Endoscopic and External Dacryocystorhinostomy: Long Term Result from a Tertiary Center in Portugal.

Dacryocystorhinostomy is the gold-standard for distal lacrimal obstructions. This study aims to report the demography, clinical presentation, influence of agger nasi opening, uncinectomy and septoplasty, the use of silicone stent tubes, complications and success of endoscopic and external dacryocystorhinostomy over a period of 11 years. Retrospective review of clinical records, from January 2012 to December 2022, at a tertiary center in Portugal. A total of 249 procedures, 6 external and 243 endoscopic, were performed, including 39 revision cases. There was a female predominance (79.9%) with a mean age at diagnosis of 66.4 years. Recurrent acute dacryocystitis, reported by 33.3%, was associated with higher success (p = 0.053). Agger nasi opening, uncinectomy and septoplasty were performed in 17.7%, 6.0% and 15.3% respectively, although associated with higher success rates, no statistically significant difference was found. Minor complication rates for both external and endoscopic approach was 33.3% and 32.1% respectively. Functional and anatomical success was 100% and 83.3%, respectively, for external dacryocystorhinostomy, and 91.4% and 85.1%, respectively, for endoscopic dacryocystorhinostomy. Revision surgery was associated with a worse anatomical success (p = 0.05). Endoscopic dacryocystorhinostomy is an effective and safe alternative to the external approach. Minor procedures can increase the success rate, but multicentre studies need to be performed for a statistically significant result.

Relationship between the Presence of Nystagmus in the Fourth Position of the Epley Maneuver and Treatment Efficacy for PSC BPPV: A Prospective Study.

OBJECTIVE: To investigate whether a specific nystagmus observed during the Epley maneuver can enable immediate reassessment of patients, eliminating the need for deferred diagnosis. STUDY DESIGN: Prospective cohort. SETTING: Tertiary center. PATIENTS: Patients with posterior semicircular canal (PSC) benign paroxysmal positional vertigo (BPPV) diagnosed by the Dix-Hallpike test between March 2022 and March 2023. INTERVENTIONS: All patients were treated with the Epley maneuver. The presence and the characteristics of the nystagmus were recorded in each of the four intermediate positions of the maneuver. Fifteen minutes later, all patients were reevaluated with the Dix-Hallpike test to determine the therapeutic success. MAIN OUTCOME MEASURES: Outcome of the Epley maneuver and its relationship with nystagmus characteristics during the four positions of the maneuver. RESULTS: Sixty-six patients (77.3% female) were included in the study, of which 66.7% exhibited right PSC BPPV. Therapeutic success of the first Epley maneuver was 74.2%. Almost one third (30.3%) of patients presented with nystagmus in the second and third positions of the Epley maneuver. All patients with down-beating and torsional nystagmus toward the opposite direction of the diagnostic nystagmus in the fourth position of the Epley maneuver needed a second rehabilitative maneuver. None of the patients without nystagmus in this fourth position remained with active BPPV after the first Epley maneuver. CONCLUSIONS: The presence of nystagmus in the fourth position of the Epley maneuver appears to have a high predictive value, reducing waiting time for a second diagnostic maneuver. Its absence may exempt subsequent reevaluation.

[Translation, Cultural Adaptation and Contributions to the Validation of the Nijmegen Cochlear Implant Questionnaire (NCIQ) for European Portuguese]. / Tradução, Adaptação Cultural e Contributos para a Validação da Escala Nijmegen Cochlear Implant Questionnaire (NCIQ) para o Português Europeu.

INTRODUCTION: The Nijmegen Cochlear Implant Questionnaire (NCIQ) scale uses a simple and easily administered questionnaire to evaluate the adaptation of individuals to their cochlear implants. The aim of this study was to validate the NCIQ for European Portuguese, through its translation and cultural adaptation. It also presents the evaluation of reproducibility and the description of the results of this questionnaire in patients using IC. MATERIAL AND METHODS: Fifty postlingually deaf adult multichannel cochlear implant users (uni- or bilateral) participated in the study. Participants used the cochlear implant for at least 12 months and were patients of the Department of Otolaryngology at the Egas Moniz Hospital in Lisbon. Permission, as well the guidelines for translation, were obtained from the authors of the scale. Translation and cultural adaptation were carried out, in addition to the evaluation of reproducibility and internal consistency. RESULTS: The participants were 44.0% male and 56.0% female, aged between 20 and 79 years (55.50 ± 15.69). The results of the study showed an overall level of satisfaction of 65.07 among cochlear implants users. The level of satisfaction of the subdomains was 64.40 in basic sound perception, 71.35 in advanced sound perception, 57.91 in speech production, 59.05 in self-esteem, 69.75 in activity and 68.50 in social functioning. Internal consistency (Cronbach α score = 0.96) and test-retest reliability coefficients proved to be strong. Furthermore, the questionnaire's overall and subdomains average scores did not differ significantly from the results obtained with the original scale. CONCLUSION: This adaptation of the NCIQ questionnaire for European Portuguese should be considered a good tool to evaluate the level of satisfaction of cochlear implant users and, so far, it is the only scale in this field validated for application in the Portuguese population.

Introdução: O questionário Nijmegen Cochlear Implant Questionnaire (NCIQ) consiste numa escala simples e de rápida aplicação para avaliar a satisfação dos indivíduos que utilizam implantes cocleares. O objetivo deste estudo foi a validação do NCIQ para o Português Europeu e avaliação da qualidade de vida em adultos utilizadores de implantes cocleares. Material e Métodos: Participaram no estudo 50 adultos utilizadores de implante coclear multicanal (uni ou bilateral), com surdez pós-lingual, no mínimo com 12 meses de uso, implantados e seguidos no serviço de Otorrinolaringologia do Hospital Egas Moniz em Lisboa. Foram pedidas a autorização e as normas para a tradução do questionário aos autores da escala e realizada a tradução e retroversão do questionário, a adaptação cultural, e a avaliação da reprodutibilidade e da consistência interna. Resultados: Os participantes eram 44,0% do género masculino e 56,0% do feminino, com idades compreendidas entre os 20 e os 79 anos (55,50 ± 15,69). Os resultados obtidos neste estudo demonstraram um nível de satisfação global de 65,07 nos utilizadores de implantes cocleares. O nível de satisfação dos subdomínios foi de 64,40 na perceção básica do som, 71,35 na perceção avançada do som, 57,91 na produção da fala, 59,05 na autoestima, 69,75 na atividade e 68,50 nas interações sociais. A versão traduzida do questionário NCIQ apresentou uma boa consistência interna para todos os domínios existentes no questionário (α de Cronbach = 0,96). Verificou-se também uma boa reprodutibilidade inter-pesquisadores. Para a pontuação global e das subescalas do questionário, os resultados médios obtidos demonstraram não haver diferenças significativas com a escala original. Conclusão: A adaptação do Nijmegen Cochlear Implant Questionnaire para Português Europeu deve ser considerada um bom instrumento para a avaliação da satisfação dos utilizadores de implantes cocleares e é, até ao momento, a única escala neste domínio validada para aplicação na população portuguesa.

Paragangliomas da Cabeça e Pescoço: A Experiência de um Centro Oncológico do Sul da Europa.

INTRODUCTION: Paragangliomas are usually benign slow-growing tumors, but they are locally invasive and can cause significant morbidity. The aim of this study was to characterize the presenting symptoms, secretory status, genetics, imaging features, treatment modalities, post-treatment complications and survival of patients with head and neck paragangliomas treated at a single institution. MATERIAL AND METHODS: We retrospectively reviewed the clinical records of patients managed at our center between 1997 and 2020. RESULTS: Seventy-three patients were included in the study, encompassing 89 head and neck paragangliomas. Forty-eight patients (65.8%) were female and 15 (20.5%) had multiple tumor sites (including 10 patients with multicentric benign paragangliomas and five with disseminated malignant disease). Regarding location, our series encompassed 40 temporal bone paragangliomas (44.9%), 24 carotid body paragangliomas (27%), 22 vagal paragangliomas (24.7%), two laryngeal paragangliomas (2.2%) and one sinonasal paraganglioma (1.1%). Excessive catecholamine secretion was detected in 11 patients (15.1%). Sixty-four patients (87.7%) underwent genetic testing. Of those, 24 (37.5%) exhibited pathogenic succinate dehydrogenase complex germline mutations. Regarding patients who presented with untreated disease, 45 patients (66.2%), encompassing 55 tumors, underwent surgery as primary treatment modality, 20 (29.4%; 23 tumors) were initially treated with radiotherapy and three patients (4.4%, encompassing three solitary tumors) were kept solely under watchful waiting. Five-year overall survival was 94.9% and disease-free survival was 31.9%. CONCLUSION: Head and neck paragangliomas are rare, slow-growing but locally aggressive tumors resulting in high morbidity but low mortality rates.

Introdução: Os paragangliomas apresentam frequentemente um comportamento benigno e um crescimento indolente. Apesar disso, são localmente invasivos, podendo causar morbilidade significativa. O objetivo deste trabalho foi descrever as manifestações clínicas, atividade secretora, estudos genéticos e imagiológicos, modalidades terapêuticas, complicações e sobrevivência dos doentes com paragangliomas da cabeça e pescoço. Material e Métodos: Estudo retrospetivo dos doentes com paragangliomas da cabeça e pescoço observados num centro hospitalar terciário entre 1997 e 2020. Resultados: Foram incluídos no estudo 73 doentes, englobando 89 paragangliomas. Quarenta e oito doentes (65,8%) eram do sexo feminino e 15 (20,5%) apresentavam múltiplos focos tumorais (10 por multicentricidade e cinco por doença maligna disseminada). Foram incluídos 40 paragangliomas do osso temporal (44,9%), 24 tumores do corpo carotídeo (27%), 22 vagais (24,7%), dois laríngeos (2,2%) e um nasossinusal (1,1%). A secreção excessiva de catecolaminas foi detetada em 11 doentes (15,1%). Sessenta e quatro doentes (87,7%) foram alvo de teste genético. Desses, 24 (37,5%) exibiram mutações patogénicas do complexo succinato desidrogenase. Dos doentes com doença primária, 45 (66,2%; 55 tumores) foram submetidos a tratamento cirúrgico, 20 (29,4%; 23 tumores) a radioterapia e três (4,4%) ficaram sob vigilância. Aos cinco anos, a sobrevida global foi de 94,9% e a sobrevida livre de doença foi de 31,9%. Conclusão: Os paragangliomas da cabeça e pescoço são tumores raros, de crescimento lento, mas localmente agressivos que resultam em elevadas taxas de morbilidade, mas baixas taxas de mortalidade.

Lateral semicircular canal-BPPV: Prospective randomized study on the efficacy of four repositioning maneuvers.

INTRODUCTION: Multiple repositioning maneuvers have been described to treat lateral semi-circular canal Benign Paroxysmal Positional Vertigo (LC-BPPV) patients. In this study, we compare efficacy of four therapeutic repositioning maneuvers for LC-BPPV patients and aim to identify clinical variables associated with persistent disease. MATERIAL AND METHODS: A prospective study was conducted at a tertiary center, between January 2017 and September 2019. Patients diagnosed with LC-BPPV were randomly treated with Gufoni or barbecue-roll maneuvers (for the geotropic variant) and Gufoni-Appiani, barbecue-roll or Zuma-e-Maia maneuvers (for the apogeotropic form). Efficacy was compared and statistical analysis was performed to find clinical factors associated with no response. RESULTS: Forty-eight patients and 82 maneuvers were included. Female patients and right side were more commonly affected. The mean age was 67 years. Seven cases (14.6%) resulted from a canal-switch. One single maneuver resolved 23 cases (47.9%) and the success rate rose to 75% at the end of the first visit (after up to 4 maneuvers) and to 93.8% after a-week of follow-up. Success rates were significantly better with Gufoni (68%) than with barbecue roll (34.8%; p=0.021) in geotropic LC-BPPV and better with Gufoni-Appiani (71.4%) than barbecue roll and Zuma-e-Maia maneuvers (33.3%; p=0.239) in apogeotropic LC-BPPV. Higher rates of persistent disease after first visit were found with older patients, left side and apogeotropic LC-BPPV and with longer latency and duration diagnostic nystagmus. CONCLUSION: Our study suggests that Gufoni and Gufoni-Appiani maneuvers may be the most efficacious treatment for geotropic and apogeotropic LC-BPPV, respectively, compared to barbecue-roll and Zuma-e-Maia maneuvers.

Tracheostomy in COVID-19 Patients: Experience at a Tertiary Center in the First 11 Months of the Pandemic.

This study aimed to evaluate the experience of tracheostomy in COVID-19 patients in a Southern Europe tertiary hospital. Retrospective observational study in tracheostomized patients from April 1, 2020 to February 28, 2021. Data related to tracheostomy were evaluated in patients with and without COVID-19, including infections in healthcare professionals involved in patient care. Forty-two tracheostomies were performed in COVID-19 patients aged 68.4 ± 11.1 years, predominantly men (71%) and caucasians (81%). They had at least 1 comorbidity (93%), on average 3. The most frequent were heart disease (71%), age > 65 years (67%) diabetes (40%) and obesity (33%). The greater number of comorbidities was associated with the lesser probability of the patient's recovery (p = .001). Age (p = .047) and renal failure (p = .013) were associated with higher mortality. Patients were tracheostomized by prolonged endo-tracheal intubation (50%), pneumonia (33%) and extubation failure (10%). Ventilation time before the tracheostomy (22.9 ± 6.5 days) was higher than ventilation time after the tracheostomy (7.1 ± 15.1 days) (p < 0.001). No differences were found in ventilation time (p = 0.094) and tracheostomy time (p = 0.514) in the different indications. There were 3 minor complications (7.1%), 25 discharges (60%) and 11 deaths (26%). During the same period 49 tracheostomies were performed in patients without COVID-19, with a homogeneous gender and age distribution, 31% without comorbidities, with an average of 1 comorbidity per patient and higher mortality (43%). Tracheostomy in COVID-19 patients proved to be a safe procedure for both patients and healthcare professionals and improves the clinical outcome of patients with severe infection. The 21-day procedure timing seems adequate. Comorbidities played an essential role in patient´s recovery. Age and renal failure are associated with a worse vital prognosis.

Personality and psychopathology in Ménière's disease.

INTRODUCTION AND OBJECTIVES: Psychological factors in vertigo patients have been extensively studied but the role of anxiety and personality traits in the clinical course of Ménière's disease (MD) is unknown. The objectives of this study are to identify and characterize psychopathology in MD and to find risk factors for an increased rate and intensity of crisis and chronic symptoms. MATERIALS AND METHODS: We performed a transversal study in all patients diagnosed with definite MD in our department during a 5-year period. Sample subjects were interviewed in 3 steps: first, an otorhinolaryngologist collected information about clinical and pharmacological background of MD; second, a psychiatrist screened for mood, anxiety and personality disorders; in a third stage, the patient completed the DHI (Dizziness Handicap Inventory), STAI-Y (State Trait Anxiety Inventory), NEO-PI-R (Neo Personality Inventory Reviewed) and VAS (Visual Analogue Scale) for vertigo and dizziness. Statistical analysis was performed to search for risk factors for multiple and intense crisis and chronic symptoms. RESULTS: Thirty-four patients completed all 3 phases of the study. A predominant dysfunctional personality trait was identified in 80% of patients (predominantly cluster C type), 35% were being treated with psychiatric medication and 34.4% had a considerable mood or anxiety disorder. All patients scored high (>7) in VAS during crisis. There was a statistically significant positive correlation between crisis rate and STAI, anxiety-subscale (N1) in NEO-PI-R, VAS and DHI scores (p<.044). Crises were more common in bilateral MD (p=.041). DHI scores were higher with higher STAI and N1 (p=.001). Disease duration and pure tone average were found to have a positive moderate correlation (p=.017). CONCLUSIONS: The positive correlations between crisis rate, chronic dizziness and anxiety-related personality traits reveal a bidirectional and intimate relationship between personality, anxiety and MD, affecting these patients' quality of life. These results support the relevance of prospecting adjuvant psychological and psychiatric approaches to these patients.

Characterization of a Portuguese family with Charcot-Marie-Tooth disease type 1E due to a novel point mutation in the PMP22 gene.

INTRODUCTION: Point mutations in the Peripheral Myelin Protein 22 (PMP22) gene comprise less than 5% of the Charcot-Marie-Tooth (CMT) type 1 cases, and individualize either the CMT 1E subtype, or Hereditary Neuropathy with Liability to Pressure Palsy. The phenotype of CMT 1E presents with a severe early-onset polyneuropathy associated with deafness, although the clinical spectrum is broad. CASE REPORT: We describe a novel PMP22 gene point mutation (c.84G>T;p.(Trp28Cys)) in three patients of a Portuguese family with variable phenotypes, ranging from asymptomatic to mild complaints of distal limb numbness and gait difficulties, with the age of onset of symptoms ranging from mid-twenties to late-sixties, and no associated disability. In all affected patients, there was evidence of diffuse demyelinating sensorimotor polyneuropathy. Hearing loss does not seem to be associated with this variant, albeit neuropathic pain was reported. CONCLUSIONS: These findings suggest that this particular point mutation in the PMP22 gene is associated with a mild phenotype, further emphasizing that there are still unknown mechanisms (genetic and/or epigenetic) that may play a role in the clinical spectrum of CMT1E patients. Next generation sequencing panels including commonly mutated genes in CMT should be considered in CMT1 cases negative for PMP22 gene duplication.

Lateral semicircular canal-BPPV: Prospective randomized study on the efficacy of four repositioning maneuvers.

INTRODUCTION: Multiple repositioning maneuvers have been described to treat lateral semi-circular canal Benign Paroxysmal Positional Vertigo (LC-BPPV) patients. In this study, we compare efficacy of four therapeutic repositioning maneuvers for LC-BPPV patients and aim to identify clinical variables associated with persistent disease. MATERIAL AND METHODS: A prospective study was conducted at a tertiary center, between January 2017 and September 2019. Patients diagnosed with LC-BPPV were randomly treated with Gufoni or barbecue-roll maneuvers (for the geotropic variant) and Gufoni-Appiani, barbecue-roll or Zuma-e-Maia maneuvers (for the apogeotropic form). Efficacy was compared and statistical analysis was performed to find clinical factors associated with no response. RESULTS: Forty-eight patients and 82 maneuvers were included. Female patients and right side were more commonly affected. The mean age was 67 years. Seven cases (14.6%) resulted from a canal-switch. One single maneuver resolved 23 cases (47.9%) and the success rate rose to 75% at the end of the first visit (after up to 4 maneuvers) and to 93.8% after a-week of follow-up. Success rates were significantly better with Gufoni (68%) than with barbecue roll (34.8%; p=0.021) in geotropic LC-BPPV and better with Gufoni-Appiani (71.4%) than barbecue roll and Zuma-e-Maia maneuvers (33.3%; p=0.239) in apogeotropic LC-BPPV. Higher rates of persistent disease after first visit were found with older patients, left side and apogeotropic LC-BPPV and with longer latency and duration diagnostic nystagmus. CONCLUSION: Our study suggests that Gufoni and Gufoni-Appiani maneuvers may be the most efficacious treatment for geotropic and apogeotropic LC-BPPV, respectively, compared to barbecue-roll and Zuma-e-Maia maneuvers.

Personality and psychopathology in Ménière's disease.

INTRODUCTION AND OBJECTIVES: Psychological factors in vertigo patients have been extensively studied but the role of anxiety and personality traits in the clinical course of Ménière's disease (MD) is unknown. The objectives of this study are to identify and characterize psychopathology in MD and to find risk factors for an increased rate and intensity of crisis and chronic symptoms. MATERIALS AND METHODS: We performed a transversal study in all patients diagnosed with definite MD in our department during a 5-year period. Sample subjects were interviewed in 3 steps: first, an otorhinolaryngologist collected information about clinical and pharmacological background of MD; second, a psychiatrist screened for mood, anxiety and personality disorders; in a third stage, the patient completed the DHI (Dizziness Handicap Inventory), STAI-Y (State Trait Anxiety Inventory), NEO-PI-R (Neo Personality Inventory Reviewed) and VAS (Visual Analogue Scale) for vertigo and dizziness. Statistical analysis was performed to search for risk factors for multiple and intense crisis and chronic symptoms. RESULTS: Thirty-four patients completed all 3 phases of the study. A predominant dysfunctional personality trait was identified in 80% of patients (predominantly cluster C type), 35% were being treated with psychiatric medication and 34.4% had a considerable mood or anxiety disorder. All patients scored high (>7) in VAS during crisis. There was a statistically significant positive correlation between crisis rate and STAI, anxiety-subscale (N1) in NEO-PI-R, VAS and DHI scores (p<.044). Crises were more common in bilateral MD (p=.041). DHI scores were higher with higher STAI and N1 (p=.001). Disease duration and pure tone average were found to have a positive moderate correlation (p=.017). CONCLUSIONS: The positive correlations between crisis rate, chronic dizziness and anxiety-related personality traits reveal a bidirectional and intimate relationship between personality, anxiety and MD, affecting these patients' quality of life. These results support the relevance of prospecting adjuvant psychological and psychiatric approaches to these patients.

Contralateral occlusion test: The effect of external ear canal occlusion on predicting conductive hearing loss.

INTRODUCTION AND OBJECTIVES: The contralateral occlusion test (COT) has the potential to allow the quantitative evaluation of unilateral conductive hearing loss. The purpose of this study was to determine the accuracy of the test in predicting the degree of hearing loss. MATERIALS AND METHODS: Fifty-three subjects with unilateral conductive hearing loss were recruited from an otolaryngology department of a tertiary hospital. The COT was performed using 128, 256, 512, 1024 and 2048Hz tuning forks with the non-affected ear canal totally occluded to determine lateralization. Pure-tone audiometry was performed to establish the presence and degree of the air-bone gap (ABG) and the pure-tone average (PTA). The tuning fork responses were correlated with the ABG and the PTA to determine their accuracy. RESULTS: The COT showed a better association between hearing loss and the lateralization response using the 512Hz tuning fork (p=0.001). The sensitivity of the 512Hz fork in detecting a PTA of at least 35.6dB was 94.6% and the specificity was 75.0% for a positive predictive value of 89.7% and a negative predictive value of 85.7%, assuming a pretest prevalence of 69.8%. CONCLUSIONS: The overall accuracy of the COT in predicting the degree of unilateral conductive hearing loss was significant. The COT had significant power in one direction: if lateralization to the affected ear occurred, it was almost certain evidence of a moderate or severe conductive hearing loss.

Contralateral Occlusion Test (COT): the effect of external ear canal occlusion with aging.

PURPOSE: This study aimed to evaluate the effects of complete external ear canal occlusion on hearing thresholds with aging. The goal was to decide which tuning fork is more appropriate to use for the contralateral occlusion test (COT), in individuals of different ages. METHODS: Forty-two normal hearing subjects between 21 and 67 years were divided into three age groups (20-30 years, 40-50 years, and 60-70 years). Participants underwent sound field audiometry tests with warble tones, with and without ear canal occlusion. Each ear was tested with the standard frequencies (250, 500, 1000, and 2000 Hz). The contralateral ear was suppressed by masking. RESULTS: Hearing thresholds showed an increase as the frequency increased from 20.85 dB (250 Hz, 20-30 years group) to 48 dB (2000 Hz, 60-70 years group). The threshold differences between occlusion and no occlusion conditions were statistically significant and increased ranging from 11.1 dB (250 Hz, 20-30 years group) to 32 dB (2000 Hz, 20-30 years group). We found statistically significant differences for the three age groups and for all evaluations except to 500 Hz difference and average difference. The mean hearing loss produced by occlusion at 500 Hz was approximately 19 dB. We found no statistically significant differences between right and left ears and gender for all measurements. CONCLUSION: We conclude that the use of the 512 Hz tuning fork is the most suitable for COT, and its use may allow clinicians to distinguish mild from moderate unilateral conductive hearing loss.

Contralateral Occlusion Test (COT): the effect of external ear canal occlusion with aging / Teste de Oclusão Contralateral (TOC): o efeito da oclusão do canal auditivo externo com a idade

ABSTRACT Purpose This study aimed to evaluate the effects of complete external ear canal occlusion on hearing thresholds with aging. The goal was to decide which tuning fork is more appropriate to use for the contralateral occlusion test (COT), in individuals of different ages. Methods Forty-two normal hearing subjects between 21 and 67 years were divided into three age groups (20-30 years, 40-50 years, and 60-70 years). Participants underwent sound field audiometry tests with warble tones, with and without ear canal occlusion. Each ear was tested with the standard frequencies (250, 500, 1000, and 2000 Hz). The contralateral ear was suppressed by masking. Results Hearing thresholds showed an increase as the frequency increased from 20.85 dB (250 Hz, 20-30 years group) to 48 dB (2000 Hz, 60-70 years group). The threshold differences between occlusion and no occlusion conditions were statistically significant and increased ranging from 11.1 dB (250 Hz, 20-30 years group) to 32 dB (2000 Hz, 20-30 years group). We found statistically significant differences for the three age groups and for all evaluations except to 500 Hz difference and average difference. The mean hearing loss produced by occlusion at 500 Hz was approximately 19 dB. We found no statistically significant differences between right and left ears and gender for all measurements. Conclusion We conclude that the use of the 512 Hz tuning fork is the most suitable for COT, and its use may allow clinicians to distinguish mild from moderate unilateral conductive hearing loss.

RESUMO Objetivo O objetivo deste estudo foi avaliar o efeito da oclusão completa do canal auditivo externo nos limiares auditivos, em indivíduos de idades distintas, para apurar qual o diapasão mais adequado na realização do teste de oclusão contralateral (TOC). Método 42 indivíduos normo-ouvintes (21-67 anos) foram divididos em três grupos etários (20-30, 40-50 e 60-70 anos). Os participantes foram avaliados com testes de audiometria tonal liminar em campo livre, com e sem oclusão completa do canal auditivo externo. Cada ouvido foi testado para as frequências 250, 500, 1000 e 2000 Hz. No ouvido contralateral, foi realizado mascaramento, para evitar a ocorrência de audição contralateral. Resultados Verificou-se aumento dos limiares auditivos, diretamente proporcional ao aumento da frequência (desde 20.85 até 48 dB). A diferença nos limiares auditivos entre a condição de oclusão e de não oclusão foi estatisticamente significativa em todas as frequências e aumentou de forma diretamente proporcional com a frequência (desde 11.1 até 32 dB). Foram também encontradas diferenças estatisticamente significativas para os três grupos etários, em todos os parâmetros, exceto na diferença a 500 Hz e na diferença total média. A perda auditiva média resultante da oclusão aos 500 Hz foi de 19 dB. Não se encontraram diferenças estatisticamente significativas entre o ouvido direito e o esquerdo, e entre o gênero. Conclusão A utilização do diapasão de 512 Hz é a mais adequada para o TOC. A sua utilização pode permitir aos clínicos, em ambiente de consulta e de forma rápida, a distinção entre perda condutiva de grau leve a moderada.

Epidemiology of epistaxis in the emergency department of a southern European tertiary care hospital.

OBJECTIVE: Epistaxis is the most common rhinological emergency seen in the emergency department. The purpose of this study was to evaluate epidemiological data of epistaxis in a southern European tertiary care hospital. METHODS: A retrospective study was conducted during the period between January 2009 and December 2015. We analyzed the distribution by cross-referencing the demographic variables, destination after medical discharge, inpatient characteristics (major comorbid diseases, medication, bleeding localization and treatment) and health-care costs with the disease. RESULTS: Epistaxis accounted for approximately 1 in 30 visits to the ED and 77 out of a population of 100,000 was served by that ED. Overall, 71,624 patients were treated and 2371 patients presented with epistaxis (3.31%). One-thousand three-hundred and twenty-seven cases were male and 1044 female (p <.001). The mean age was 56 years (±26). Age distribution was bimodal, with peaks among those <10 years and >70 (p <.001). Epistaxis was more common in the winter months (p < 0.001). The main referral destinations (6.8%) included outpatient (2.9%) and inpatient (1.9%) services. Hospitalization was more frequent between the ages of 60 and 80 years (p =.029), and the major comorbidity was hypertension (47.8%). Medication interfering with haemostasis was documented in 30.4%. Most inpatient epistaxis was managed in a non-interventional manner and only. 5% of patients needed surgery. The mean total health-care cost was 69.8 € per episode. CONCLUSION: Emergency epistaxis was more frequent in men, the elderly, patients with underlying comorbidities, during the winter months, and showed a higher risk of referral and hospitalization with increasing age (as a result of an aging population in western countries). The main hospital expenses for epistaxis are related to hospitalization and health care costs.