Recovery rate and factors associated with smell and taste disruption in patients with coronavirus disease 2019.

PURPOSE: To determine the occurrence of olfactory and gustatory disruptions in COVID-19 patients, their association with demographic and clinical features and prognosis. MATERIAL AND METHODS: This observational cohort study involved consecutively diagnosed COVID-19 patients tested between March the 3rd 2020 and March the 24th 2020, in a geographically defined cohort area. All COVID-19 patients were evaluated in a University Hospital. The primary outcome of interest is the prevalence of smell and taste alterations, factors associated and recovery rate. Univariate and multivariate analysis by logistic regression was performed to detect factors associated to these symptoms. RESULTS: 151 patients were included and 99 (65.6%) reported olfactory or gustatory symptoms. Olfactory dysfunction was reported by 75 patients (49.7%). Isolated anosmia was found in 2 patients (1.3%). Gustatory dysfunction was reported by 91 patients (60.3%). Factors associated with higher prevalence of smell dysfunction included age, sex, and comorbidities. The time to smell disruption development was significantly shorter in mild to moderate patients than in severe patients (p = 0.043). In 85.3% of patients with smell disruption, the symptom had been resolved in the first 2 months. 14.7% of patients remained symptomatic after 3 months of follow-up. CONCLUSIONS: Olfactory and gustatory dysfunction was common in COVID-19 patients. Smell disruption has high recovery rate and was associated with age, sex, and clinical severity. It may be beneficial to investigate the appearance of taste and/or smell disruptions in individual patients, with respect to diagnosis and prognosis.

Recommendations for head and neck surgical oncology practice in a setting of acute severe resource constraint during the COVID-19 pandemic: an international consensus.

The speed and scale of the global COVID-19 pandemic has resulted in unprecedented pressures on health services worldwide, requiring new methods of service delivery during the health crisis. In the setting of severe resource constraint and high risk of infection to patients and clinicians, there is an urgent need to identify consensus statements on head and neck surgical oncology practice. We completed a modified Delphi consensus process of three rounds with 40 international experts in head and neck cancer surgical, radiation, and medical oncology, representing 35 international professional societies and national clinical trial groups. Endorsed by 39 societies and professional bodies, these consensus practice recommendations aim to decrease inconsistency of practice, reduce uncertainty in care, and provide reassurance for clinicians worldwide for head and neck surgical oncology in the context of the COVID-19 pandemic and in the setting of acute severe resource constraint and high risk of infection to patients and staff.

Minimally invasive video-assisted submandibular sialadenectomy: surgical technique and results from two institutions.

BACKGROUND: Submandibular gland excision is traditionally performed using a transcervical approach. However, innovative surgical trials have recently been conducted to investigate techniques that can prevent or reduce visible scarring and nerve injury. The aim of the present study was to evaluate the feasibility of a new approach to submandibular gland excision that is based on the use of a minimally invasive video-assisted technique and an ultrasound scalpel in an endoscopic neck surgery program with a low annual flow of procedures. METHODS: We retrospectively studied 15 patients with submandibular gland disease who underwent minimally invasive video-assisted submandibular sialadenectomy performed by two surgeons at two institutions. Eight patients had proximally located salivary calculi, three had chronic sialadenitis, and four had benign neoplasms. All dissections were carried out by a single-port gasless approach, using the Miccoli technique, involving endoscope magnification and an ultrasonic scalpel. RESULTS: All 15 submandibular gland resections were performed successfully, with no conversions to conventional open resection. The operative time ranged from 45 to 125 min (median 84 min). A total of 67 % of patients were discharged the day after surgery, and the maximum length of stay was 3 days. One patient experienced postoperative bleeding, and one experienced postoperative infection. There was no neural injury. The incision scar healed well in all cases, and all patients reported excellent cosmetic results. CONCLUSIONS: Endoscopic submandibular gland resection using a minimally invasive video-assisted technique, endoscopic magnification, and ultrasonic scalpel was feasible and resulted in excellent surgical outcomes.

TransOral endoscopic UltraSonic Surgery (TOUSS): a preliminary report of a novel robotless alternative to TORS.

The objective of this study is to describe and evaluate the feasibility of TransOral UltraSonic Surgery (TOUSS), a new endoscopic alternative to transoral robotic surgery for approaching pharyngeal and laryngeal tumours based on ultrasonic scalpel as a resection tool. This is a prospective study on 11 consecutive patients with pharyngeal and supraglottic carcinomas between December 2013 and August 2014. All tumours were resected transorally with 35 cm ThunderbeatTM. Exposure was achieved using GyrusTM FK-retractor and Olympus ENDOEYE Flex 5 mm 2D/10 mm 3D deflecting tip video laparoscopes. We evaluated tumour staging, surgical margins, surgical time, blood transfusions, tracheostomy, enteral feeding, postoperative pain and hospital stay. The operating room setup and procedure are described. This series comprised seven early and four locally advanced carcinomas. The mean setup for TOUSS and resection time were 16 and 70.9 minutes. No major intraoperative complications were identified. The average time of nasogastric feeding tube dependence (n = 9) was 13 days. Gastrostomy was performed in one patient. The average hospital stay was 14.3 days. Postoperative pain was satisfactory treated with nonsteroidal anti-inflammatory drugs. We have described TOUSS as a new feasible and intuitive procedure to approach endoscopically pharyngeal and supraglottic tumours, with good intraoperative conditions and functional outcomes.

Evidence-Based Recommendations in Primary Tracheoesophageal Puncture for Voice Prosthesis Rehabilitation.

Head and neck cancer, the seventh most common cancer worldwide, often affects the larynx, with a higher incidence in men. Total laryngectomy, a common treatment, results in the loss of phonation, and tracheoesophageal voice rehabilitation is the current rehabilitation method of choice. Despite ongoing debates regarding the timing of tracheoesophageal puncture (TEP), a crucial procedure for voice prosthesis placement, the secondary puncture continues to be the preferred choice in the majority of cases. This underscores the persistent controversy and the absence of consensus in this field. The aim of this manuscript was to define evidence-based recommendations regarding the procedure of primary TEP with voice prosthesis placement, establish the conditions and requirements for performing primary TEP, determine the indications and contraindications of primary TEP, as well as to define the complications and management of primary TEP. A total of 19 statements were formulated, with 78.95% of them having a Level of Evidence 4 and a Grade of Recommendation C. There is not sufficient evidence comparing the outcomes of primary TEP versus secondary TEP. Future studies with robust methodologies are needed to clarify the role of primary and secondary TEP in the rehabilitation of patients undergoing total laryngectomy.

Executive Summary of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management.

The Airway section of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) present the Guidelines for the integral management of difficult airway in adult patients. This document provides recommendations based on current scientific evidence, theoretical-educational tools and implementation tools, mainly cognitive aids, applicable to the treatment of the airway in the field of anesthesiology, critical care, emergencies and prehospital medicine. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations and optimization in the progression of the application of strategies to preserve adequate alveolar oxygenation in order to improve safety and quality of care.

Impact of the COVID-19 pandemic on the training of otorhinolaryngology residents.

BACKGROUND AND OBJECTIVES: Training in surgical specialties has declined during the COVID-19 pandemic. A study was carried out to further analyze the impact of the COVID-19 pandemic on specific aspects of clinical, training, and research activities performed by the otolaryngology residents in Spain. METHODS: A cross-sectional qualitative study was conducted during the last two weeks of February 2021. The study consisted of an online survey taken by otolaryngology residents who had undertaken one-year continuing training from February 15, 2020, to February 15, 2021, and consisted of 26 questions exploring the impact of the COVID-19 on the health of the ENT residents and training activities. Categorical variables were reported as frequency and percentage. When indicated, Pearson's Chi-square test (χ2) with Yates's correction and Pearson's correlation coefficient (r) were used. RESULTS: 143 completed surveys were received from 264 Residents (54.17%). 36 residents (25.2%) have suffered from the disease due to SARS-CoV-2. Most of them only developed mild symptoms (86.1%), with 3 requiring hospitalisation (8.3%). The origin of infection was unknown in all reported cases and the need for confinement was principally due to either attending an asymptomatic patient in 9 cases (6.3%) or to being supposedly in close contact with an asymptomatic person in 22 (15.4%). 60.1% of the residents surveyed reported having lost more than 6 months of their training period, and in 18.8% of cases, it was as high as 10 and 12 months. There has been a reduction of more than 75% of what was planned in surgical training (p<0.05) of tympanoplasty, mastoidectomy, stapedectomy, cochlear implants, endoscopic sinonasal and anterior skull base surgery, septoplasty and turbinoplasty. CONCLUSIONS: The decline in ENT activity and residents having to assist in other COVID-19 units during the most critical moments of the pandemic, has caused the main reduction in their training capacity. Contagion mainly occurred through contact with asymptomatic carriers during patient care and through supposedly close contact with asymptomatic carriers. Virtual activities have been widely accepted, but they have not completely replaced all residents' training needs. Measures should be implemented to recover lost training, especially surgical practical learning in otology and rhinology.

[Impact of the COVID-19 pandemic on the training of otorhinolaryngology residents]. / Impacto de la pandemia COVID-19 en la formación de los residentes de otorrinolaringología.

Background and objectives: Training in surgical specialties has declined during the COVID-19 pandemic. A study was carried out to further analyze the impact of the COVID-19 pandemic on specific aspects of clinical, training, and research activities performed by the otolaryngology residents in Spain. Methods: A cross-sectional qualitative study was conducted during the last two weeks of February 2021. The study consisted of an online survey taken by otolaryngology residents who had undertaken one-year continuing training from February 15, 2020, to February 15, 2021, and consisted of 26 questions exploring the impact of the COVID-19 on the health of the ENT residents and training activities. Categorical variables were reported as frequency and percentage. When indicated, Pearsons Chi-square test (χ2) with Yates's correction and Pearson's correlation coefficient (r) were used. Results: 143 completed surveys were received from 264 residents (54.17%). 36 residents (25.2%) have suffered from the disease due to SARS-CoV-2. Most of them only developed mild symptoms (86.1%), with 3 requiring hospitalization (8.3%). The origin of infection was unknown in all reported cases and the need for confinement was principally due to either attending an asymptomatic patient in 9 cases (6.3%) or to being supposedly in close contact with an asymptomatic person in 22 (15.4%). 60.1% of the residents surveyed reported having lost more than 6 months of their training period, and in 18.8% of cases, it was as high as 10 and 12 months. There has been a reduction of more than 75% of what was planned in surgical training (P < .05) of tympanoplasty, mastoidectomy, stapedectomy, cochlear implants, endoscopic sinonasal and anterior skull base surgery, septoplasty and turbinoplasty. Conclusions: The decline in ENT activity and residents having to assist in other COVID-19 units during the most critical moments of the pandemic, has caused the main reduction in their training capacity. Contagion mainly occurred through contact with asymptomatic carriers during patient care and through supposedly close contact with asymptomatic carriers. Virtual activities have been widely accepted, but they have not completely replaced all residents' training needs. Measures should be implemented to recover lost training, especially surgical practical learning in otology and rhinology.

Intraoperative monitoring of the facial nerve during parotid gland surgery in Otolaryngology services - Head and Neck Surgery. / Monitorización intraoperatoria del nervio facial durante la cirugía de la glándula parótida en servicios de otorrinolaringología - cirugía de cabeza y cuello.

INTRODUCTION: Facial nerve injury remains the most severe complication of parotid gland surgery. Due to the increasing evidence about the advantage of the use of intraoperative facial nerve monitoring, a survey was distributed among members of the Spanish Society of Otorhinolaryngology-Head and Neck Surgery with the objective of determining patterns of its use. MATERIAL AND METHODS: A questionnaire which included 12 separate questions in 3 sections was distributed via email through the official email of the Spanish Society of Otorhinolaryngology-Head and Neck Surgery. The first section of questions was in relation to demographic characteristics, the second section was related to the pattern of monitoring use and the third section referred to litigation related to facial palsy. RESULTS: 1544 anonymous questionnaires were emailed. 255 surveys were returned, giving an overall response rate of 16.5%. From these, 233 (91.3%) respondents perform parotid gland surgery. Two-hundred nineteen (94%) respondents use intraoperative facial nerve monitoring. Of the respondents,94% used intraoperative facial nerve monitoring if in their current practice they performed fewer than 10 parotidectomies per year and 93.8% if they performed more than 10 (OR, 1.02; 95% CI, 0.68-1.45; p=.991). With regard to lawsuits, just 3 (1.2%) of the respondents had a history of a parotid gland surgery-associated lawsuit and in just one case the facial nerve monitor was not used. CONCLUSION: Our data demonstrate that most otolaryngologists in Spain use intraoperative facial nerve monitoring during parotid gland surgery. Almost all of them use it to improve patient safety and consider that facial nerve monitoring should be helpful preventing inadvertent injury.

Timing of elective tracheotomy and duration of mechanical ventilation among patients admitted to intensive care with severe COVID-19: A multicenter prospective cohort study.

BACKGROUND: Optimal timing for tracheotomy for critically ill COVID-19 patients requiring invasive mechanical ventilation (IMV) is not established. METHODS: Multicenter prospective cohort including all COVID-19 patients admitted to intensive care units (ICUs) in 36 hospitals who required tracheotomy during first pandemic wave. With a target emulation trial framework, we studied the causal effects of early (7-10 days) versus late (>10 days) tracheotomy (LT) on time from tracheotomy to weaning, postoperative mortality, and tracheotomy complications. RESULTS: Of 696 patients, 20.4% received early tracheotomy (ET). ET was associated with faster weaning (hazard ratio [HR] [95% confidence interval, CI]: 1.25 [1.00-1.56]) without differences in mortality (HR [95% CI]: 0.85 [0.60-1.21]) or complications (adjusted rate ratio [95% CI]: 0.56 [0.23-1.33]). CONCLUSIONS: ET had a similar or lower post-tracheotomy weaning time than LT, potentially shortening IMV and ICU stays, without changing complication or mortality rates in COVID-19 patients.

Subjective evaluation of smell and taste dysfunction in patients with mild COVID-19 in Spain.

BACKGROUND: Has been described the loss of smell and taste as onset symptoms in SARS-CoV-2. The objective of this study was to investigate the prevalence in Spain. METHODS: Prospective study of COVID-19 confirmed patients through RT-PCR in Spain. Patients completed olfactory and gustatory questionnaires. RESULTS: A total of 1043 patients with mild COVID-19 disease. The mean age was 39 ±â€¯12 years. 826 patients (79.2%) described smell disorder, 662 (63.4%) as a total loss and 164 (15.7%) partial. 718 patients (68.8%) noticed some grade of taste dysfunction. There was a significant association between both disorders (p < 0.001). The olfactory dysfunction was the first symptom in 17.1%. The sQOD-NS scores were significantly lower in patients with a total loss compare to normosmic or hyposmic individuals (p = 0.001). Female were significantly more affected by olfactory and gustatory dysfunctions (p < 0.001). The early olfactory recover in 462 clinically cured patients was 315 (68.2%), during the first 4 weeks. CONCLUSION: The sudden onset smell and/or taste dysfunction should be considered highly suspicious for COVID-19 infection.

ANTECEDENTES Y OBJETIVO: En la infección por SARS-CoV-2 la pérdida repentina del olfato y/o gusto han sido descritas como síntomas iniciales. El objetivo principal de este estudio es conocer la prevalencia de estos síntomas en España. MATERIALES Y MÉTODOS: Estudio prospectivo de pacientes con COVID-19 confirmado mediante RT-PCR en España. Se utilizaron los cuestionarios traducidos y validados. RESULTADOS: Un total de 1043 pacientes COVID-19 leve. Edad media de 39 ±â€¯12 años. 826 pacientes (79,2%) refirieron algún grado de alteración del olfato, 662 (63,4%) pérdida total y 164 (15,7%) parcial. 718 pacientes (68,8%) notaron alteración del gusto. Hubo una asociación significativa entre ambos trastornos (p < 0,001). La disfunción olfatoria fue el síntoma inicial en el 17,1%. Las puntuaciones del sQOD-NS fueron significativamente menores en pacientes con una alteración total. Ambas alteraciones fueron proporcionalmente mayores en las mujeres (p < 0,001). De 462 pacientes clínicamente curados 315 (68,2%) recuperaron el olfato dentro de las primeras 4 semanas. CONCLUSIONES: La alteración repentina del olfato y el gusto debería ser reconocida como un síntoma de alarma de posible infección por COVID-19.

[Subjective evaluation of smell and taste dysfunction in patients with mild COVID-19 in Spain]. / Evaluación subjetiva de las alteraciones del olfato y del gusto en pacientes con afectación leve por COVID-19 en España.

BACKGROUND: Has been described the loss of smell and taste as onset symptoms in SARS-CoV-2. The objective of this study was to investigate the prevalence in Spain. METHODS: Prospective study of COVID-19 confirmed patients through RT-PCR in Spain. Patients completed olfactory and gustatory questionnaires. RESULTS: A total of 1043 patients with mild COVID-19 disease. The mean age was 39±12 years. 826 patients (79.2%) described smell disorder, 662 (63.4%) as a total loss and 164 (15.7%) partial. 718 patients (68.8%) noticed some grade of taste dysfunction. There was a significant association between both disorders (p<.001). The olfactory dysfunction was the first symptom in 17.1%. The sQOD-NS scores were significantly lower in patients with a total loss compare to normosmic or hyposmic individuals (p=.001). Female were significantly more affected by olfactory and gustatory dysfunctions (p<.001). The early olfactory recover in 462 clinically cured patients was 315 (68.2%), during the first 4 weeks. CONCLUSION: The sudden onset smell and/or taste dysfunction should be considered highly suspicious for COVID-19 infection.

Recommendations of the Spanish Society of Otolaryngology and Head and Neck Surgery for performing tracheotomies in patients infected by the coronavirus, Covid-19. / Recomendaciones de la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello para la realización de traqueotomías en relación con pacientes infectados por coronavirus COVID-19.

The recent COVID-19 (coronavirus) pandemic is causing an increase in the number of patients who, due to their pulmonary ventilatory status, may require orotracheal intubation. COVID-19 infection has demonstrated a high rate of transmissibility, especially via the respiratory tract and by droplet spread. The Spanish Society of Otolaryngology and Head and Neck Surgery, based on the article by Wei et al. of 2003 regarding tracheotomies performed due to severe acute respiratory syndrome (SARS), has made a series of recommendations for the safe performance of tracheotomies.

Strategies for the practice of otolaryngology and head and neck surgery during the monitoring phase of COVID-19. / Estrategias para la práctica de la otorrinolaringología y cirugía de cabeza y cuello durante la fase de control de la COVID-19.

The appearance of a new coronavirus disease called COVID-19 at the end of 2019 and its pandemic expansion in the world has changed the usual practice of the specialty of Otorhinolaryngology (ENT). After a phase of exponential growth of infections, it has been possible to enter a phase of control of the spread of the disease in which the possibility of infection persists, and the appearance of new cases is considered acceptable by the health system. The aim of this document is to review the available evidence and propose strategies and recommendations for the medical-surgical practice of otorhinolaryngology and head and neck surgery, which allow establishing the usual activity, adapting the safety and efficacy standards to the current situation. Therefore, it is required to identify and classify patients according to criteria of infectious-immunological status, and to establish recommendations for protection in consultations, hospitalization and the operating room, which avoid the transmission of the disease to other users and healthcare personnel, in the specific context of the development of our specialty. This document is the result of the collaboration of all the scientific commissions and the SEORLCCC COVID-19 committee.

[Strategies for the practice of otolaryngology and head and neck surgery during the monitoring phase of COVID-19]. / Estrategias para la práctica de la otorrinolaringología y cirugía de cabeza y cuello durante la fase de control de la COVID-19.

The appearance of a new coronavirus disease called COVID-19 at the end of 2019 and its pandemic expansion in the world has changed the usual practice of the specialty of Otorhinolaryngology (ENT). After a phase of exponential growth of infections, it has been possible to enter a phase of control of the spread of the disease in which the possibility of infection persists, and the appearance of new cases is considered acceptable by the health system.The aim of this document is to review the available evidence and propose strategies and recommendations for the medical-surgical practice of otorhinolaryngology and head and neck surgery, which allow establishing the usual activity, adapting the safety and efficacy standards to the current situation. Therefore, it is required to identify and classify patients according to criteria of infectious-immunological status, and to establish recommendations for protection in consultations, hospitalization and the operating room, which avoid the transmission of the disease to other users and healthcare personnel, in the specific context of the development of our specialty. This document is the result of the collaboration of all the scientific commissions and the SEORLCCC COVID-19 committee.

Systematic review of international guidelines for tracheostomy in COVID-19 patients.

At this moment, the world lives under the SARS-CoV-2 outbreak pandemic. As Otolaryngologists - Head & Neck Surgeons, we need to perform and participate in examinations and procedures within the head and neck region and airway that carry a particularly high risk of exposure and infection because of aerosol and droplet contamination. One of those surgical procedures in demand at this moment is tracheostomy due the increasing ICU admissions. This review of international guidelines for tracheostomy in COVID-19 infected patients, aims to summarize in a systematic way the available recommendations: indications, timing, technique and safety measures for tracheostomy, from all over the world.

[Consensus document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on tracheotomy in patients with COVID-19 infection]. / Documento de consenso de la Sociedad Española de Medicina Intensiva, Crítica, y Unidades Coronarias (SEMICYUC), la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) y la Sociedad Española de Anestesiología y Reanimación (SEDAR) sobre la traqueotomía en pacientes con COVID-19.

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

Executive summary of the SEORL CCC-SEEN consensus statement on post-thyroidectomy hypoparathyroidism. / Resumen ejecutivo del documento de consenso SEORL CCC-SEEN sobre hipoparatiroidismo postiroidectomía.

Hypoparathyroidism is the most common complication after total or completion thyroidectomy. It is defined as the presence of hypocalcemia accompanied by low or inappropriately normal parathyroid hormone (PTH) levels. Acute hypocalcemia is a potential lethal complication. Hypocalcemia treatment is based on endovenous or oral calcium supplements as well as oral calcitriol, depending on the severity of the symptoms. The risk of clinical hypocalcemia after bilateral thyroidectomy is considered very low if postoperative intact PTH decrease less than 80% with respect to preoperative levels. These patients could be discharged home without treatment, although this threshold may vary between institutions, and we recommend close surveillance in cases with increased risk (Graves disease, large goiters, reinterventions or evidence of parathyroid gland removal). Long-term treatment objectives are to control the symptoms and to keep serum calcium levels at the lower limit of the normal range, while preserving the calcium phosphate product and avoiding hypercalciuria.

Executive summary of the SEORL CCC-SEEN consensus statement on post-thyroidectomy hypoparathyroidism. / Resumen ejecutivo del documento de consenso SEORL CCC-SEEN sobre hipoparatiroidismo postiroidectomía.

Hypoparathyroidism is the most common complication after total or completion thyroidectomy. It is defined as the presence of hypocalcemia accompanied by low or inappropriately normal parathyroid hormone (PTH) levels. Acute hypocalcemia is a potential lethal complication. Hypocalcemia treatment is based on endovenous or oral calcium supplements as well as oral calcitriol, depending on the severity of the symptoms. The risk of clinical hypocalcemia after bilateral thyroidectomy is considered very low if postoperative intact PTH decrease less than 80% with respect to preoperative levels. These patients could be discharged home without treatment, although this threshold may vary between institutions, and we recommend close surveillance in cases with increased risk (Graves disease, large goiters, reinterventions or evidence of parathyroid gland removal). Long-term treatment objectives are to control the symptoms and to keep serum calcium levels at the lower limit of the normal range, while preserving the calcium phosphate product and avoiding hypercalciuria.