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Abstract Introduction Epistaxis is a common presentation among children. Objective To investigate the suitability of a simple tool of assessment for patients with epistaxis that could guide in subgrouping those with possible bleeding tendencies who may need further assessment. Methods Children who presented to a tertiary outpatient clinic with epistaxis of an unknown cause were recruited. They underwent thorough clinical assessment and answered the pediatric bleeding questionnaire and the epistaxis severity score. All patients underwent complete blood count as well as coagulation profile, and confirmatory diagnostic tests were performed as needed. Results Among the 30,043 patients who presented to the outpatient clinic over a year, 100 children had epistaxis, with an estimated annual frequency of 1 in 300. A total of 84% of the patients were younger than 12, and nearly half of these were younger than 6 years. Seventy-six patients had recurrent epistaxis, and 12 had systemic comorbidities. A significant higher percentage of patients presented with epistaxis in the hot months of the year. A total of 90% of the patients presented anterior bleeding, and the majority were treated with nasal compression only. Forty-three patients presented with epistaxis only; 37 of them were diagnosed as idiopathic epistaxis, and 6 had local causes. Fifty-seven patients presented with other bleeding manifestations, 47 of whom had a definite bleeding disorder and the other 10 had undiagnosed bleeding tendency. Those with other bleeding manifestations showed a higher frequency of positive family history of epistaxis; of being referred from a primary care physician; of having alarming low platelet count, and of presenting less seasonal variability. A bleeding score ≥ 2 showed significant value in suspecting an underlying systemic pathology as a cause of epistaxis. Conclusion The pediatric bleeding questionnaire is a useful and simple tool in the identification of pediatric patients who need further diagnostic testing to detect any underlying bleeding tendency.

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Abstract Introduction Idiopathic rhinitis is a nonallergic and noninfectious rhinitis characterized mainly by nasal obstruction and rhinorrhea, resulting from an autonomic imbalance. Botulinum toxin type A (BTX-A) demonstrated its action in reducing rhinorrhea and nasal obstruction when injected into the nasal turbinates or septum. Objective To analyze the effects of intranasal BTX-A injection to control the symptoms of idiopathic rhinitis and its possible adverse effects. Method Patients with idiopathic rhinitis were divided into two groups. Group A had 15 participants (8 female and 6 male), of ages from 47 to 84 years (mean 66.57 years), and these received 60 U of Dysport (Ipsen Ltd, Maidenhead, Berkshire, UK) in each inferior nasal turbinate; group B had 12 participants (1 male and 11 female), of ages from 50 to 76 years (mean 60 years), and they received 1 ml of 0.9% saline. The individuals were reevaluated in the 1st, 2nd, 4th, 8th, and 12th weeks after injection by a questionnaire, accompanied by nasal inspiratory peak flow and acoustic rhinometry. Results Group A showed significant improvement, mainly regarding the symptoms of sneezing/itching and nasal obstruction, over time and when compared to group B. Acoustic rhinometry confirmed the improvement in nasal obstruction. There was no relationship between the nasal peak flow data and the nasal obstruction score. No major adverse effects have been reported. Conclusion The injection of botulinum toxin in the inferior nasal turbinates of patients with idiopathic rhinitis reduces the symptoms of sneezing, itching, nasal obstruction, and runny nose without significant adverse effects, suggesting that it is an option in the treatment of these patients.

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Abstract Introduction The importance of temporal ordering and sequencing in the auditory system is discussed because these are considered basic functions for language. Objective To verify the correlation between the practice of choir music and the temporal ordering in elderly with no prior formal musical experience. Method The study design is cross-sectional. The sample consisted of 85 elderly individuals of both genders, ≥ 60 years old, and it was composed of 43 elderly individuals with no prior formal musical experience but choir participation (research group) and 42 elderly individuals who never sang in a choir and had no music training during their life (control group). The research group was divided based on three categories of choir time. The performances of the research and control groups were compared with pitch pattern sequence (PPS), verbal condition (PPSverb), humming condition (PPShum), and duration pattern sequence (DPS) tests. Results The mean PPShum and PPSverb showed a statistically significant difference by choir time with a different mean of PPShum between the no singing experience group (59%) and the > 10 years of singing experience group (90%) (p= 0.02). Regarding the averages of PPSverb, there was a statistically significant difference between the no singing experience (23%) and > 10 years of choir time (54%) (p= 0.02) groups. Conclusion The findings indicate a better performance in the temporal ordering of the elderly who are not formal musicians but who have choir experience in the research group in relation to those with no choir experience in the control group.

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Abstract Introduction Palatine and pharyngeal tonsils are the first line of defense against pathogens. Clinically, two alterations may require surgical removal of the tonsils: hypertrophy and recurrent tonsillitis. The two conditions probably result from a dysfunction of the immune system. Objective To evaluate possible differences in the plasma levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and interleukin-10 (IL-10) in patients submitted to adenotonsillectomy. Methods Prospective, longitudinal study with 25 children undergoing adenotonsillectomy separated into 3 different groups: recurrent tonsillitis (RT), composed of 7 patients; recurrent hypertrophy tonsillitis (RTTH), with 8 patients; and the tonsillar hypertrophy (TH) group, with 10 patients. Ten healthy control children (SD) were also included in the study. Peripheral blood was collected, and plasma was separated to measure the levels of TNF-α, IL-6, and IL-10. The Mann-Whitney test was used for statistical analysis. Results The plasma level of IL-6 was higher in the RT (p= 0.0394) and TH (p= 0.0009) groups, compared with the control group. The TH group also had higher levels of IL-6 than the RT group (p= 0.039). The IL-6/IL-10 ratio was higher in the RT (p= 0.029) and TH (p= 0.0005) groups compared with the control group. Between the RT and RTTH groups, the IL-6/IL-10 ratio was higher in the RT group, with a statistically significant difference (p= 0.0091). Conclusion Patients with a history of chronic tonsillitis had higher levels of IL-6, compared with the control group.

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Abstract Introduction External auditory canal cholesteatoma (EACC) is often misdiagnosed. Objectives To outline the clinical presentation of EACC, and to describe its radiological findings on high-resolution computed tomography (HRCT) of the temporal bone. Methods The clinical records of all patients diagnosed with EACC from April 2017 to March 2020 in a tertiary care center were retrospectively reviewed. The clinical presentation, the findings on the HRCT of the temporal bone, and the treatment provided were analyzed. Results A total of 9 patients, 7 males and 2 females, with a mean age of 30 years, were diagnosed with primary EACC. Six patients presented with otorrhoea, three, with otalgia, three. with hearing loss, and one with facial palsy. Some patients had multiple symptoms. The most common findings on otomicroscopy were destruction of the posterior and inferior canal walls, with cholesteatoma and intact tympanic membrane (six patients). Two patients had aural polyp, and one had a narrow ear canal due to sagging of the posterior canal wall. On HRCT, all nine patients showed soft-tissue density in the external auditory canal with erosion of the canal wall. The disease extended to the mastoid in eight cases, and to the cavity of the middle ear in one. There were three cases of dehiscence of the facial canal. Dehiscence of the dural and sinus plates was observed in two cases each. Eight patients underwent mastoidectomy, and one underwent debridement with canalplasty. Conclusion Review of the clinical and radiological findings is essential to reduce the rate of misdiagnosis.

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Abstract Introduction Total thyroidectomy remains highly technical, with a significant risk of recurrent laryngeal nerve (RLN) compromise and hypoparathyroidism. After identifying RLN, at the level of the ligament of Berry, local factors may compel the surgeon to either dissect along the nerve or the thyroid capsule. Objective The objective of the present study is to compare these two approaches in terms of outcomes and complication rates. Methods This is a retrospective analysis from September, 2013 to April 2019 of 511 consecutive patients undergoing thyroidectomy. General demographics and disease parameters were recorded. At the discretion of the surgeon and according to the demands of the local operative factors, the patients either had dissection along the RLN or along the thyroid capsule. Perioperative and postoperative parameters such as blood loss, duration of surgery, hospital stay, pain scores, analgesia requirements and complications were recorded. The groups were compared with the Pearson chi-squared test or with the Fisher exact test. A p-value < 0.05 was considered statistically significant. Results The incidence of transient hypocalcaemia and transient RLN compromise were higher when dissection was performed along the nerve as opposed to the plane along the thyroid capsule. Other parameters including operative time, hospital stay, pain scores, analgesia requirement, wound infection, seroma, hemorrhage, and recurrence did not differ between the groups. Subgroup analysis of the patients who presented with complications showed that local factors, malignancy, and extent of surgery correlated positively with complications when dissected along the RLN. Conclusion Dissection along the capsule of the thyroid during thyroidectomy is a safer plane in terms of low rate of transient RLN injury and hypoparathyroidism as opposed to dissection along the nerve.

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Abstract Introduction In the current era, the major indication for septoplasty is nasal obstruction due to deviated nasal septum (DNS). Even though septoplasty is a commonly performed surgery, its effectiveness in relieving nasal obstruction in DNS has not been proven. Objective The present study involved the measurement of both objective (nasal patency) and subjective (quality of life measures) outcome measures for the evaluation of the efficacy of septoplasty as compared with medical management. Methods Patients with DNS presenting with nasal obstruction were included and randomized into a septoplasty group or into a nonsurgical management group, with 70 patients in each group. The improvement in nasal obstruction was assessed subjectively by the visual analogue scale (VAS), and the sino-nasal outcome test-22 (SNOT-22) and the nasal obstruction symptom evaluation (NOSE) questionnaires and was measured objectively by assessment of nasal patency by peak nasal inspiratory flow (PNIF) at 0, 1, 3, and 6 months of treatment in both groups. Results The average VAS, SNOT-22 and NOSE scores for the septoplasty versus the nonsurgical group before treatment were 6.28 versus 6.0, 19.5 versus 15, and 14 versus 12, respectively, and at 6 months post-treatment, the scores were 2.9 versus 5.26, 10 versus 12, and 8 versus 10 (p= 0.001), respectively. The average PNIF scores at 0 and 6 months were 60/50 l/min and 70/60 l/min, respectively, in the septoplasty group (p= 0.001); the scores at 0 and 6 months in the nonsurgical management group were 60/60 l/min and 70/70 l/min, respectively (p= 0.001). Conclusion Surgical correction of DNS by septoplasty improves nasal obstruction better than nonsurgical management at 6 months postsurgery.

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Abstract Introduction Therapeutic dry needling (DN) is effective in reducing the discomfort of chronic somatosensory tinnitus in patients with myofascial trigger points (MTP)s. Objective To evaluate the efficacy of DN in chronic somatosensory tinnitus discomfort in patients with MTP. Methods Placebo-controlled paired trial that included 16 patients with a diagnosis of somatosensory chronic tinnitus and with the presence of at least one active or latent MTP. Treatment was performed in two phases: (1) four sessions (one session per week for four consecutive weeks) of placebo DN and (2) four sessions of therapeutic DN with a gap (washout) of 15 days between these phases. Results The Tinnitus Handicap Inventory (THI) variable and its emotional domain had a statistically significant reduction in therapeutic DN when compared with placebo DN (p= 0.024 and p = 0.011, respectively). The tinnitus visual analogic scale (VAS) signaled a reduction in tinnitus discomfort when compared with moments before and after therapeutic DN (p< 0.05). Conclusion The therapeutic DN technique for MTP in patients with chronic tinnitus of somatosensory origin proved effective in reducing symptom discomfort, as measured by the THI (total score) and its emotional domain when compared with placebo DN.

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Abstract Introduction The high phonatory demand required of teachers is a direct cause of the onset of vocal symptoms and of the development of laryngeal disorders. Objective To describe the findings of the laryngeal screening performed as part of the Vocal Health Program held in the Federal Distrcit of Brazil in 2014 and 2015. Methods The study was performed with 361 dysphonic teachers from public schools who attended the laryngeal screening (videolaryngoscopy) part of the program. Data on anamnesis, the degree of dysphonia, the findings of the laryngeal screening, the referrals made after the laryngeal screening, and the result of the assessment of vocal aptitude for work were analyzed from the forms of each participating teacher. Results The sample of the present study (N= 361) represents 18.23% of the 1,980 teachers that went through the vocal screening of the program in 2014 and 2015. In total, 98 (27.15%) teachers presented mild dysphonia, 221 (61.22%), moderate dysphonia, and 42, (11.63%) severe dysphonia. Regarding the laryngeal screening (videolaryngoscopy exam), 269 teachers (74.52%) presented laryngeal disorders, and the main ones found were vocal nodules (43.87%), signs of laryngopharyngeal reflux (37.17%), hourglass chink (18.22%), vascular dysgenesis (18.22%), midposterior triangular chink (9.67%), and double chink (8.55%). Conclusion Laryngeal screening through videolaryngoscopy and auditory-perceptual screening of the voice as part of vocal health programs are essential to define the diagnosis and therapeutic conduct for teachers with dysphonia. Together with intervention activities, continuing education and adequate and accessible treatment, the periodic evaluation of vocal health can contribute to reduce absenteeism and improve the quality of life and of the voice of teachers.

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Abstract Introduction Distortion product otoacoustic emissions (DPOAE) and their suppression may be considered useful in monitoring cochlear function and the efferent auditory pathway inhibitory effect. Nonetheless, the establishment of reliable parameters of response variations is of great importance. Objectives To verify the replicability of test and retest in the research of the inhibitory effect of the efferent pathway using contralateral suppressing stimulus during DPOAE recording for clinical applicability. Methods Cross-sectional study with 48 volunteers, aged 18 to 30 years, with normal audiometric thresholds. The procedures included were audiometric and immittance measures to overrule any conductive or sensorineural conditions and DPOAE recordings without and with contralateral suppression with a 60 dBHL white noise. Distortion product otoacoustic emissions amplitudes were analyzed and compared in both conditions with Wilcoxon test, and the Spearman correlation test was used to assess test-retest reliability. Results The comparative analysis showed differences between amplitudes in test and retest conditions only in 1,500 Hz for DPOAE measures with all other tested frequencies showing no differences, and no difference was observed in all recorded frequencies in the test and retest comparison for DPOAE suppression. The degree of correlation between test and retest of DPOAE amplitude was good at 6,000 Hz and strong (r > 0.880) at the other frequencies. For DPOAE with suppression, all frequencies presented strong correlation between test and retest: 1,500 Hz (r = 0.880), 2,000 Hz (r = 0.882), 3,000 Hz (r = 0.940), and 6,000 Hz (r = 0.957). Conclusions The study found good replicability in contralateral suppression of DPOAE with potential clinical applicability, and we recommend conducting the test from 2000Hz to higher frequencies for more reliable results.

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Abstract Introduction The treatment of cholesteatoma is generally surgical, and the major obstacle is the high prevalence of recidivism. The endoscopic ear surgery technique is proposed to minimize this problem. Objectives To utilize endoscopes to visualize and manipulate cholesteatoma residues after microscopic removal Methods Cross-sectional study. Thirty-two patients with cholesteatoma underwent microscopic wall-up mastoidectomy combined with the endoscopic approach. The subjects were assessed for the presence and location of covert disease. Results Of the 32 cases, 17 (53.12%) had residual cholesteatoma in the endoscopic phase. Minimal disease was found, usually fragments of the cholesteatoma matrix. Pars tensa cholesteatomas had more covert disease than pars flaccida cholesteatomas (62.50% vs 43.75%). Posterior recesses (47.05%) and tegmen tympani (41.17%) were the locations with more covert disease (p< 0.05). Conclusion Cholesteatomas of the pars tensa presented more residual disease and were significantly more common in the posterior recesses and tegmen tympani.

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Abstract Introduction Coronavirus disease 2019 (COVID-19) is a dangerous infectious disease caused by a newly discovered severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that has various clinical presentations. Numerable cases with non-specific olfactory and gustatory dysfunctions in COVID-19 have been reported from all over the globe. This is important as awareness will let people to self-isolate and help in limiting disease spread. Objective To objectively evaluate the frequency of olfactory and gustatory dysfunction, which may occur independently or with other symptoms, in laboratory confirmed COVID-19 patients at an early stage of the disease. Methods Objective evaluation of olfactory and gustatory function of 322 COVID-19 patients treated at our hospital, (SMGS, Government Medical College, Jammu), from August 2020 until November 2020. Results Our study population included 127 (39.4%) males and 195 (60.6%) females. Two hundred and twenty-six (70.2%) COVID-19 patients experienced olfactory and gustatory disorders. One hundred and sixty-five (51.2%) cases experienced both olfactory and gustatory disorders. Isolated olfactory dysfunction was reported in 34 (10.6%) patients, while 27 (8.4%) patients experienced only gustatory dysfunction. Conclusion The olfactory and gustatory dysfunctions, without any nasal obstruction or rhinorrhea, are significant symptoms in the clinical presentation of early COVID-19 patients. This presentation can be recognized at the earliest one, and it can reduce the high communicability of the COVID-19 disease.

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Abstract Introduction Knowledge about the positive effects that music and dance bring, in its various forms, to the healthy human brain, is important not only in the context of basic neuroscience but may also strongly affect practices in neurorehabilitation. Objective To verify the relationship between hearing and movement and, specifically, to analyze the interference of professional dance practice and formal musical training in the magnitude of the vestibule-cervical and vestibular reflexes. Method The sample consisted of 92 subjects, aged between 18 and 35 years old, 31 professional musicians, 31 ballet dancers, and 30 control subjects. Only subjects with normal hearing sensitivity were included. Cervical vestibular evoked myogenic potential (cVEMP) was recorded in the sternocleidomastoid muscle, and ocular vestibular evoked myogenic potential (oVEMP) was recorded in the lower oblique muscle of the eye, using tone-bursts (500Hz). Analysis of variance (ANOVA) or Kruskall-Wallis tests were performed. Results The cVEMP presented earlier and higher amplitude waves when recorded in the group of dancers, with a significant difference between all tested groups for latency and amplitude of the N23 wave; the comparison was restricted between dancers and control groups, with no difference between ballet dancers and musicians. The N1 wave of the oVEMP presented lower latencies in dancers than in musicians and controls (p= 0.001). No significant differences were found between the groups for the P1 wave. Conclusion Greater magnitudes of vestibule-cervical reflex responses and faster vestibule-ocular reflex responses were observed in dancers. Dance practice provides greater development of the vestibular system, but musical training also contributes to the magnitude of these responses.

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Abstract Introduction Extraparotid Warthin tumor (WT) is a very rare entity, especially when synchronous with oral cancer (OC). Objective The present study presents a case series of extraparotid WTs detected in the surgical specimen of patients treated for OC. Methods From 2007 to 2016, 336 patients were operated for OC in our institution. Neck dissection was performed in 306 patients. Results In the 306 patients operated for OC whose necks were dissected, unexpected WTs were observed in 4 surgical neck specimens. In 3 cases, extraparotid WTs were responsible for tumor, node, metastasis (TNM) overstaging before surgery. Conclusion Extraparotid WTs may be discovered during neck dissection in ∼ 1% of OC patients, and they may mimic neck metastasis, especially in positron-emission tomography/computed tomography (PET/CT) imaging.

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Abstract Introduction Diabetes mellitus is a metabolic disease associated with a rise in the level of blood glucose. Individuals with diabetes mellitus are more likely to develop hearing loss, tinnitus, and dizziness due to macro- and microvascular complications. The extent to which auditory and vestibular functions are impaired in individuals with type-2 diabetes mellitus is still under debate. Objective To systematically review studies focusing on auditory and vestibular functions in individuals with type-2 diabetes mellitus. Data Synthesis A search was conducted in the PubMed, MedlinePlus, Ingenta Connect and Google Scholar databases for articles published until June 2019. A total of 15,980 articles were primarily retrieved, 33 of which were shortlisted based on the inclusion criteria set by the investigators for the systematic review. Out of 33 full-length articles, 26 evaluated the functioning of the auditory system, while 7 evaluated the functioning of the vestibular system. Most studies related to auditory functioning reported a significant effect of type-2 diabetes mellitus on the peripheral auditory system, whereas studies on vestibular functioning reported no significant effect of diabetes mellitus on the functioning of the peripheral vestibular end-organ. Conclusion Overall, the results of various audiological and peripheral vestibular tests reveal distinctive peripheral and/or central auditory and vestibular end-organ impairments in individuals with type-2 diabetes mellitus.