implanted, while 14% of them were engaged in sign language. Although all of the children showed a significant improvement in communication, the emotional issues of some families and the severity of the handicaps negatively impacted the outcomes. In spite of the families' acknowledgement of some benefits, the diagnosis of autism spectrum disorder caused frustration, requiring a readjustment of the expectations. Conclusion The questionnaire turned out to be an adequate tool to reveal the social-emotional benefits of cochlear implantation. Although oral language was not the major outcome in these cases, the cochlear implant benefits involved the whole family. All of the families recommended the implant to other children in a similar situation. <![CDATA[Comparison of 1α-25-dihydroxyvitamin D3 and IgE Levels between Allergic Rhinitis Patients and Healthy People]]> Abstract Introduction Allergic rhinitis is one of the most common allergic diseases that cause a decrease in quality of life. Over the last decades, the increase in the number of cases is supposed to be a result of industrialization and lifestyle changes. Vitamin D, which is a steroid hormone, has a significant immunomodulatory and antioxidant role in the human body. Objective The objective of the present study is to investigate the role of 1α-25-dihydroxyvitamin D3 levels in allergic rhinitis patients and to compare them to the levels found in the healthy population. Methods A total of 256 participants were included in the present study. Allergic rhinitis is diagnosed with the help of the Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines confirmed through skin prick tests. Control subjects were selected among people without allergy history, which was also confirmed through skin prick tests. The levels of 1α-25-dihydroxyvitamin D3, immunoglobulin E (IgE), and eosinophil counts were measured in blood samples from both groups. Results The mean value of serum levels of 1α-25-hydroxyvitamin D3 was 25.5 ± 3.74 in the allergic rhinitis group, and 31.58 ± 3.85 in the control subjects. This difference reveals statistically-decreased levels in the allergic rhinitis group (p&lt; 0.05). The total IgE levels are increased in the allergic rhinitis group (p&lt; 0.05) and negatively correlated with the serum levels of 1α-25-hydroxyvitamin D3 (r = - 0.259, p&lt; 0.05). Conclusion Lower serum levels of 1α-25-hydroxyvitamin D3 were detected in the allergic rhinitis population. This data is also correlated to the IgE response in the study group. A supplement of 1α-25-hydroxyvitamin D3 in deficient patients might be helpful to relieve symptoms and signs of allergic rhinitis, but further studies are needed. <![CDATA[The Role of Modified Expansion Sphincter Pharyngoplasty in Multilevel Obstructive Sleep Apnea Syndrome Surgery]]> Abstract Introduction Obstructive sleep apnea syndrome (OSAS) is a sleep disorder caused by an excessive narrowing of the pharyngeal airway that also collapses during inspiration, with an important role played by the lateral pharyngeal wall in the development of the obstruction. Objective To describe our surgical experience with modified expansion sphincter pharyngoplasty (MESP) in the management of lateral collapse in upper airway multilevel surgery. Methods A total of 20 patients with moderate to severe OSAS were recruited in the Ear, Nose and Throat (ENT) Department of the University of Palermo, Italy. All of the enrolled patients refused the ventilatory therapy. The subjects were evaluated for snoring, and daytime sleepiness had a clinical evaluation including collection of anthropometric data and ENT examination and rhinofibroscopy with Müller maneuver. The patients undergoing upper airway multilevel surgery and we selected for MESP the patients with an oropharyngeal transverse pattern of collapse at Müller maneuver. Results In the postoperative assessment, all of the patients reported a reduction in snoring scores and daytime sleepiness. We observed a reduction in the mean apnea-hypopnea index (AHI) of 57.5% of the sample, which decreased from a mean value of 41.7 ( ± 21.5) to 17.4 ( ± 8.9) (p&lt; 0.05), with a success rate, according to the Sher criteria, of 65%. We observed very few postoperative complications. Conclusion Modified expansion sphincter pharyngoplasty in multilevel surgical therapy preceded by a careful selection of patients has proven to be effective in treating patients with moderate to severe syndromes. <![CDATA[Timing of Tracheostomy in Intensive Care Unit Patients]]> Abstract Introduction The ideal timing of tracheostomy in intensive care units (ICUs) for critically ill patients undergoing prolonged mechanical ventilation (MV) is still a controversial issue. Objectives To determine the proper timing of tracheostomy and its impact on various clinical outcomes of adult patients in ICUs undergoing prolonged MV. Methods The present study consisted of a sample of 67 ICU adult patients who were submitted to open surgical tracheostomy and divided into two groups: 30 patients in the early tracheostomy (ET) group (within 1–10 days post intubation), and 37 patients in the late tracheostomy (LT) group (within 11–21 days post intubation). The correlation between the timing of tracheostomy of each group and various associated ICU clinical parameters were analyzed. Results The sample consisted of 61.19% male and 38.81% female patients, with a mean age of 47.263 ± 7.581 years. The mean MV duration in days was 7.91 ± 4.937 standard deviation (SD) in the ET group, and 15.32 ± 7.472 SD in the LT group (p= 0.001), with a mean sedation time of 6.13 ± 4.647 SD in the ET group, and of 11.98 ± 6.596 SD in the LT group (p= 0.001). The duration of the weaning process duration had a mean of 2.75 ± 2.586 SD days in the ET group, and of 5.39 ± 5.817 SD days in the LT group (p= 0.025), with a weaning failure rate of 28.57% in the ET group and 71.42% in the LT group (p= 0.01). The Mean ICU stay was 26.18 ± 4.732 SD in the ET group, and 11.98 ± 6.596 SD in the LT group (p= 0.879), and the incidence of ventilator-associated pneumonia (VAP) of 23.33% in the ET group and of 27.02% in the LT group (p= 0.15). Conclusion Early tracheostomy had a notable benefit in shortening the duration of the MV, lessening the sedation time and minimizing the risks of weaning failure, but it had no significant impact on both the overall duration of ICU stay and VAP incidence. <![CDATA[Surgically-Treated Locoregionally Advanced Hypopharyngeal Cancer: Outcomes]]> Abstract Introduction Hypopharyngeal tumors are head and neck malignancies associated with a great mortality rate, and the treatment of advanced lesions constitutes a challenging problem. Pharyngolaryngectomy continues to be the gold standard treatment modality for locally-advanced diseases, and it is currently used as the primary treatment or in cases of relapse after an organ preservation strategy. Objective This study aims to compare the survival rates of patients with advanced hypopharyngeal tumors treated with pharyngolaryngectomy as a primary or salvage option, and identify possible prognostic factors. Methods All patients with advanced hypopharyngeal squamous cell carcinomas who performed pharyngolaryngectomy between 2007 and 2014 were reviewed retrospectively. Results A total of 87 patients fulfilled the aforementioned criteria, and the sample had a mean age of 57.2 years and a male predominance of 43:1. The tumors were located in the pyriform sinus walls (81 tumors), in the posterior pharyngeal wall (4 tumors) and in the postcricoid region (2 tumors). A total of 60 patients underwent surgery as the primary treatment option, and 27 were submitted to salvage pharyngolaryngectomy after a previous treatment with chemoradiotherapy or radiotherapy. The 5-year overall survival was of 25.9%, the 5-year disease-free survival was of 24.2%, and the disease-specific survival was of 29.5%. Conclusion The patients treated with pharyngolaryngectomy as the primary option revealed a better 5-year-disease free survival than the patients who underwent the salvage surgery (35.8% versus 11.7% respectively; p&lt; 0.05). The histopathological criteria of capsular rupture of the lymph nodes (30.1% versus 19.8% respectively for the primary and salvage groups; p&lt; 0.05) and vascular invasion (30.5% versus 22.5% respectively; p&lt; 0.05) reduced the 5-year disease-free survival. Pharyngolaryngectomy as the primary intent revealed a lower local recurrence rate than the salvage surgery (40.6% versus 83.3% respectively; p&lt; 0.05). <![CDATA[Level V Clearance in Neck Dissection for Papillary Thyroid Carcinoma: A Need for Homogeneous Studies]]> Abstract Introduction Papillary thyroid carcinoma has a very high rate of lateral neck node metastases, and there is almost unanimity concerning the fact that some sort of formal neck dissection must be performed to address the clinical neck disease in these cases. Although there is an agreement that levels II to IV need to be cleared in these patients, the clearance of level V is debatable. Objectives We herein have tried to analyze various papers that have documented a structured approach to neck dissection in these patients. Moreover, we have also tried to consider this issue through various aspects, like spinal accessory nerve injury and the impact of neck recurrence on survival. Data Synthesis The PubMed, Medline, Google Scholar, Surveillance, Epidemiology, and End Results (SEER), and Ovid databases were searched for studies written in English that focused on lateral neck dissection (levels II–IV or II–V) for papillary thyroid carcinoma. Case reports with 10 patients or less were excluded. Conclusions The current evidence is equivocal whether to clear level V or not, and the studies published on this issue are very heterogeneous. Level II-IV versus level II-V selective neck dissections in node-positive papillary thyroid carcinoma patients is far from categorical, with pros and cons for both approaches. Hence, we feel that there is a need for more robust homogeneous data in order to provide an answer to this question. <![CDATA[Physical Therapy for Posterior and Horizontal Canal Benign Paroxysmal Positional Vertigo: Long-term Effect and Recurrence: A Systematic Review]]> Abstract Introduction Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo, and it is characterized by episodes of vertigo roundabout when the head is moved. A systematic review was performed using the most important scientific databases. This review included studies published in English in the last ten years, performed in adults, with emphasis on the diagnosis and treatment of BPPV. Objective To investigate the long-term effectiveness of vestibular rehabilitation (VR) in patients with BPPV and the rate of recurrence of symptoms. Data Synthesis A total of 38 studies were identified, of which only 12 met the inclusion criteria. The majority of the studies stated that VR is effective in decreasing the symptoms, with a short-term efficacy of 84.7%, and 89.2% in the long term in the reviewed studies. Conclusion Valuable studies show the beneficial effects of the maneuvers for the treatment of BPPV and their long-term effectiveness. This strengthens the conclusion that this treatment is effective in resolving symptoms and decreasing recurrences. <![CDATA[Parameters for Applying the Brainstem Auditory Evoked Potential with Speech Stimulus: Systematic Review]]> Abstract Introduction Studies using the Brainstem Auditory Evoked Potential with speech stimulus are increasing in Brazil, and there are divergences between the methodologies used for testing. Objectives To analyze the parameters used in the study of the Brainstem Auditory Evoked Potentials with speech stimulus. Data Synthesis The survey was performed using electronic databases. The search strategy was as follows: “Evoked potentials, auditory” OR “Brain stem” OR “Evoked potentials, auditory, brain stem” AND “Speech.” The survey was performed from June to July of 2016. The criteria used for including articles in this study were: being written in Portuguese, English or Spanish; presenting the description of the testing parameters and the description of the sample. In the databases selected, 2,384 articles were found, and 43 articles met all of the inclusion criteria. The predominance of the following parameters was observed to achieve the potential during study: stimulation with the syllable /da/; monaural presentation with greater use of the right ear; intensity of 80 dB SPL; vertical placement of electrodes; use of in-ear headphones; patient seated, distracted in awake state; alternating polarity; use of speech synthesizer software for the elaboration of stimuli; presentation rate of 10.9/s; and sampling rate of 20 kHz. Conclusions The theme addressed in this systematic review is relatively recent. However, the results are significant enough to encourage the use of the procedure in clinical practice and advise clinicians about the most used procedures in each parameter.