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Abstract Introduction It is now evident that the loss of smell and/or taste may be consistent accompanying symptoms of the SARS-CoV-2 infection. Objective To estimate the social behavior of recent anosmic non-hospitalized patients in the COVID-19 pandemic and to try to obtain the natural pattern in society in a cross-sectional study. Methods A cross-sectional study conducted on 4,860 patients with anosmia complaints during the COVID-19 pandemic. Patients who needed a consultation for an anosmia complaint confirmed that they had completed the survey regarding age, gender, history of general diseases, history of nasal disease, associated COVID-19 symptoms, smoking, blood group, and risk factors. Results A total of 4,860 patients with a mean age of 34.26 ± 11.91 years completed the study. There was a predominance of female patients: 3,150 (58.9%). Most patients (4,083 patients; 83%) developed sudden anosmia. In 85% (4131 patients) of the patients, a previous history of contact with anosmic patients was present. The most prevalent blood group was O (39%). In total, 67.4% of the patients underwent medical treatment. A history of unusual influenza attacks in December 2020 was reported by by 27% (1312 patients) of the patients. Conclusion Despite large diversity of behaviors among anosmic patients in the COVID-19 pandemic, we can observe a great similarity in the pattern of anosmia in non-hospitalized patients, especially in the way it spreads, the predisposing factors, and the individual recovery.

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Abstract Introduction The COVID-19 pandemic has had a high impact on surgical training around the world due to required measures regarding the suspension of elective procedures and the dismissal of nonessential personnel. Objectives To understand the impact the pandemic had on head and neck surgery training in Brazil. Methods We conducted a 29-question online survey with head and neck surgery residents in Brazil, assessing the impact the pandemic had on their training. Results Forty-six residents responded to the survey, and 91.3% of them reported that their residency was affected by the pandemic, but most residents were not assigned to work directly with patients infected with the new coronavirus (71.4%). All residents reported decrease in clinic visits and in surgical procedures, mostly an important reduction of ∼ 75%. A total of 56.5% of the residents described that the pandemic has had a negative impact on their mental, health and only 4 (8.7%) do not have any symptoms of burnout. The majority (78.3%) of the residents reported that educational activities were successfully adapted to online platforms, and 37% were personally infected with the virus. Conclusion Most surgical residencies were greatly affected by the pandemic, and residents had an important decrease in surgical training. Educational activities were successfully adapted to online modalities, but the residency programs should search for ways of trying to compensate for the loss of practical activities.

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Abstract Introduction Coronavirus disease 2019 (COVID-19) has dramatically spread all over the world, crossing the borders of all countries. It is presented mainly by lower respiratory tract symptoms such as fever, cough, dyspnea, and chest tightness. However, COVID-19 causes different upper respiratory tract-related symptoms including nasal congestion, sore throat, and olfactory dysfunction. Objective To discuss different ear, nose and throat (ENT) manifestations in COVID-19-positive patients and their relation to other manifestations and to the severity of COVID-19. Methods We detected ENT manifestations in polymerase chain reaction (PCR)-confirmed positive COVID-19 patients at Zagazig Isolation Hospitals (Zagazig University hospitals, Zagazig Chest hospital, Al-Ahrar hospital, and Zagazig Fever hospital) with proportional allocation in the period from April 15 to June 15, 2020. All patients were subjected to full history taking and COVID-19 was categorized into 4 classes of severity after all patients underwent computed tomography (CT) of the chest. Afterwards, the collected data was analyzed and compared. Results Among the included 120 COVID-19 patients, the most frequent reported ENT manifestations were; sore throat (30%), nasal congestion (28.3%), nasal obstruction (26.7%), sneezing (26.6%), headache (25%), smell and taste dysfunction (25%), rhinorrhea (20%), upper respiratory tract infection (URTI) (15%), and tonsil enlargement (10%). The most common non-ENT manifestations were fever (88.3%), cough (63.3%), and dyspnea (45%). Conclusion Fever and cough are the dominant symptoms of COVID-19, but ENT manifestations for COVID-19 are common and should be a part of the suspected clinical criteria for COVID-19, particularly if the nasal examination was nonsignificant. The most common symptoms are sore throat, followed by nasal congestion and obstruction, headache, and lastly, olfactory dysfunction.

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Abstract Introduction Dysphonia is an oral communication disorder. The voice and hearing are interrelated aspects. Hearing is an important sensory input for monitoring the vocal pattern. The relation between hearing abilities and dysphonia represents a contribution both in scientific and in clinical terms, especially in cases in which satisfactory results are not achieved in the therapeutic process. Objective To characterize long-latency auditory evoked potential (P300) with tonal and complex stimuli, and to make a behavioral evaluation of auditory processing in adults with behavioral dysphonia. Method The sample used for the present study consisted of 20 subjects from both genders with ages ranging from 18 and 58, who were diagnosed with behavioral dysphonia. The evaluations occurred in a single 2-hour session, in which the procedures of clinical history, pure tone and speech audiometries, acoustic immittance measures, and behavioral and electrophysiological evaluations of auditory processing were performed. Results The descriptive measures of P3 latency elicited by tonal and complex stimuli showed similar results for the right and left ears, without statistically significant differences. In the qualitative analysis, the results observed were within the normality patterns for the P3 component for both tonal and complex stimuli. As for the behavioral evaluation of auditory processing, abnormal results were observed in 100% of the sample. Abnormalities were found in the auditory skills of ordering and temporal resolution and figure-background obtained from the duration pattern, random gap detection, and dichotic tests (syllables and words), respectively. Conclusion The evaluated patients presented central auditory processing disorder, evidenced by behavioral assessment.

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Abstract Introduction Persistent postural-perceptual dizziness (PPPD) is a functional vestibular disorder characterized by chronic dizziness, unsteadiness, and hypersensitivity to motion. Preexisting anxiety disorders and neurotic personality traits confer vulnerability to PPPD. High anxiety during acute vertigo or dizziness incites it. A functional magnetic resonance imaging (fMRI) study of chronic subjective dizziness found unexpectedly hypoactive responses to vestibular stimulation in cortical regions that integrate threat assessment and spatial perception. Objective This fMRI study used non-moving, but emotionally charged visual stimuli to investigate the brain's activity of PPPD patients and control subjects. Methods The participants included 16 women with PPPD and 16 age-matched women who recovered completely from acute episodes of vertigo or dizziness capable of triggering PPPD. Brain responses to positive, neutral, and negative figures from the International Affective Picture System were measured with fMRI and compared between the groups. Dizziness handicap, anxiety, and depression were assessed with validated questionnaires. Results Between group analyses: Participants with PPPD showed reduced activity in anterior cingulate cortex and increased activity in left angular gyrus in response to negative versus positive stimuli, which was not observed in recovered individuals. Within group analyses: Participants with PPPD had increased activity in visuospatial areas (parahippocampal gyrus, intraparietal sulcus) in negative versus positive and negative versus neutral contrasts, whereas recovered individuals had increased activity in anxiety regions (amygdala, orbitofrontal cortex). Conclusion Patients with PPPD may be more attuned to spatial elements than to the content of emotionally charged visual stimuli.

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Abstract Introduction The newborn hearing screening (NHS) is the most effective strategy for detecting newborns and infants suspected to have hearing loss. Objective To verify possible associations between the route of delivery and the results of the NHS conducted at 3 independent times (24, 36, and 36 hours with a facilitator auricular maneuver [FAM]) in the lives of full-term newborns. Methods A descriptive, observational, prospective study performed with a sample of 462 newborns, with a gestational age ≥ 37 weeks, without risk indicators of hearing loss. The NHS was conducted as a routine element of the facilities, two times: at 24 and 36 hours of life. In the presence of a “failure” in the last test, a new one was immediately performed, following the FAM. Statistic analyses were carried out on the program SPSS version 21.0 (IBM Inc., Armonk, NY, USA). Results Of the 462 newborns assessed, 304 (65.80%) were born by vaginal delivery. There was a statistical significance of “pass” in the NHS for the 24-hour evaluation (p≤ 0.001 for a vaginal delivery and p= 0.002 for a cesarean delivery), with the prevalence of the “pass” index being higher when the baby's lifespan was greater. A statistically significant difference was not observed when the NHS results were compared by taking into account the babies' routes of delivery and the different times of life. Conclusion These findings show that full-term babies who were born by cesarean did not show more “failure” in the NHS results, contradicting the hypothesis of the study. Furthermore, to reduce the false-negative rates, regardless of the route of delivery, this assessment should be conducted after the first 24 hours of the newborns' life.

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Abstract Introduction The transmastoid approach is the most recommended technique to Bonebridge surgery, while in patients with bad anatomy or in the canal wall down technique, retrosigmoid or Middle Fossa Approaches are the alternative surgical options. Objective To describe a novel alternative approach called inverted middle fossa approach (IMFA) and its technique and audiological outcomes. Methods Seven patients submitted to the IMFA were included. All patients presented conductive and mixed hearing loss with bone thresholds of the audiogram > 40 dB. The audiological test was conducted pre- and postoperatively. Results A total of 5 males and 2 females, aged 13,8 years old (range 6–25 years old) were studied. The average follow-up was of 20 months (12 to 32 months). All patients presented aural atresia, except one with severe osseous-fibrous dysplasia of the temporal bone. Two patients showed bilateral compromise, three patients had associated Goldenhar and Treacher Collins syndrome. On the preoperative audiograms, air conduction (AC) thresholds showed a PTA4 (0.5, 1, 2 and 4 kHz) of 66.7 dB (standard deviation [SD] = ± 7.8), while the bone conduction thresholds reached an average of 11.2 dB (SD = ± 6.9). The postoperative thresholds did not change, and additional sensorineural damage was not observed before activation. Four weeks after surgery, all the patients were fitted with the external processor. The postoperative audiological aided exam showed AC PTA 4 thresholds of 18.9 dB (SD = ± 5.9). Conclusion The IMFA allows the nearest position of the microphone to the external auditory canal. The technique is a suitable option to the 3 classical approaches with similar rate of audiological results. More investigation is needed to determine the benefit of the novel approach compared with the others.

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Abstract Introduction After pleomorphic adenoma, Warthin tumor gets its popularity as the second most common benign neoplasm of the parotid gland. Fine-needle aspiration cytology (FNAC) is the most cost-effective and minimally-invasive way to determine the histological character of a parotid gland tumor. Objective To determine the accuracy of FNAC in the diagnosis of Warthin Tumour. Methods A retrospective study conducted between 2014 and 2018. Out of 243 FNACs performed for parotid lesions, a histopathological correlation was established in 74 cases to reveal the accuracy of FNAC in the diagnosis of Warthin tumor. Results A total of 243 FNACs of parotid lesions were performed, and a histopathological correlation was established in 74 (30.4%) cases. Later on, we confirmed that 16 (21.6%) out of these 74 patients had cases of Warthin tumor. In total, 15 (20.3%) out of those 74 cases were confirmed as Warthin tumors on the initial cytology, which revealed a true positive concordance between the cytology and the final histological diagnosis; 55/74 (74%) were true negative results; on the other hand, 1/74 (1.4%) was a false negative, and 3/74 (4.1%) were false positive results. The sensitivity of the FNAC in the diagnosis of Warthin tumor was of 93%, while the specificity was of 94.8%, and the accuracy, of 94.6%. Conclusion In the present study, FNAC had a high diagnostic accuracy, reaching 94%.

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Abstract Introduction The predictability of nasal tip projection and rotation after aesthetic surgery is a challenge. Tongue-in-groove (TIG) is an effective technique to control tip projection and rotation, but there may be a small loss of projection and rotation of the tip lobe due to lack of support between the anterior septal angle and the domus, since this region is sustained by medial crusts suture-linked and interdomus sutures. Objective To describe a new surgery technique in an attempt to correct the lack of support for the nasal tip after lowering the nasal dorsum. Methods The horn technique consists in preserving a square of cartilage during the removal of the nasal dorsum and septum excess in patients with long and projected nose. This piece will give greater support to the TIG technique and greater predictability of the rotation and projection of the nasal tip. Results Between 2016 and 2018, 50 patients with long and projected noses were submitted to the “horn technique” surgery. They were submitted to the TIG technique associated to the horn technique. A retrospective review of the preoperative and postoperative photographs (3 months to 1 year) of these patients treated with the horn technique were analyzed and showed better support of the nasal tip. Conclusion The horn technique provides greater support to the projection and rotation of rhinoplasties in patients with long and projected nose.

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Abstract Introduction Mucopolysaccharidosis (MPS) is a set of rare diseases caused by deficiency of lysosomal enzymes that lead to the accumulation of glycosaminoglycans (GAG) in tissues and organs, which, in turn, is responsible for the multisystemic clinical, chronic, and progressive symptoms. Objective To describe the profile of the otorhinolaryngological clinical examination and audiology tests of patients with MPS disease. Methods The present study is a case series. The evaluation was performed, initially, in 24 patients with MPS types I, II, IIIA, IV and VI. Results The most common hearing complaint was hearing loss, which was confirmed by audiology tests in almost 100% of the patients, most of whom presented conductive hearing loss. Conclusions It is important to evaluate the complaints, physical examination, and audiology tests in patients with MPS. The otorhinolaryngologistshould be part of the group of professionals that follows these patients to better monitor their hearing and provide early hearing rehabilitation.

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Abstract Introduction The middle cranial fossa approach is performed by fewer neurotologists owing to a reduced number of indications. Consistent landmarks are mandatory to guide the surgeon in a narrow field. Objectives We have evaluated the incus and malleus head and the incudomalleal joint (IMJ) as a key landmark for identifying the superior semicircular canal (SSC) and to get oriented along the floor of the middle cranial fossa. Methods A combination of 20 temporal bone dissections and CT imaging were utilized to test and describe these landmarks. Results The blue line of the SSC is consistently identified along the prolongation of a virtual line through the IMJ and the angulation toward the root of zygoma. The mean distance from the zygoma toward the IMJ ranged from 1.60 to 1.90cm. Once the IMJ was identified, the blue line of the SSC was consistently found along the virtual line through the IMJ within 5 to 9mm. Conclusions The IMJ is a safe and consistent anatomical marker in the surgical approach to the middle cranial fossa floor. Opening the tegmen 1.5 to 2cm medial to the root of the zygoma and identifying the joint allows to trace a virtual line toward the SSC within 5 to 9mm. Knowledge of the close relationship between the direction of the IMJ and the superior canal can be used in all transtemporal approaches, thus orienting the surgeon in a rather narrow field with limited retraction of the dura and brain.

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Abstract Introduction Mismatch negativity (MMN) is a promising instrument for the investigation of different auditory disorders, as it does not need behavioral responses. Objective To analyze the influence of the ear, gender and age variables in the MMN in children with typical development; and to compare the different measures of this potential, using verbal and nonverbal stimuli in the sample studied, providing reference values. Methods Observational, descriptive, cross-sectional, quantitative study, with 23 children, aged from 5 to 11 years and 11 months old, divided by age group. Mismatch negativity was performed using verbal and nonverbal stimuli, and the data was analyzed by means of the statistical Student t-test. Results No significant differences were noted for the ear, gender and age variables in the MMN with both stimuli. There were significant differences for the latency, duration and area variables when the stimuli were compared. The reference values established for nonverbal stimuli were: latency 249.8 milliseconds, amplitude 2.28 µv, duration 82.97 milliseconds, and area 137.3 microvolt x microseconds (μVx μs); as for the verbal stimuli, they were: latency 265.3 milliseconds, amplitude - 2.82 µv, duration 110.5 milliseconds, and area 225.5 microvolt x microseconds (μVx μs). Conclusion The variables studied did not influence the recordings of the MMN. Latency, duration and area of the MMN with verbal stimuli were higher. It was possible to furnish reference values for children with typical development in the age group studied.

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Abstract Introduction Individual variability in the language outcomes of children with cochlear implantation (CI) is a major concern. In CI rehabilitation, there is lack of a protocol regarding uniform post-CI language assessment interval duration, which can ensure better understanding of the trajectory of language growth as well as optimize language outcomes by providing feedback in fine tuning the language intervention program. Objective To evaluate the receptive and expressive language in Hindi speaking children with up to 2 years of CI experience using revised receptive-expressive emergent language test-3ed. (REELT-3) at 6 months intervals and to compare it with that of children with normal hearing (NH). Methods The present study included 192 children divided in 2 groups, 96 children with CI (15.8 ± 6.7 months), and 96 age-matched children with NH (22.3 ± 7.9 months). A cross-sectional, prospective study design was used to measure the language ability score (LAS) at an interval of 6 months from the time of implantation (TIA), which is 0 to 6 months, 7 to 12 months, 13 to 18 months, and 19 to 24 months of CI usage. Results The two-way analysis of variance revealed that the LAS after 18 months of CI usage was similar to (F (3, 92) = 8.63, p= 0.19, ηp2 = 0.028) that of the children with NH. However, other demographic factors, for instance, gender (F (3, 92) = 1.73, p= 0.505, ηp2 = 0.002), parent's education, (F (3, 92) = 2.05, p= 0.937, ηp2 = 0.031), and financial background (F (3, 92) = 2.49, p= 0.351, ηp2 = 0.076) had no major impact on language. Conclusion Eighteen months of CI usage duration can potentially stimulate receptive and expressive language up to age-matched children with NH. A protocol of periodic assessment of language, at least of 6 months, may be developed to optimize language outcomes.

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Abstract Introduction The measurement of extended high-frequency (EHF) audiometry has become more popular recently, mainly in connection with ototoxicity and noiseinduced hearing loss. New-onset tinnitus evaluation includes a standard hearing test that shows no pathology. Objective The aim of the present study was to evaluate the possibility that acute tinnitus is essentially connected to sudden sensory neural hearing loss (SSNHL), by utilizing EHF audiometry in cases in which standard audiometry for frequencies between 250 Hz to 8 kHz is within normal limits. Methods A retrospective study was conducted between January 2009 and May 2014 that included all patients presenting with acute tinnitus and normal standard audiometry. All patients underwent EHF audiometry and were treated accordingly. Results Thirty-two patients with acute tinnitus and asymmetric sensorineural hearing loss on EHF audiometry were identified. The average deltas between the ears were between 9.2 and 33dB (worse in the affected ear). Conclusion Extended high-frequency audiometry up to 20,000 Hz should be performed in all patients with acute tinnitus and standard audiometry within normal limits.

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Abstract Introduction Chronic rhinosinusitis (CRS) is commonly classified based on the presence or absence of nasal polyps (NPs). Eosinophil infiltration is observed in NPs of patients in Western countries. In contrast, in East Asian countries, including Japan, CRS with NPs (CRSwNP) is subdivided based on the presence (eosinophilic CRS [ECRS]) or absence (non-eosinophilic CRS [NECRS]) of eosinophils in NPs. However, detailed analyses of other immune cells, such as lymphocytes, in NPs have not been performed. Therefore, clarification of the types of cells that infiltrate NPs is important to understand CRS pathogenesis. Objectives We analyzed the lymphocytes that infiltrate the paranasal sinus mucosa of ECRS and NECRS patients. Methods Eighteen patients with CRSwNP participated in this study, out of whom 6 were NECRS patients, and 12 were ECRS patients. The mucosa specimens, collected from patients during sinus surgeries, were subjected to collagenase treatment to prepare single cell suspensions. Then, mononuclear cells were isolated, and CD4+ T, CD8+ T, and CD20+ B-cell populations were examined using flow cytometry. Results In both NECRS and ECRS patients, CD8+ T-cells were dominant over CD4+ T-cells. Notably, CD4+ T-cell/B-cell ratio, but not CD8+ T-cell/B-cell or CD4+ T-cell/CD8+ T-cell ratios, was significantly higher in ECRS patients than in NECRS patients. Conclusion The CD4+ T-cell/B-cell ratio can be used as a potential indicator to differentiate between ECRS and NECRS.

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Abstract Introduction Postoperative neck hematoma (PNH) is an uncommon but potentially-lethal complication of thyroid surgery. Objective To identify the risk factors for postthyroidectomy hematoma requiring reoperation, the timing, the source of the bleeding, the related respiratory distress requiring tracheotomy, and the late outcomes. Methods We retrospectively analyzed the records of 5,900 consecutive patients submitted to surgery for thyroid diseases at a single institution. Results In total, PNH occurred in 62 (1.1%) patients. Most cases of bleeding occurred within the first 6 hours after thyroidectomy, but 12.5% of the hematomas were observed after 24 hours. Obvious bleeding points were detected in 58.1% of the patients during the reoperation, with inferior thyroid artery branches and superior thyroid vessels being the most frequent bleeding sources. Only two patients required urgent tracheostomy. There were no hematoma-related deaths. Permanent hypoparathyroidism and recurrent laryngeal nerve injury are more frequent following reoperation for PNH. The factors significantly associated with PNH were: older age, concurrent lymph node dissection, and chronic lymphocytic thyroiditis. Gender, previous neck irradiation, presentation at diagnosis (symptomatic or incidental), substernal goiter, thyroidectomy for hyperthyroidism, prior thyroid surgery, malignant histology, the extent of the surgery (total versus non-total thyroidectomy), the use of energy-based vessel sealing devices, the use of the hemostatic agent Surgicel, and the placement of a surgical drain were not significantly associated with PNH. Conclusion Hematoma after thyroid surgery is an uncommon complication, but it is related to significant postoperative morbidity. A better understanding of the risk factors and of the time until hematoma formation can help target high-risk patients for preventive measures and closer postoperative observation.

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Abstract Introduction Although the pathogenesis of sudden sensorineural hearing loss (SSNHL) has been discussed in the literature, many unclear points remain. Several authors have hypothesized that oxidative stress plays a role in the pathogenesis of noise-related hearing loss, as well as in drug- and aging-related hearing loss. Reactive oxygen species (ROS) may contribute to the pathogenesis of SSNHL in a similar way as in cases of ototoxicity, noise-induced hearing loss and presbyacusis. Objective The aim of the present study was to find potential peripheral biomarkers to show the levels of oxidative stress in samples of peripheral blood collected from SSNHL patients with and withouth metabolic disease. Methods In total, 80 consecutive patients with SSNHL were evaluated in the otolaryngology emergency room and outpatient clinic of a tertiary hospital between May 2017 and May 2019. All patients underwent detailed anamnesis, physical examination, audiometry, magnetic resonance imaging (MRI) of the inner ears, and blood tests for serum lipids and plasma activity of thiobarbituric acid reactive species (TBARS). Results No significant effect of malondialdehyde (MDA) activity was observed regarding the hearing recovery of patients who developed SSNHL. Conclusion We did not observe a significant correlation between the concentration of TBARs in the peripheral blood or the presence of arterial hypertension and the severity of the initial hearing loss or the prognosis of hearing recovery in patients with SSNHL. The concentration of TBARs in the peripheral blood may not adequately represent the abnormalities that occur in the intracoclear environment.

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Abstract Introduction Head and neck cancer of unknown primary (HNCUP) is a rare condition whose prognostic factors that are significant for survival vary between studies. No randomized treatment study has been performed thus far, and the optimal treatment is not established. Objective The present study aimed to explore various prognostic factors and compare the two main treatments for HNCUP: neck dissection and (chemo) radiation vs primary (chemo) radiation. Methods A national multicenter study was performed with data from the Swedish Head and Neck Cancer Register (SweHNCR) and from the patients' medical records from 2008 to 2012. Results Two-hundred and sixty HNCUP patients were included. The tumors were HPV-positive in 80%. The overall 5-year survival rate of patients treated with curative intent was 71%. Age (p< 0.001), performance status (p= 0.036), and N stage (p= 0.046) were significant factors for overall survival according to the multivariable analysis. Treatment with neck dissection and (chemo) radiation (122 patients) gave an overall 5-year survival of 73%, and treatment with primary (chemo) radiation (87 patients) gave an overall 5-year survival of 71%, with no significant difference in overall or disease-free survival between the 2 groups. Conclusions Age, performance status, and N stage were significant prognostic factors. Treatment with neck dissection and (chemo) radiation and primary (chemo) radiation gave similar survival outcomes. A randomized treatment study that includes quality of life is needed to establish the optimal treatment.

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Abstract Introduction The role of elastin in tympanic retractions and chronic otitis media is not well established. Williams Syndrome (WS), a pathology related to a mutation in the elastin gene, could generate tympanic retractions. Objective To compare the prevalence of tympanic retractions among patients with WS and controls. Methods WS patients (n= 43 ears) and controls (n= 130 ears) were evaluated by digital otoscopic examination and the degree of tympanic membrane retraction was classified by 2 blinded experienced otolaryngologists. Results The agreement rate between the evaluators was 71.1% for pars tensa and 65% for pars flaccida retraction (p< 0.001). The pars tensa and pars flaccida retractions are present in patients with WS after an adjusted residue of respectively - 2.8 and - 2.6 (p= 0.011 and p= 0.022) compared with controls. Conclusions Tympanic membrane retractions are not more common in the WS group when compared with controls.

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Abstract Introduction The quality of information on websites about tonsillectomy regarding the knowledge level may be low. Tonsillectomy is a surgical procedure to hypertrophy of the palatine and pharyngeal tonsils. So, it is an invasive procedure with possible complications, which creates insecurity in parents. Significantly, Internet searches have been increased to address possible health concerns, questioning the quality of websites about tonsillectomy. Objective To evaluate the readability, reliability, and comprehensiveness of the Italian websites dedicated to parental guidance regarding the indications for tonsillectomy in children. Methods The search engine google.it was used to search the websites. The Gulpease index, which is a widely used readability formula ranging from 0 (difficult) to 100 (easy readability), was employed to evaluate these websites. The Health on the Net Code of Conduct (HONcode) was used to assess the quality of information, by taking ethical principles into account, with values ranging from 0 to 13. The content comprehensiveness of the web pages was assessed by assigning points ranging from 1 (very insufficient) to 5 (very satisfying) to each page. A final comparison with previous studies on tonsillectomy published on websites from other countries was performed. Results Fourteen Italian websites were selected, and the Gulpease index showed a mean average of 40.77 ± 8.45. The mean of the HONcode analysis was 6.00 ± 1.92, in which the principles with the poorest scores were Attribution and Update. As far as the comprehensiveness of the websites is concerned, the resulting mean was 2.57 ± 0.77, in which Indications was the topic with the highest mean, whereas Benefits was the one with the lowest. Conclusion The Italian websites were characterized by a lower readability level, a middle position regarding ethical principles, and the same (insufficient) comprehensiveness of tonsillectomy when compared with websites from different countries.

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Abstract Introduction Increases in spontaneous activity in the neurons of the auditory cortex are presumed as the pathophysiology of tinnitus. Objective To investigate the effectiveness of transcranial magnetic stimulation (TMS) in the treatment of tinnitus. Methods A total of 62 patients between the ages of 22 and 74 with chronic subjective tinnitus were enrolled in the study. The inclusion criteria were normal findings on an otolaryngologic examination and normal ranges of complete blood count, routine biochemical parameter levels, thyroid function, air-bone gap on pure-tone audiometry, and middle-ear pressure and stapedial reflex on tympanometry. The patients were randomized into 2 groups: 40 patients were placed in the treatment for TMS (tTMS) group, and the rest (22 patients) were placed in the sham TMS group. The frequency and severity of the tinnitus, as well as the tinnitus handicap inventory (THI) score of each patient were measured before and one month after the treatment, and the values were statistically evaluated. Results We observed a statistically significant improvement in the tTMS group (p< 0.05 and p< 0.05 respectively) regarding the THI and tinnitus severity scores. The sham TMS group showed no significant improvement in terms of the THI (p> 0.05). However, the tinnitus severity showed a significant increase in this group (p< 0.05). The comparison of differences in the changes in the THI and the tinnitus severity scores showed a significant statistical improvement in the tTMS group compared with the sham TMS group (p< 0.05 and p< 0.05 respectively). Conclusion Transcranial magnetic stimulation was found to be effective in the treatment of tinnitus, and may be adopted as a treatment for tinnitus after further comprehensive studies.

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Abstract The number of critically-ill coronavirus disease 2019 (Covid-19) patients requiring mechanical ventilation is on the rise. Most guidelines suggest keeping the patient intubated and delay elective tracheostomy. Although the current literature does not support early tracheostomy, the number of patients undergoing it is increasing. During the pandemic, it is important that surgeons and anesthesiologists know the different aspects of tracheostomy in terms of indication, procedure, tube care and complications. A literature search was performed to identify different guidelines and available evidence on tracheostomy in Covid-19 patients. The purpose of the present article is to generate an essential scientific evidence for life-saving tracheostomy procedures.

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Abstract Introduction Menière disease (MD) is a disorder characterized by episodes of vertigo, sensorineural hearing loss, tinnitus and aural fullness. Objectives To assess the effect of ventilation tube insertion (VTI) on vertiginous episodes in patients (≥ 18 years old) with MD. Data Synthesis A systematic literature search on randomized clinical trials (RCTs), nonrandomized trials and other systematic reviews was performed. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to assess the overall certainty of evidence. Two RCTs and four nonrandomized studies were identified. Data extraction was only possible for one RCT. Results showed that the number of patients with no vertigo attacks significantly increased following active treatment (relative risk 1.52; [95% confidence interval: 1.19–1.94]). The quality of evidence was rated as low. None of the nonrandomized trials included a proper control group, which hindered data extraction and quality assessment. Conclusion There are currently no RCTs that specifically assess the efficacy of VTI in patients with MD. Current limited data suggest a considerable positive effect on the number of vertiginous episodes in patients with MD. However, due to poor evidence, a fluctuating course and a substantial placebo-effect associated with MD-treatment, no solid conclusion(s) regarding the efficacy of VTI can be made. There is a need for high-quality RCTs.

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Abstract Introduction Narrow-band imaging is an endoscopic diagnostic tool that, focusing on superficial vascular changes, is useful to detect suspicious laryngeal lesions, enabling their complete excision with safe and tailored resection margins. Objectives To analyze the applications and benefits of narrow-band imaging in detecting premalignant and malignant laryngeal lesions through a comparison with white-light endoscopy. Data Synthesis A literature search was performed in the PubMed, Scopus and Web of Science databases using strict keywords. Then, two authors independently analyzed the articles, read the titles and abstracts, and read completely only the relevant studies according to certain eligibility criteria. In total, 14 articles have been included in the present review; the sensitivity, specificity, positive and negative predictive values, and accuracy of pre- and/or intraoperative narrow-band imaging were analyzed. The analysis showed that narrow-band imaging is better than white-light endoscopy in terms of sensitivity, specificity, positive and negative predictive values, and accuracy regarding the ability to identify cancer and/or precancerous laryngeal lesions. Moreover, the intraoperative performance of narrow-band imaging resulted more effective than the in-office performance. Conclusion Narrow-band imaging is an effective diagnostic tool to detect premalignant and malignant laryngeal lesions and to define proper resection margins. Moreover, narrow-band imaging is useful in cases of leukoplakia that may cover a possible malignant lesion and that cannot be easily assessed with white-light endoscopy. Finally, a shared, simple and practical classification of laryngeal lesions, such as that of the European Laryngological Society, is required to identify a shared lesion management strategy. Key Points Narrow-band imaging is useful in detecting suspicious laryngeal lesions and proper resection margins showing intraepithelial papillary capillary loops (IPCLs) that are considered a main cancer feature. Narrow-band imaging is used both pre- and intraoperatively, but it provides more precise information if used during surgery. Compared with white-light endoscopy, narrow-band imaging enables a better assessment of the lesions covered by a thick white plaque (such as in cases of leukoplakia) The classification of the European Laryngological Society is the simplest and the most practical for the identification of various laryngeal lesions compared with other classifications.