International Archives of Otorhinolaryngology, Volume: 17, Issue: 2, Published: 2013
  • Editorial

    Jotz, Geraldo Pereira
  • Phonoaudiology guidance in the preoperative period in the head and neck tumors Original Article

    Scheidt, Grasiella Aparecida Nau; Fleig, Raquel; Nascimento, Iramar Baptistella do

    Abstract in English:

    INTRODUCTION: The habit of smoking and intake of alcoholic drinks can lead to the incidence of malignant tumors in several areas, including the head or neck. Phonoaudiology is an area of oncology that is always seeking to expand its applications in oncological head and neck cases, with intervention in pre- and post-operative periods and in different clinical fields. AIM: To evaluate and describe the impact of phonoaudiology preoperative guidance in patients, specifically smokers and alcohol drinkers, with head and neck cancer. METHODS: Series Study. Interviews were conducted by telephone with 40 individuals diagnosed with malignant head and neck tumors. Questionnaires regarding the use of tobacco and alcohol were administered before and after the phonoaudiology preoperative guidance. RESULTS: Among the 40 individuals who received phonoaudiology preoperative guidance, 26 were smokers before the orientation. Of these 26 individuals, 18 (69.24%) abandoned tobacco dependence, 4 (15.38%) did not quit smoking, and 4 (15.38%) quit smoking for a few months before resuming smoking after receiving phonoaudiology preoperative guidance. Regarding alcohol consumption, 31 individuals ingested alcohol before phonoaudiology preoperative guidance. Of these 31 individuals, 17 (54.84%) abandoned alcohol dependence, 8 (25.81%) did not abstain from alcohol consumption, and 6 (19.35%) resumed alcohol consumption after a period of abstinence after receiving phonoaudiology preoperative guidance. CONCLUSION: Phonoaudiology preoperative orientations are effective in the treatment of head and neck malignant tumors.
  • Hearing complaints and the audiological profile of the users of an academic health center in the western region of São Paulo Original Article

    Samelli, Alessandra Giannella; Andrade, Camila Quintiliano de; Pereira, Marília Barbieri; Matas, Carla Gentile

    Abstract in English:

    INTRODUCTION: Few population-based studies have quantified hearing levels in Brazil; additional studies on this subject are needed. PURPOSE: The purpose of this study was to characterize hearing complaints and the audiological profile of the population served by the Clinical Audiology Service of an Academic Health Center in the western region of São Paulo, Brazil, between 2003 and 2008. An additional aim was to check whether there is a positive association between the signs/symptoms and type of hearing loss. METHODS: This was a retrospective study of the records of 2,145 patients. The health history, tonal and vocal audiometry, and imitanciometry findings were analyzed. RESULTS: The mean age of the patients was 20.6 years. The majority of the subjects had normal hearing thresholds, and the prevalence of hearing loss was approximately 35%. As the patient's age increased, the frequency of conductive hearing loss decreased and that of sensorineural hearing loss increased. There was a tendency toward hearing loss worsening with age. CONCLUSION: Hearing complaints can predict the type of hearing loss; therefore, they should always be valued because they can be used as a form of screening and thus help to determine the diagnostic hypothesis. This could help to reduce the gap between the patient's perception of the complaints and the audiological assessment and thus improve the prognosis.
  • Olfactory neuroepithelium in the superior and middle turbinates: which is the optimal biopsy site? Original Article

    Pinna, Fabio de Rezende; Ctenas, Bruno; Weber, Raimar; Saldiva, Paulo Hilario; Voegels, Richard Louis

    Abstract in English:

    INTRODUCTION: Olfactory neuroepithelium (ON) biopsy has several therapeutic applications for both disorders of olfaction and neurodegenerative diseases. Successful collection of ON is still anything but routine due to a dearth of studies on the distribution of ON in the superior and middle turbinates. AIM: To determine the location in which ON is most likely to be present in endoscopically removed cadaver superior and middle turbinates as well as the influences of gender, age, and naris side on the presence of ON and the extent to which it is present. METHODS: We conducted a prospective anatomical study. The superior and middle turbinates on both sides endoscopically removed from 25 fresh cadavers (less than 12 h post-mortem). The turbinates were halved into anterior and posterior segments for a total of 200 specimens, which were analyzed after hematoxylin and eosin and immunohistochemical staining. Hematoxylin and eosin-stained slides were subjected to blind examination by 3 independent pathologists, and the presence of ON was graded on a 5-point scale from 0 to 4. Kappa measurement was used to determine the agreement between pairs of observers. RESULTS: ON was present in 82.9% of superior turbinate samples and in 17.1% of middle turbinate samples. Immunohistochemistry detected ON in superior turbinates only by S-100 staining and only in 15 fragments. Gender, age, and naris side had no statistically significant effects on the presence of ON. CONCLUSION: When biopsying ON, the posterior portion of the superior turbinate should be targeted whenever possible because it has the highest concentration of ON among the nasal structures.
  • Quality of life in adolescents with hearing deficiencies and visual impairments Original Article

    Torres, Vanthauze Marques Freire; Marinho, Christielle Lidianne Alencar; Oliveira, Carolina Gabriela Gomes de; Vieira, Sandra Conceição Maria

    Abstract in English:

    INTRODUCTION: The term quality of life (in Portuguese, Qualidade de Vida; QV) has been expanded and modified over the years and has come to signify social development in terms of education, health, and leisure as well as economic issues. OBJECTIVE: To analyze the perception of QV in adolescents with hearing and visual impairments and the effects of socio-demographic characteristics on the domains of QV. METHODS: This descriptive series study comprised 42 adolescents aged 10 to 19 years who were students at Recife's state schools. The World Health Organization Quality of Life-Abbreviated questionnaire was used to evaluate QV. The data were analyzed using descriptive statistics and the Mann-Whitney and Kruskal-Wallis tests with a significance level of p < 0.05. RESULTS: The global perception of QV was higher among adolescents with visual impairments than among those with hearing impairments. Among the individual components of QV, the environment domain garnered the lowest scores independent of the type of impairment. The subjects with visual impairments reported higher scores for social relationships, while the psychological domain scored higher among those with hearing impairments. The students integrated into normal classrooms perceived better QV in the psychological and social relationships domains than did those who sat in special classrooms. CONCLUSION: The environmental domain was the worst component of the QV of handicapped adolescents, suggesting a need for greater investments in policies to improve the QV of this population.
  • Vestibular evoked myogenic potentials and digital vectoelectronystagmography's study in patients with benign paroxysmal positional vertigo Original Article

    Lira-Batista, Marta Maria da Silva; Dorigueto, Ricardo Schaffeln; Ganança, Cristina Freitas

    Abstract in English:

    INTRODUCTION: Benign Paroxysmal Positional Vertigo (BPPV) is a very common vestibular disorder characterized by brief but intense attacks of rotatory vertigo triggered by simple rapid movement of the head. The integrity of the vestibular pathways can be assessed using tests such as digital vectoelectronystagmography (VENG) and vestibular evoked myogenic potentials (VEMP). AIM: This study aimed to determine the VEMP findings with respect to latency, amplitude, and waveform peak to peak and the results of the oculomotor and vestibular components of VENG in patients with BPPV. METHODS: Although this otoneurological condition is quite common, little is known of the associated VEMP and VENG changes, making it important to research and describe these results. RESULTS: We examined the records of 4438 patients and selected 35 charts after applying the inclusion and exclusion criteria. Of these, 26 patients were women and 9 men. The average age at diagnosis was 52.7 years, and the most prevalent physiological cause, accounting for 97.3% of cases, was ductolithiasis. There was a statistically significant association between normal hearing and mild contralateral sensorineural hearing loss. The results of the oculomotor tests were within the normal reference ranges for all subjects. Patients with BPPV exhibited symmetrical function of the semicircular canals in their synergistic pairs (p < 0.001). The caloric test showed statistically normal responses from the lateral canals. The waveforms of all patients were adequate, but the VEMP results for the data-crossing maneuver with positive positioning showed a trend toward a relationship for the left ear Lp13. There was also a trend towards an association between normal reflexes in the caloric test and the inter-peak VEMP of the left ear. It can be concluded that although there are some differences between the average levels of the VENG and VEMP results, these differences were not statistically significant. CONCLUSION: In conclusion, the results of audiologic assessment, hearing thresholds, positioning maneuvers, and caloric tests have no effect on the quantitative results of VEMP. Additional research is warranted to establish the relationships among VENG, VEMP, and BPPV, especially as concerns the oculomotor tests.
  • Association between complaints of dizziness and hypertension in non-institutionalized elders Original Article

    Lopes, Anália Rosário; Moreira, Michelle Damasceno; Trelha, Celita Salmaso; Marchiori, Luciana Lozza de Moraes

    Abstract in English:

    INTRODUCTION: Advancing age increases the risk for a number of chronic diseases. Hypertension and dizziness are highly prevalent in the elderly population and represent major health problems. OBJECTIVE: To verify the association between complaints of dizziness and the presence of hypertension in non-institutionalized elders. METHODS: This was a prospective cross-sectional cohort study of the elderly population of Londrina, Paraná in terms of aging and longevity. The required sample size was calculated, and subjects e" 60 years of age of both genders were selected at random. Data were collected using a questionnaire covering socio-demographic information and self-reported cases of hypertension and dizziness. Statistical analysis was performed using the chi-square test with p d" 0.05 as the level of significance. RESULTS: The study included 493 elderly subjects, of whom 257 (52.1%) complained of dizziness and 308 (62.5%) reported a diagnosis of arterial systemic hypertension. Dizziness was significantly associated with hypertension (χ² = 6.26, p = 0.01) and female sex. CONCLUSIONS: Hypertension and dizziness were both highly prevalent and were significantly associated, showing the great need for investments in preventive measures.
  • Effect of fractionated radiotherapy on the parotid gland: an experimental study in Brazilian minipigs Original Article

    Stramandinoli-Zanicotti, Roberta Targa; Sassi, Laurindo Moacir; Schussel, Juliana Lucena; Torres, Maria Fernanda; Funchal, Melissa; Smaniotto, Gustavo Henrique; Dissenha, José Luis; Carvalho, Andre Lopes

    Abstract in English:

    INTRODUCTION: Radiotherapy (RT) of head and neck neoplasms often damages the salivary glands. AIM: To examine the pattern of morphologic changes resulting from RT of the head and neck region in minipig parotid glands in a clinical and experimental research setting. METHODS: Twelve 18-month-old male Brazilian minipigs weighing 30-40 kg were selected. Eight minipigs were assigned to the experimental group (group 1) and 4 to the control group (group 2). The RT was performed under general anesthesia at Erasto Gaertner Hospital, Curitiba, Brazil, using an á/â ratio of 2.5. The minipigs from group 1 underwent 3 sessions of irradiation with Cobalt 60 of the head and neck, bilaterally, with 3 exposures of 8 Gy each at 7-day intervals for a total dose of 24 Gy. The animals were sacrificed 12 weeks post-RT. RESULTS: The irradiated parotid glands displayed reductions in the size and number of acini as well as loss of secretory granules. The presence of fibrosis and loss of parenchyma relative to non-irradiated glands were observed, with an average reduction in volume of 54%. CONCLUSIONS: Our results demonstrate that this model for parotid gland damage resulting from an RT regimen appears to be useful for preclinical large animal studies of RT-induced damage and testing novel potential treatment options. Although recent advances in radiation therapy, such as intensity-modulated radiation therapy, have reduced the dose and limited the field of radiation, considerable salivary gland injury still occurs and can greatly impact the patient's quality of life after cancer treatment.
  • A brief history of mastoidectomy Original Article

    Bento, Ricardo Ferreira; Fonseca, Anna Carolina de Oliveira

    Abstract in English:

    AIM: To describe to the new generation of otologists the origins of mastoidectomy as well as the difficulties our predecessors encountered and the solutions they devised to improve otologic surgery. METHODS: Retrospective literature review-based study. RESULTS: Before the mid-19th century, mastoidectomy was performed only sporadically and in most cases as a desperate attempt to save the lives of people suffering from complications of infectious otitis. The drainage of acute abscesses became a common procedure at the beginning of the 20th century, within the pre-antibiotic era. The first documented surgical incision to drain an infected ear was described by the French physician Ambroise Paré in the 16th century. The credit for performing the first mastoidectomy for the removal of purulent secretions went to Jean-Louis Petit. Mastoidectomies were normally performed to treat infections. However, mastoidectomies were also carried out for other purposes, particularly for the treatment of deafness and tinnitus, during various periods. Sir Charles Ballance credited Johannes Riolanus with recommending mastoidectomy for the treatment of tinnitus. William Wilde began the era of modern mastoidectomy with his introduction of the eponymous retroauricular incision. CONCLUSION: Mastoidectomy has evolved significantly throughout its history. Improvements in mastoidectomy have relied on the introduction of more elaborate surgical procedures, especially the advances in surgical equipment during the last century. Mastoidectomy continues to be a life-saving surgical procedure.
  • Hearing loss in the elderly: History of occupational noise exposure Original Article

    Meneses-Barriviera, Caroline Luiz; Melo, Juliana Jandre; Marchiori, Luciana Lozza de Moraes

    Abstract in English:

    INTRODUCTION: Noise exposure is one of the most common health risk factors, and workers are exposed to sound pressure levels capable of producing hearing loss. AIM: To assess the prevalence of hearing loss in the elderly and its possible association with a history of occupational noise exposure and with sex. METHODS: A prospective study in subjects aged over 60 years. The subjects underwent anamnesis and audiological assessment. The Mann-Whitney test and multiple logistic regression, with 95% confidence interval and p < 0.05, were used for statistical analysis. RESULTS: There were 498 subjects from both sexes, and the median age was 69 years. From the comparison between men and women, we obtained the medium hearing I (500, 1000, and 2000 Hz p = 0.8318) and the mean hearing II (3000, 4000, and 6000 Hz; p < 0.0001). Comparing the thresholds of individuals with and without a history of occupational noise exposure, we obtained the medium hearing I (p = 0.9542) and the mean hearing II (p = 0.0007). CONCLUSION: There was a statistically significant association between hearing loss at high frequencies and the risk factors being male and occupational noise exposure.
  • Auditory complaints and audiologic assessment in children with surgically repaired cleft lip and palate Original Article

    Cerom, Jaqueline Lourenço; José, Maria Renata; Azenha, Fabiana de Souza Pinto; Macedo, Camila de Cássia; Alvarenga, Kátia de Freitas; Lopes, Andréa Cintra; Feniman, Mariza Ribeiro

    Abstract in English:

    INTRODUCTION: At the initial consultation, the speech-language pathologist and audiologist may consider possible diagnostic hypotheses based on the child's history and the parents' complaint. AIM:To investigate the association of hearing complaints with the findings obtained in the conventional audiologic assessment in children with cleft lip and palate. Retrospective study. METHODS: We analyzed medical charts of 1000 patients with cleft lip and palate who underwent surgical repair between 1988 and 1995 at a mean age of 6 years 8 months. We excluded charts with records of inconsistent audiological responses and charts with missing data for any of the audiologic evaluations considered. Thus, the sample consisted of 393 records. RESULTS: Two hundred thirty-nine patients presented hearing loss in one or both ears, but only 3.8% reported hearing complaints. The most frequent were otorrhea followed by otalgia. There was no statistical significance between the complaint and gender (p = 0.26) nor between the complaint and hearing loss (p = 0.83). CONCLUSION: This study showed no association between the hearing complaint and the conventional audiologic assessment.
  • Advances in the treatment of children with phonological disorders Original Article

    Ceron, Marizete Ilha; Pagliarin, Karina Carlesso; Keske-Soares, Márcia

    Abstract in English:

    INTRODUCTION: Treatment of phonological disorders considering extra-linguistic and linguistic variables are important to ensure that the alteration is resolved promptly and in the best manner as possible. AIM: To analyze therapeutic advances (phonetic inventory, phonological system, and distinctive features) in children with phonological disorders by considering the therapeutic approach used, the severity of the phonological disorder, age, and the number of therapeutic sessions. METHODS: We conducted a case series study of 94 children aged 3 years, 9 months through 8 years, 5 months. The children were divided into groups based on the therapeutic approach used (Modified Cycles, Maximal Oppositions, ABAB-Withdrawal, and Multiple Probes), the severity of their phonological disorder, age, and the number of therapy sessions with each individual. Phonetic inventory, the phonological system, and the number of altered distinctive features were analyzed. RESULTS: The greater the number of therapy sessions, the greater the number of sounds acquired. The number of sounds present in the phonetic inventory and phonological system increased and the severity of the phonological disorder decreased with all of the therapeutic approaches studied. There was also a reduction in the incidence of altered distinctive features. CONCLUSION: There was a favorable evolution in phonetic inventory and phonological system acquisitions as well as a reduction in the number of altered distinctive features for all 3 therapeutic models regardless of the severity of the phonological disorder, age, or number of sessions.
  • Sound pressure level in a municipal preschool Original Article

    Kemp, Adriana Aparecida Tahara; Delecrode, Camila Ribas; Guida, Heraldo Lorena; Ribeiro, André Knap; Cardoso, Ana Claúdia Vieira

    Abstract in English:

    AIM: To evaluate the sound pressure level to which preschool students are exposed. METHODS: This was a prospective, quantitative, nonexperimental, and descriptive study. To achieve the aim of the study we used an audio dosimeter. The sound pressure level (SPL) measurements were obtained for 2 age based classrooms. Preschool I and II. The measurements were obtained over 4 days in 8-hour sessions, totaling 1920 minutes. RESULTS: Compared with established standards, the SPL measured ranged from 40.6 dB (A) to 105.8 dB (A). The frequency spectrum of the SPL was concentrated in the frequency range between 500 Hz and 4000 Hz. The older children produced higher SPLs than the younger ones, and the levels varied according to the activity performed. Painting and writing were the quietest activities, while free activities period and games were the noisiest. CONCLUSION: The SPLs measured at the preschool were higher and exceeded the maximum permitted level according to the reference standards. Therefore, the implementation of actions that aim to minimize the negative impact of noise in this environment is essential.
  • The relationship between the speech perception and the degree of satisfaction among adult users of cochlear implants Review Article

    Granço, Fernanda Soares; Fernandes, Nayara Freitas; Morettin, Marina; Costa Filho, Orozimbo Alves; Bevilacqua, Maria Cecília

    Abstract in English:

    INTRODUCTION: In recent years, the benefits associated with the use of cochlear implants (CIs), especially with regard to speech perception, have proven to surpass those produced by the use of hearing aids, making CIs a highly efficient resource for patients with severe/profound hearing loss. However, few studies so far have assessed the satisfaction of adult users of CIs. OBJECTIVE: To analyze the relationship between the level of speech perception and degree of satisfaction of adult users of CI. METHODS: This was a prospective cross-sectional study conducted in the Audiological Research Center (CPA) of the Hospital of Craniofacial Anomalies, University of São Paulo (HRAC/USP), in Bauru, São Paulo, Brazil. A total of 12 users of CIs with pre-lingual or post-lingual hearing loss participated in this study. The following tools were used in the assessment: a questionnaire, "Satisfaction with Amplification in Daily Life" (SADL), culturally adapted to Brazilian Portuguese, as well as its relationship with the speech perception results; a speech perception test under quiet conditions; and the Hearing in Noise Test (HINT)Brazil under free field conditions. RESULTS: The participants in the study were on the whole satisfied with their devices, and the degree of satisfaction correlated positively with the ability to perceive monosyllabic words under quiet conditions. The satisfaction did not correlate with the level of speech perception in noisy environments. CONCLUSION: Assessments of satisfaction may help professionals to predict what other factors, in addition to speech perception, may contribute to the satisfaction of CI users in order to reorganize the intervention process to improve the users' quality of life.
  • Noise-Induced Hearing Loss (NIHL): literature review with a focus on occupational medicine Review Article

    Metidieri, Mirella Melo; Rodrigues, Hugo Fernandes Santos; Oliveira Filho, Francisco José Motta Barros de; Ferraz, Daniela Pereira; Almeida Neto, Antonio Fausto de; Torres, Sandro

    Abstract in English:

    According to the Ministry of Health (2006), Noise-Induced Hearing Loss (NIHL) is hearing loss caused by prolonged exposure to noise. It is characterized as sensorineural hearing loss and is usually bilateral, irreversible, and progressive while the exposure to noise continues. A NIHL is a predictable and preventable disease with an epidemiologically relevant prevalence in urban communities. The hearing loss begins and predominates in the frequencies of 3, 4, and 6 kHz and eventually progresses to 8, 2, 1, 5, and 25 kHz. In Brazil, regulatory standard 15 limits the exposure to continuous noise to no more than 4 hours' exposure to 90 dBA and a maximum level of 85 dB for a full 8-hour working period. As NIHL is a preventable and predictable disease, preventive action by professionals may be able to change the prevalence of hearing loss in noisy environments.
  • Extramedullary nasal plasmacytoma: Literature review and a rare case report Case Report

    Corvo, Marco Antonio dos Anjos; Granato, Lídio; Ikeda, Felipe; Próspero, José Donato de

    Abstract in English:

    INTRODUCTION: Extramedullary plasmacytoma is a plasma cell tumor that grows within any of the soft tissues of the organism. Similar to all plasmacytic dyscrasia, the disease is extremely rare. AIM: This study reports a case of an extramedullary plasmacytoma of the nasal cavity and provides a literature review on the topic. CASE REPORT: A 51-year-old woman presented at our tertiary university hospital with a 6-month history of progressive nasal obstruction, predominantly to the right side, and self-limiting epistaxis. Examination revealed a large pale-reddish tumor within the right nasal cavity. Anatomopathological analysis showed features consistent with a plasmacytoma diagnosis, which was subsequently confirmed by immunohistochemical techniques. Further assessment revealed the solitary nature of the condition, consistent with extramedullary plasmacytoma. Radiotherapy was initiated, which led to partial regression of the symptoms. The tumor was surgically removed by using a mid-facial degloving approach. The patient evolved with a naso-oral fistula and underwent 3 corrective surgeries. No evidence of associated systemic disease was found after 5 years of follow-up. CONCLUSIONS: This case report, which describes a rare tumor of the nasal cavity, is expected to improve the recognition and referral of this condition by ear, nose, and throat (ENT) specialists for multidisciplinary management and long-term follow-up.
  • Chondro-osseous respiratory epithelial adenomatoid hamartoma of the nasal cavity Case Report

    Fedda, Faysal; Boulos, Fouad; Sabri, Alain

    Abstract in English:

    INTRODUCTION: Chondro-osseous respiratory epithelial adenomatoid hamartoma (COREAH) is a benign lesion of the nose and sinuses that is extremely rare, with only 2 cases reported in the literature to date. CASE REPORT: We present herein the third reported case of COREAH, in a 38-year-old woman who presented with left nasal obstruction and a mass in her left nasal cavity. The mass was completely resected endoscopically. Microscopic examination showed hamartomatous proliferation of respiratory-type glands with mucinous metaplasia admixed with numerous spicules of mature bone, characteristic of COREAH. CONCLUSION: COREAH is a benign hamartomatous proliferation of respiratory epithelium, submucosal glands, and chondro-osseous mesenchyme. The clinical differential diagnoses for such lesions include glandular hamartoma, inflammatory polyp, inverted papilloma, and low-grade sinonasal adenocarcinoma. Recognition of this lesion as benign despite its potentially worrisome radiographic appearance is important to avoid an unnecessarily radical surgical procedure.
  • Results of the implantation of bone-anchored hearing aids in patients with treacher-collins syndrome Case Report

    Oliveira, Alexandra Kolontai de Sousa; Ferro, Lília Pereira Abreu; Silva, Jaiede Nicacio da; Okada, Daniel Mochida

    Abstract in English:

    INTRODUCTION: Treacher-Collins syndrome is characterized by craniofacial malformations, narrowing of the external auditory canal (EAC), and, in 30% of cases, agenesis of the canal and ossicular chain defects. The use of hearing aids (HA) is not possible in cases in which agenesis or stenosis of the EAC accompanies conductive deafness. In contrast, bone conduction implants such as the Bone Anchored Hearing Aid (BAHA®) allow direct stimulation of the cochlea and are thus superior to conventional hearing aids in cases of severe conductive hearing loss. OBJECTIVE: To present 2 cases of patients with Treacher-Collins syndrome who underwent implantation of BAHA®. CASES REPORTS: The first patient was a 52-year-old woman diagnosed with Treacher-Collins syndrome who presented with severe bilateral mixed hearing loss and a history of unsuccessful previous use of a bone contact conduction device. The BAHA® implantation was uneventful, and the post-operative results were good. The second patient was a 14-year-old girl who was also diagnosed with Treacher-Collins Syndrome with bilateral moderate conductive hearing loss by audiometry. The use of a bone vibrator contact device did not improve her hearing; however, implantation of a BAHA® resulted in a decreased gap postoperatively. FINAL COMMENTS: BAHA® hearing devices provide adequate rehabilitation and consequent improvement of the quality of life in patients with Treacher-Collins syndrome.
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