Resumo em Inglês:

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

Resumo em Inglês:

Abstract Introduction The COVID-19 pandemic has led to a reduction in surgical and clinical volume, which has altered the traditional training experience of the otolaryngology resident. Objective To describe the strategies we utilized to maximize resident education as well as ensure patient and staff safety during the pandemic. Methods We developed a system that emphasized three key elements. First and foremost, patient care remained the core priority. Next, clinical duties were restructured to avoid unnecessary exposure of residents. The third component was ensuring continuation of resident education and maximizing learning experiences. Results To implement these key elements, our residency divided up our five hospitals into three functional groups based on geographical location and clinical volume. Each team works for three days at their assigned location before being replaced by the next three-person team at our two busiest sites. Resident teams are kept completely separate from each other, so that they do not interact with those working at other sites. Conclusions Despite the daily challenges encountered as we navigate through the COVID-19 pandemic, our otolaryngology residency program has been able to establish a suitable balance between maintenance of resident safety and well-being without compromise to patient care.

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Abstract Introduction Studies have found that elderly patients with benign paroxysmal positional vertigo (BPPV) may present low levels of vitamin D (25 (OH) D), changes in bone mineral density, and diabetes mellitus (DM). Objective To investigate the possible association between BPPV, bone mineral density, hypovitaminosis D, 25 (OH) D and DM. Methods The sample consisted of 109 elderly subjects. The BPPV was verified by a standardized questionnaire and the Dix-Hallpike maneuver. Blood samples were collected for the investigation of 25 (OH) D serum levels. The bone mineral density was evaluated by means of a densitometer. Diabetes mellitus verification was performed using a self-reported questionnaire. Results Of the 109 participants, 17 had BPPV. There was a statistically significant difference between BPPV and gender (p = 0.027, phi = 0.222), with female representing 88.2% of those with BPPV. In the group with BPPV, there was a statistically significant difference for the amount of vitamin D found (p = 0.001) and for age (p = 0.001). In the elderly group with DM and BPPV, a difference was found for the standard deviation of the femur (p = 0.022) with posthoc Dunn, identifying the difference between diabetics with and without BPPV (p = 0.047). Conclusion Although no association was found (25 (OH) D levels) with BPPV in the general population of this study, it was observed that there was an association with bone mineral density in the elderly group with DM and BPPV, and, in the group with BPPV, there was an association between the amount of vitamin D and age.

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Abstract Introduction Facial plastic and reconstructive surgery (FPRS) is a key part of the curriculum for otolaryngology residents. It is important to gain an understanding of the breadth of exposure and level of competence residents feel with these concepts during their residency. Objective To determine the level of FPRS exposure and training otolaryngology residents receive during their residency. Methods A survey was emailed to all Accreditation Council for Graduate Medical Education (ACGME) accredited otolaryngology residents. The survey aimed to find the level of exposure to FPRS procedures otolaryngology residents get and how confident they feel with their training in cosmetic FPRS. Results A total of 213 residents responded to the survey for an overall response rate of 13.4%. There was an even mixture of residents from all postgraduate year (PGY) levels, with 58% of respondents being male. Almost all (98%) of the residents felt FPRS was important to otolaryngology residency training. Exposure to procedures varied with 57% performing or assisting with cosmetic minor procedures, 81% performing or assisting with cosmetic major procedures, and 93% performing or assisting with reconstructive procedures. Only 49% of residents felt their programs either very or somewhat adequately prepared them in cosmetic facial plastic surgery. Conclusion There was a wide variability in the FPRS procedure exposure. Most residents felt procedures were a vital part of otolaryngology residency training, but not all were able to participate in them. Only half of the residents felt well-prepared in cosmetic procedures.

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Abstract Introduction Cortical auditory evoked potentials (CAEPs) can be used to evaluate both peripheral and cortical components of auditory function, and contribute to the assessment of functional sensitivity and auditory thresholds, especially in neonates and infants. Auditory evoked potentials reflect auditory maturity and precede the acquisition of more complex auditory and cognitive skills, and are therefore crucial for speech and language development. Objective The aim of the present study was to determine the presence, latency and amplitude of CAEP components in response to verbal stimuli in children aged 2 years old. Methods The sample consisted of 19 subjects, 10 of whom were male while 9 were female. All of the participants were 24 months old at the time of assessment. Results A total of 17 of the participants displayed all components of the CAEP. Additionally, no significant differences were observed between genders or ears in the present sample. The presence of all components of the CAEP in subjects aged 2 years old confirms the existence of a critical period for the maturation of auditory pathways in the first 2 years of life. Conclusion In the present study, in addition to the P1/N1 components, it was possible to observe the presence of the CAEP P2/N2 components in individuals aged 24 months, confirming the existence of a critical period for the maturation of the auditory pathways in the first 2 years of life.

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Abstract Introduction Over the last decades, there has been a tremendous increase in the number of cochlear implant recipients and, consequently, there is a recent increase of interest in the proper understanding of the anatomy of the round window (RW), which is the most important anatomical land mark during cochlear implant surgery. Objectives The present study was undertaken to assess the detailed surgical and radiological anatomy of the RW prechamber; its shape, directions, measurements, common anatomic variations, and its relationships with different surrounding structures as related to cochlear implantation. Methods A total of 20 cadaveric specimens of human temporal bone were microscopically dissected for the anatomical assessment of the measurements of the RW and its relation to surrounding structures in the tympanum. A total of 20 patients were subjected to cochlear implantation, and a radiological and surgical assessment of the anatomy of their RW prechambers was performed. Results The distances between the RW and the facial canal (FC), the jugular fossa (JF), the carotid canal (CC), and the oval window (OW) were measured. Among the cases subjected to cochlear implantation, the infracochlear tunnel was studied radiologically; the lengths of the anterior and posterior pillars were assessed, and the relation with the direction at which the RW faces was statistically analyzed. Conclusions Proper understanding of the topographic anatomy of the RW, including its direction of opening and the distances from different adjacent structures in the tympanum, is essential for a successful cochlear implantation surgery, since it can help decision-making before the surgery and is useful to avoid many complications, such as misplaced electrode and iatrogenic injury to the surrounding structures.

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Abstract Introduction The association between prenatal Zika virus infection and hearing alterations in offspring has been the object of some studies, although few have assessed children without microcephaly. However, a current trend to include prenatal Zika virus exposure in the group of risk indicators for hearing loss is noted. Objective To present a series of 27 children prenatally exposed to the Zika virus submitted to multiple hearing assessments over time. Methods A cohort of children born to symptomatic mothers with laboratorial Zika virus infection confirmation during pregnancy was submitted to an otoacoustic emission test, auditory brainstem response test (automated, neurodiagnostic and frequency-specific), audiometry, and imitanciometry over a period of 36 months since birth. The hearing assessment was performed independently of the presence of microcephaly or other apparent signs of congenital Zika syndrome. Results The hearing tests presented predominantly normal results. Some children had signs of middle ear pathology. The only microcephalic child had normal electrophysiological tests, as well as preserved audiometric thresholds, but presented altered motor responses to sound. Conclusion Prenatal exposure to Zika virus does not always determine hearing impairment. This risk seems to be more associated to the severity of the central nervous system damage. Hearing screening and follow-ups of the affected children are important, as well as further research in this area.

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Abstract Introduction Vitamin D is known to have immunomodulatory functions and has action on chronic inflammatory processes, such as nasal polyposis. Objective The present study assessed the levels of 25-hydroxy vitamin D and high-sensitivity C-reactive protein (hs-CRP) in patients with nasal polyposis, as compared with healthy control subjects, and identified their association with disease severity in nasal polyposis. It further assessed the levels of 25-hydroxyl vitamin D and hs-CRP in patients with nasal polyposis and atopy and compared it with patients with nasal polyposis without atopy. Methods This was a cross-sectional study involving 2 groups: 80 patients with nasal polyposis and 80 healthy subjects. In patients with nasal polyposis, the disease severity is assessed by the sino-nasal outcome test (SNOT20) and by the Lund & Mackay staging system. Levels of 25-hydroxy vitamin D and hs-CRP were measured by enzyme-linked immunosorbent assay (ELISA). Result The mean 25-hydroxyl vitamin D levels (ng/ml) was 12.01 ± 7.29 for cases and 22.87 ± 14.95 for controls, with p < 0.0001. The mean hs-CRP levels (mg/L) was 5.99 ± 2.74 in cases and 2.41 ± 1.95 in controls, with p < 0.0001. The severity of polyposis correlated negatively with serum levels of 25-hydroxy vitamin D and positively with hs-CRP. Conclusion The study has thus shown significant correlation between vitamin D deficiency and inflammation in patients with nasal polyps.

Resumo em Inglês:

Abstract Introduction Historically, concerns about complications following parathyroid surgery, such as airway compromise, bleeding and hypocalcemia, have precluded its consideration as a short-stay surgical procedure. Recent advancements in perioperative care have resulted in several publications demonstrating that parathyroidectomy can be safely performed as a short-stay procedure. Objectives The aim of the present study was to describe the process of implementing a short-stay protocol focusing on preoperative patient education and postoperative calcium management for those undergoing surgery for primary hyperparathyroidism (PHP). Method A retrospective audit of consecutive parathyroidectomies performed for PHP over the period between 2010 and 2013 was performed. A short-stay protocol (SSP) was introduced focusing on postoperative calcium management. Results were reaudited over the period between 2013 and 2015. Results Consecutive parathyroidectomies in 76 patients were included in the study. A total of 42 patients underwent parathyroidectomy prior to the introduction of the protocol. A total of 26.2% of these patients were symptomatic from hypercalcemia. A total of 40 out of 42 (95.2%) patients had a biochemical cure. A total of 36 out of 42 (85.7%) cases were due to parathyroid adenomas. A total of 34 patients underwent surgery following the introduction of the protocol. A total of 13 out of 34 (38.2%) of the patients had symptomatic hypercalcemia. A total of 33 out of 34 (97.1%) had a biochemical cure. A total of 32 out of 34 (94.1%) cases were due to parathyroid adenomas. The length of stay decreased from a median of 3 days (range 2–9 days; mean 3.32) preprotocol to a median of 2 days (range 2–3 days; mean 2.16) postprotocol (p < 0.0001) with no difference in the 30-day unplanned readmission rate (4.8 versus 2.9%; p = 0.999). Conclusions The postoperative length of stay after parathyroidectomy for PHP can be safely reduced through patient education and by rationalizing postoperative calcium management without adversely affecting outcomes.

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

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Abstract Introduction The current Italian law does not include any guidance regarding voice education, prevention of voice disorders and screening in subjects with high vocal loading such as teachers. Objectives We aimed to check the correlation between the Vocal Tract Discomfort Scale (VTDS) with the Voice Symptom Scale (VoiSS) for the evaluation of Italian teachers. In addition, we aimed to investigate whether there are differences in the frequency and intensity of discomfort symptoms in teachers with disabilities comparing vocal tract discomfort symptoms in teachers with high risk (HRVD) and low risk (LRVD) of vocal disorders according to the VoiSS cutoff (> 15.5). Methods We analyzed 160 Italian teachers (111 women and 49 men) that completed the VTDS and VoiSS at vocal evaluation. The Spearman correlation test was applied to all variables. The Mann-Whitney U test was used to compare the average number of discomfort symptoms among HRVD and LRVD teachers. Results A moderate positive correlation was observed between the average number, frequency, and intensity of discomfort symptom and the total score, physical domain score, and limitation domain score of the VoiSS. Only the emotional domain score of the VoiSS showed a weak positive correlation (p < 0.001). Teachers considered in the HRVD group according to the VoiSS score had a higher number, frequency, and intensity of vocal tract discomfort symptoms. Conclusion There is correlation between the VTDS and VoiSS scales. Like the VoiSS, the VTDS is a questionnaire that detects HRVD teachers. Therefore, the results suggest that both questionnaires could be useful for a preventive voice program for Italian teachers

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Abstract Introduction Hearing loss interferes in the development of language and verbal capacities, which causes learning difficulties and deleterious effects. Objective To analyze the prevalence and associated factors for hearing loss in school-age individuals of the municipality of Natal, state of Rio Grande do Norte, Northeast Brazil. Methods Cross-sectional study that evaluated 238 school-age individuals (6–17 years old) in municipal public schools. Meatoscopy was performed and school-age individuals answered the questions “Do you think that you hear well?” and “Do you have earaches?”. Auditory evaluation was performed with a Telessaúde audiometer. The responsible adults answered socioeconomic, speech and audiology aspects and risk factors for hearing loss questionnaire. Results The prevalence of hearing loss was 16% (11.7–21.4%); 16% reported not to hear well, 18.9% reported earaches, and 26.1% presented altered meatoscopy. The prevalence of hearing loss was higher in school-age individuals who reported hearing difficulties, in children between the ages of 6 and 12, and with altered meatoscopy results (p < 0.05). Airway infection (PR = 3.37; 95% confidence interval [CI]: 1.48–7.68) was found as a risk factor associated with hearing loss, remaining significant in the multivariate model (PR = 6.79; 95%CI: 1.98–23.26; p = 0.002). Conclusions Hearing loss in this sample is above the values reported in other studies performed in Brazil for this age group. This highlights the necessity of better structure of speech and audiology attention, so that auditory health promotion actions can be systematized for this population.

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Abstract Introduction Hearing impairment is a common disease worldwide, with a comprehensive impact, and cochlear implantation (CI) is an intervention for profound hearing impairment. Objective To study the outcome one and three years after unilateral CI on hearing, health-related quality of life and level of depression and anxiety, and the correlation between the outcomes. Second, to study whether age, gender, etiology, operated side, residual hearing or cognitive performance can predict the outcome. Methods A prospective longitudinal study including adults with profound postlingual hearing impairment, with respect to hearing (speech recognition), health-related quality of life (Health Utilities Index 3) and level of depression and anxiety (Hospital Anxiety and Depression scale), pre-CI, and one and three years post-CI. The total sample was composed of 40 participants (40% of men), with a mean age of 71 years. Results Speech recognition and the overall health-related quality of life improved one year post-CI (p = 0.000), without correlation (ρ= 0.27), and with no difference three years post-CI. The hearing attribute (in the health-related quality of life instrument) improved one and three years post-CI (p = 0.000). The level of anxiety did not change one and three years post-CI. The level of depression improved one year post-CI (p = 0.036), and deteriorated three years post-CI (p = 0.031). Age, etiology, operated side, residual hearing and cognitive performance did not predict the outcome, but the female gender did significantly improve speech recognition compared with men (p = 0.009). Conclusion The CI significantly improved speech recognition, health-related quality of life and level of depression one year post-CI without mutual correlation, and women performed significantly better than men. There were no further improvements three years post-CI, apart from the hearing attribute.

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Abstract Introduction Branchial cleft anomalies are the second most common congenital anomaly in children. However, some lesions may not develop clinically and are not diagnosed until adulthood. The recent literature of branchial cysts (BCs) in the adult population is really scanty. For this reason, we analyzed the clinical and surgical management of the adult population treated for a BC at a tertiary care general hospital. Methods A retrospective review of the clinical records of all the patients with histological diagnosis of BC who were surgically treated at the Social Security Hospital in Quito, Ecuador, was performed. Fifty-one patients (27 women) with congenital anomalies of the 2nd (43 patients with cysts) and 3rd (6 patients with cysts and 2 with fistula) branchial arches were diagnosed and treated. Diagnosis was made on clinical grounds and by computed tomography scan. Results The 43 patients with a 2nd branchial cleft cyst underwent complete surgical excision through a wide mid-neck transverse cervicotomy. The 6 cases of 3rd branchial cleft cyst underwent surgical resection through a lower-neck transverse incision, and the 2 patients with clinical fistula in the lower aspect of the neck were operated on via an elliptical incision around this external fistula opening. Postoperative evolution was uneventful in all patients. Conclusions Branchial cysts can occasionally be diagnosed in adult patients in the setting of a general hospital population. A correct clinical and imaging assessment was diagnostic in most patients. Complete surgical resection was curative in all our patients, and postoperative complications were exceptional.

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Abstract Introduction Coronavirus disease 19 (COVID-19) is potentially the greatest global public health crisis of this century. This disease emerged as an outbreak of pneumonia of unknown cause in Wuhan, the capital city of the Hubei province in China, in December 2019. Otolaryngologists, head and neck surgeons and dentists are at an increased risk of occupational disease. Objective The present review summarizes currently published evidence of Covid-19 epidemiology, clinical characteristics, treatment and prevention. No proven effective treatments for this disease currently exist. Data Synthesis COVID-19 started from a zoonotic transmission event associated with a large seafood market that also traded in live wild animals, and it soon became clear that efficient person-to-person transmission was also occurring. Symptoms are varied, and not all patients develop all of them. Conclusion Social distancing seems to have been successful in several places in the world. However, this recommendation alone is not enough to contain the disease, and it is not a long-term solution. Large-scale testing by health professionals of representative samples of the population may give an estimate of the progression of the disease. Different treatments are under test and bring hope of a cure to the population. However, no current treatments (April 27, 2020) have been proven to be the key to success in the treatment of patients with COVID-19. Planetary health is a useful concept to understand the current drivers of this pandemic and to draw a roadmap for science and healthcare that may guide actions to fight economic depression and ensure a healthy recovery.

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Abstract Introduction Severe acute respiratory syndrome coronavirus 2 was first described in December 2019 in China leading to a Public Health Emergency of International Concern. It was named by the World Health Organization as Coronavirus Disease 2019 (COVID-19), and it garnered unprecedented attention from public health researchers around the world, and studies analyzing chloroquine and hydroxychloroquine as a possible therapy have arisen in the last 2 months. Objective To review the literature and describe updated facts about the ototoxicity of chloroquine and hydroxychloroquine, an important side effect that can be present in patients with COVID-19 treated with these drugs. Data Synthesis The most typical treatment regimen is 5 days of hydroxychloroquine at daily doses of 400 to 600 mg. There is no randomized clinical trial that can prove so far the efficacy of this medication, and few studies have evaluated adverse events potentially linked to their use in patients with COVID-19. While there is no concrete evidence on the incidence of ototoxicity using chloroquine in the short term, we need to consider that, as a pandemic disease, millions of patients with COVID-19 may receive this treatment, and ototoxicity can be a possible adverse event. Conclusion Despite the urgent global situation caused by the COVID-19, the risk of irreversible hearing loss may outweigh the unproven benefit of using hydroxychloroquine or chloroquine, especially in patients with mild forms of COVID-19, who may be cured with supportive treatment. The potential hearing loss that can be caused by these medications may advise against their use in COVID-19 patients.

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

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Abstract Coronavirus disease 2019 (COVID-19) is a pandemic and rapidly progressing infectious disease that represents a global health care emergency due to severe acute respiratory syndrome. Rapid tests detect antigen or antibody presence, which is useful for patient care and for assisting in disease surveillance and epidemiological research. The complicating aspect of the COVID-19 spread may be due to asymptomatic individuals. Unfortunately, asymptomatic individuals are not detected in the early stages of infection, which could help to prevent community spread. The present paper shares an opinion through the proposal of a research model for detecting COVID-19 among asymptomatic carriers.

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