Skin and soft tissue complications of bone-anchored hearing aids: Introducing a new classification system.

OBJECTIVES: There have been significant surgical and technological advances in bone-anchored hearing aid (BAHA) design, function, and implantation technique, but peri-implant skin complications remain the most frequent complication. The most important aspect in dealing with cutaneous complications is to identify the type of cutaneous lesion. Although Holger's Classification has been an extremely useful clinical tool, this grading system has been shown to be unsuitable for some cases. We therefore propose a new consistent and easy assessment classification of cutaneous complications associated with BAHA. METHODS: A retrospective clinical study was carried out at a tertiary centre, between January 2008 and December 2014. All patients under 18 years old with a unilateral BAHA were included in the study. RESULTS: A total of 53 children, with a BAHA, were included in the study. Post-operative skin complications were observed in 49.1% of the patients. Of the children, 28.3% presented with soft tissue hypertrophy, the most frequently reported skin complication, and grading according to the Holger's classification was not considered feasible. To overcome the difficulties we face in clinical practice, a new classification was developed and presented. CONCLUSION: The new proposed classification - Coutinho Classification - aims to fill the gaps in the one used currently by introducing new clinical features, most importantly the presence/absence of tissue overgrowth, and by providing a better description of what each category encompasses. This is an inclusive and objective new classification system, maintaining applicability, and useful in guiding the treatment.

Unilateral Vocal Fold Paralysis and Voice Therapy: Predictors of Long-Term Quality of Life.

To date, little is known about the long-term predictors of quality of life (QoL) in unilateral vocal fold paralysis (UVFP). The main objective of this study was to evaluate the predictors of long-term QoL in UVFP patients submitted to voice therapy (VT) exclusively. Data from patients diagnosed with UVFP who followed a VT program between 2013 and 2019 were reviewed. Video laryngoscopy (VL) records were obtained at the beginning and at the end of VT. To assess QoL, Voice Handicap Index 30 (VHI-30) score was assessed in three temporal frames: before voice therapy (pre-VT), at the last VT session (post-VT), and in the present (cur-VHI). A longitudinal analysis was performed regarding the evolution of QoL and the factors influencing QoL through time were analyzed. Seventy-eight percent of patients had iatrogenic UVFP. The mean time of follow-up after VT was 3.942 years (range 6 months-7 years). There was a significant improvement in QoL through all time points (F (2,88)=72.179, p<0.001), with VHI-30 decrease from the baseline pre-VT to post-VT(p<0.001) and from post-VT to cur-VT (p=0.0013). In the iatrogenic UVFP population, patients starting VT earlier showed better long-term QoL (p=0.023). UVFP patients with dysphagia at presentation showed significantly worse QoL in the late follow-up (p=0.016). Hence, iatrogenic UVFP patients beginning VT rapidly may show better QoL in the future. Also, our results suggest that dysphagia at UVFP onset may predict higher morbidity later in life.

Nasopharyngeal Approach to a Cholesterol Granuloma of the Petrous Apex.

Cholesterol granulomas are rare cystic inflammatory lesions characterized by the formation of cholesterol crystals. They are the most prevalent lesions of the petrous apex and when symptomatic, hearing loss, vertigo, tinnitus, headache, and facial pathology can be present. Surgical management is recommended in symptomatic patients. There are different surgical approaches to cholesterol granulomas. The aim of this article is to present and describe an endoscopic endonasal nasopharyngeal approach to a cholesterol granuloma and explain the advantages and disadvantages.

Presbylarynx: Is It a Sign of the Health Status of the Elderly?

PURPOSE: Only a full understanding of how different diseases affect the same or different anatomical/functional entities, may provide a clue on how comorbidity should be taken into consideration. The aim of this study was to evaluate the chronic medical illnesses of an elderly population, in order to analyze potential correlation of specific comorbidities with presbylarynx. METHODS: This case-control, prospective, observational, and cross-sectional study was carried out on consecutive subjects observed by otorhinolaryngology, in a tertiary center, from January to September 2020. The inclusion criteria were ability to report an accurate medical history and ≥65 years of age. The exclusion criteria were neurologic diagnoses, autoimmune disease, history of thoracic or head and neck surgery, cancer, radiotherapy, thyroid pathology, vocal fold mass lesions, acute laryngitis, or vocal fold paralysis. Based on videostroboscopy of the larynx, the patients were subdivided into two main groups: presbylarynx versus no presbylarynx. Health status was assessed by evaluation of chronic medical illnesses (individual diagnoses of chronic conditions plus Charlson comorbidity index [CCI]), functional status (Katz index of independence in activities of daily living and functional Ambulation ambulation classification), and emotional status (Geriatric Depression Scale). RESULTS: A total of 174 subjects (60 males; 114 females) were included (mean age = 73.99 years; range 65-95 years). Presbylarynx was identified in 71 patients (41%). A statistically significant difference was found concerning diabetes mellitus type 2 (T2DM); P< 0.001), asthma or chronic obstructive pulmonary disease (COPD; P< 0.001), and psychiatric disorder (P< 0.001). The mean score of CCI between "presbylarynx" and "no presbylarynx" groups was statistically different (P= 0.021). Results showed an association between some functional dependence (P< 0.001), and mild or severe depression (P< 0.001) and the presence of presbylarynx. CONCLUSIONS: Presbylarynx may be considered a sign of the health status of the elderly. Based on CCI, It was found that patients with higher probability of 10-year mortality exhibit more endoscopic signs of presbylarynx. It was also found that patients with better scores in functionality scales exhibited less endoscopic findings compatible with presbylarynx. Among chronic medical illnesses, T2DM, asthma, or COPD may be considered risk factors for noticeable endoscopic signs of presbylarynx.

Presbylarynx: validation of a classification based on morphological characteristics.

PURPOSE: Validation of a classification to stratify presbylarynx into three types. METHODS: Evaluate the reproducibility of this classification. 30 video recordings of rigid laryngostroboscopies were presented to 20 otorhinolaryngologists from five tertiary hospitals: 10 residents and 10 specialists. Specialists with different differentiations were included. RESULTS: Among 1200 evaluations performed (30 video recordings × 20 raters, twice), average intra-rater agreement rate was 0.847 (p < 0.001). The average inter-rater reliability was 0.67 ± 0.179 on the first evaluation, and 0.691 ± 0.131 on the second evaluation. CONCLUSIONS: This study presented the validation of a classification that allows stratifying laryngeal endoscopic signs in elderly patients with presbyphonia. We believe that this classification will enrich the diagnostic protocol of the aging voice and will improve the documentation of treatment outcomes.

Impact of adenotonsillectomy in pediatric respiratory function.

INTRODUCTION: Adenotonsillar hypertrophy (ATH) is an important health condition that leads to upper airway obstruction and constitutes the main cause of obstructive sleep disordered breathing (OSDB) in children. The aim of this study was to analyze the effect of surgical intervention on spirometrical parameters of children with ATH/OSDB and upper airway recurrent infections (URTIs). MATERIAL AND METHODS: The study covered children treated surgically in a Pediatric Ambulatory Unit in a tertiary hospital. Spirometric tests were performed before and three months after surgery and results were compared. RESULTS: A total of 78 children were enrolled with a mean age of 6.95 ±â€¯2,81 years. There was a significant improvement in forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), peak expiratory flow (PEF) and forced expiratory flow rate at 25% (F25) values after surgery in children suffering from OSDB (FVC pre: 1.52 ±â€¯0.47 L vs FVC post: 1.85 ±â€¯0.63 L, p < 0.001; FEV1 pre: 1.24 ±â€¯0.38 L vs FEV1 post: 1.39 ±â€¯0.40 L, p = 0.014; PEF pre: 2.04 ±â€¯0.85 L/s vs PEF post: 2.33 ±â€¯0.76 L/s, p = 0.014; F25 pre: 1.77 ±â€¯0.77 L/s vs F25 post: 2.02 ±â€¯0.73 L/s, p = 0.030). On a multivariate analysis model, preoperative tonsil size and performing tonsillectomy were the most significant determinants of improvement in spirometric values (p < 0.05). Children with isolated adenoid hypertrophy without tonsillar obstruction and those with URTIs alone did not show relevant differences in spirometric values after surgery (p > 0.05). No significant differences were found concerning pre-operative and post-operative forced expiratory flow rate at 75% (F75) and forced expiratory flow between 25 and 75% of the pulmonary volume (FEF25-75%) in any group (p > 0.05). CONCLUSIONS: Surgery seems effective in ameliorating spirometry values in patients with OSDB and ATH, namely FVC, FEV1, PEF and F25. Spirometry may give a clue on the importance of adequate surgical resolution of pediatric lymphoid hypertrophy obstruction. No significant differences exist on spirometric parameters of children with isolated adenoid hypertrophy and URTIs without ATH. Further studies are needed in order to evaluate the potential benefit of spirometry utilization in the daily clinical setting.

Geriatric otorhinolaryngology: reasons for outpatient referrals from generalists to ENT specialists.

PURPOSE: To determine the main symptoms leading to referral of geriatric patients from primary care to otorhinolaryngology. METHODS:  Retrospective, observational study performed on patients aged 65 and older, referred from Primary Care to the Otorhinolaryngology and Head and Neck Surgery department of a tertiary centre during 2019 and 2020. Symptoms leading to otorhinolaryngological referral were categorized as "Oto-neurological symptoms", "Nasal symptoms", "Pharyngolaryngeal symptoms", "Other Head and Neck symptoms" and "Other Reasons". Data regarding age, gender and whether patients maintain follow-up or have been discharged was also collected. RESULTS:  The study population included a total of 1304 patients (697 female; 607 male). Oto-neurological symptoms were found to be the most prevalent symptoms, with 65% of patients reporting oto-neurological symptoms as at least one of the reasons for referral. Hearing loss was the most commonly reported symptom, with an association found between this symptom and age (p < 0.001). Results also showed an association between the female gender and vertigo/dizziness (p < 0.001) and tinnitus (p = 0.007). An association between the male gender and nasal symptoms was also found (p = 0.018), particularly nasal obstruction (p = 0.003) and epistaxis (p = 0.028). No statistically significant associations were found among the pharyngolaryngeal group. CONCLUSIONS:  This retrospective observational study allowed for a better understanding of the type of otorhinolaryngological symptoms affecting elderly patients and driving otorhinolaryngology evaluation, cementing hearing loss as one of the major complaints among older adults and allowing for a better preparation by otorhinolaryngologists for the changing needs of this subset of the population.

Clues for facial canal dehiscence in chronic otitis media.

INTRODUCTION AND OBJECTIVES: The goal of this study was to determine the impact of external and middle ear findings in the incidence of facial canal dehiscence (FCD) during mastoidectomy for chronic otitis media. MATERIAL AND METHODS: We examined the operative details of 186 patients who underwent primary tympanomastoidectomy for chronic otitis media between January 2015 and January 2020 retrospectively. In this study we only evaluated the second portion of the facial nerve canal. RESULTS: The global prevalence of FCD was 22.6% (42/186 patients) with a higher incidence, of 38.7% (36/93), in patients with chronic otitis media with cholesteatoma (C-COM). Associations were found between facial canal dehiscence, labyrinthine fistula (p˂ .001) and facial nerve paralysis (p˂ .001). Ossicular erosions were observed at a significant level in patients with facial canal dehiscence, the incidence of FCD was significantly higher (p=.005, Odds ratio 5.489) when malleus and incus were eroded, incus plus stapes were eroded (p=.014; OR 4.059) and malleus, incus, and stapes together were eroded (p=.002; OR 4.929). CONCLUSIONS: This study revealed an incidence of facial canal dehiscence of 22.6%. It also revealed that the presence of lateral semicircular canal fistula is associated with a higher prevalence of facial canal dehiscence. The same was noted in the case of some ossicular erosions, especially the combinations of eroded malleus and incus, incus and stapes, and all 3 ossicles. These findings raise awareness about the usefulness of middle ear findings in predicting FCD, thus providing valuable information for the otological surgeon to avoid iatrogenic injuries.

Presbylarynx: How Easy Is It To Recognize The Aging Signs? A Prospective Study With Inter- And Intra-Rater Reliability In Laryngoscopic Evaluation.

PURPOSE: To determine if recognition of presbylarynx is easy and straightforward. METHOD: First, a systematic review regarding the structural features of the geriatric larynx through laryngostroboscopy was performed, and its results were presented to the raters in an educational session. Then, video recordings of rigid laryngostroboscopies were randomly selected and presented to a panel of otorhinolaryngologists. Intra- and inter-rater reliability were determined. RESULTS: Based on the main findings of the systematic review, raters were invited to consider the diagnosis of presbylarynx when one or more of the following endoscopic signs were present: atrophic vocal folds (VF), VF bowing, prominence of vocal processes, or spindle-shaped glottal gap. Twenty otorhinolaryngologists from five tertiary hospitals participated in this study (residents and specialists). Among 300 evaluations performed (15 video recordings x 20 raters), the intra-rater agreement was 93.0%. The Cohen´s Kappa for intra-rater reliability was higher than 0.600 for all the raters except for two residents. Cohen´s Kappa was higher among specialists (0.893) than among residents (0.826). The highest Cohen´s Kappa was registered for evaluations performed by specialists with differentiation in laryngology (0.933). Presbylarynx was identified mostly in laryngostroboscopic recordings of subjects older than 65 years. CONCLUSION: we consider the answer to "Presbylarynx: How easy is it to recognize the aging signs" to be "After education on signs of presbylarynx, it is easy." This answer is supported by the high rate of intra- and inter-rater agreement, in a blinded and randomized presentation of laryngostroboscopic recordings, and by the fact that the diagnosis of presbylarynx was mostly attributed to videos regarding subjects aged 65 years and older. It proves that is not difficult to recognize aging signs in the larynx. Thus, in the future, more education regarding presbylarynx and further studies to improve criteria for its diagnosis may improve the management of the aging voice.

The Spare Roof Technique as a New Approach to the Crooked Nose.

Background: The literature reporting outcomes in crooked nose patients submitted to surface dorsal preservation techniques is almost nonexistent. Objectives: To evaluate aesthetic and functional outcomes in crooked nose patients undergoing rhinoplasty with the Spare Roof Technique (SRT). Methods: Prospective, interventional, and longitudinal study performed on patients presenting a crooked nose undergoing primary rhinoplasty by SRT. The validated Portuguese version of the Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty and a visual analog scale were used to assess aesthetic and functional outcomes, respectively. Patients completed the questionnaire preoperatively and again 3 and 12 months postoperatively. Results: The study population included 54 Caucasian Mediterranean patients (34 female), mean aged 34.5 years. The SRT resulted in a highly significant improvement in all questions regarding subjective body image in relation to nasal appearance and subjective nasal function. The mean preoperative aesthetic Utrecht Questionnaire sum score was 13.4 (standard deviation [SD] 0.5), which improved to 9.2 (SD 0.15) at 12 months postsurgery (p < 0.001). Conclusions: The SRTa is a reliable technique that can help deliver consistently good results in reduction rhinoplasty in patients with a crooked nose.

Hearing rehabilitation with osseointegrated hearing implant in bilateral congenital external auditory canal atresia.

INTRODUCTION AND OBJECTIVES: Congenital atresia of the external auditory canal (EAC) is a congenital defect present in one in every 10,000-20,000 births. It causes conductive hearing loss, with an air-bone gap of 50-60dB. Early amplification is essential in bilateral cases to ensure normal language development. The aim of this study is to present the osseointegrated hearing implant as a treatment for bilateral EAC atresia, reviewing the audiometric results and the rate of complications. MATERIAL AND METHODS: Retrospective analysis of patients diagnosed with bilateral congenital EAC atresia under follow-up in the pediatric ENT clinic of the ENT and Head and Neck Surgery department of a Portuguese Tertiary Hospital, between 2003 and 2019. We reviewed the medical records and collected information on the assessment of the initial audiometric status. In the cases submitted for implantation with an osseointegrated hearing implant, we analyzed the details of follow-up, including immediate and long-term post-operative complications, as well as the audiometric results. RESULTS: We present 8 pediatric patients, 6 girls and 2 boys, with a diagnosis of bilateral congenital EAC atresia. The audiometric assessment revealed moderate to severe bilateral conductive hearing loss with a mean speech recognition threshold (SRT) of 51dB. Six patients underwent osseointegrated hearing implantation. All 6 patients showed good audiometric results, with an average SRT of 20dB and closure of the air-bone gap. CONCLUSIONS: The osseointegrated hearing implant was an effective treatment option in these patients, without significant morbidity or complications. Osseointegrated hearing implantation should be considered first line treatment for children with bilateral congenital EAC atresia, as it presents good functional results and a high level of patient satisfaction.

The Caucasian Hump: Radiologic Study of the Osteocartilaginous Vault versus Surface Anatomy. Clinical Implications in Structured and Preservation Rhinoplasty.

BACKGROUND: The relation between the osteocartilaginous nasal vault and nasal hump characteristics has not been fully investigated. METHODS: Measurements were collected from computed tomographic nasal scans in the midsagittal plane in adult Caucasian patients seeking rhinoplasty because of nasal hump from January of 2015 to December of 2018. Measurements were compared to those of sex- and age-matched patients not seeking rhinoplasty (control group). Patients with other significant nasal deformities were excluded. The correlations between nasal hump length, height, and osteocartilaginous nasal vault measurements were assessed. Distances from the beginning of the nasal hump to the kyphion and ethmoidal points were measured as well. The location of the nasal hump apex in relation to the keystone area structures was detailed. RESULTS: The study included 134 Caucasian patients, with 67 presenting nasal hump. The mean patient age was 32.9 years and 69.6 percent were female patients. Nasal hump measured a mean 17 ± 2.7 mm in length and 1.8 mm (range, 1.1 to 3.8 mm) in height. Nasal hump length correlated with nose length and nasal bone length. Nasal hump height correlated with nose length and the angle over the kyphion. In 97 percent of patients, the nasal hump began caudal to the ethmoidal point, and in all patients, the kyphion was underneath the nasal hump. The nasal hump is not a symmetric structure and, in all patients, its apex was situated above the septal cartilage. CONCLUSIONS: The nasal hump characteristics are mainly attributable to the septal cartilage, and this should be the cornerstone of any dorsal hump reduction strategy. The caudal aspect of the nasal bones contributes to the nasal hump, whereas the posterior ethmoidal plate rarely does.

SARS-CoV-2 and hearing: An audiometric analysis of COVID-19 hospitalized patients.

PURPOSE: COVID-19 associated hearing loss is still an ongoing matter of debate. No original studies exist on audiological effects of SARS-CoV-2 infection in hospitalized patients. The main objective was to determine whether SARS-CoV-2 may affect auditory function in clinically ill COVID-19 patients. MATERIALS AND METHODS: COVID-19 patients with moderate-severe disease and without prior history of hearing abnormalities were enrolled from a tertiary referral center, and matched with controls. Participants performed an audiometric evaluation, and thresholds were compared. RESULTS: 120 ears from 60 patients were enrolled. Patients with COVID-19 showed worse mean auditory thresholds starting from 1000 Hz through higher frequencies, when compared to controls (1000 Hz: 18.52 ± 5.49 dB HL in controls vs 25.36 ± 6.79 dB HL in COVID-19, p < 0.001; 2000Hz: 17.50 ± 5.57 dB HL in controls vs 21.96 ± 7.05 dB HL in COVID-19, p = 0.010; 3000Hz: 17.97 ± 8.07 dB HL in controls vs 25 ± 9.38 dB HL in COVID-19, p = 0.003; 4000 Hz: 20.16 ± 10.12 dB HL in controls vs 29.55 ± 11.26 dB HL in COVID-19, p = 0.001; 8000 Hz: 31.09 ± 12.75 dB HL in controls vs 40.71 ± 19.40 dB HL in COVID-19, p = 0.030; Pure Tone Average: 20.42 ± 4.29 dB HL in controls vs 24.85 ± 5.62 dB HL in COVID-19, p = 0.001). Statistical significance persisted after adjusting for confounders such as age, gender and various comorbidities (p < 0.05). CONCLUSIONS: SARS-CoV-2 may affect hearing in COVID-19 patients with moderate-severe disease. Results are in line with the previous suggested effects of COVID-19 on auditory system. This study is expected to encourage further research on this topic.

Unilateral Vocal Fold Paralysis and Voice Therapy: Does Age Matter? A Prospective Study With 100 Consecutive Patients.

OBJECTIVE: To use a multidimensional assessment to analyze potential influence of "aging" in the functional outcomes achieved by a group of patients with recent onset of unilateral vocal fold paralysis (UVFP) who underwent voice therapy. DESIGN: Prospective, observational, and cross-sectional study. SETTING: Otolaryngology department, Centro Hospitalar do Porto. PARTICIPANTS: Patients with UVFP who underwent voice therapy. MAIN OUTCOME MEASURES: Data regarding gender, age, side and position of the paralyzed vocal fold, etiology, comorbidities, and Voice Handicap Index (VHI)-30 questions, before and after voice therapy, were collected. Glottal insufficiency was also evaluated, by endoscopic laryngoscopy, before and after voice therapy. RESULTS: A total of 100 patients (76 females and 24 males) with UVFP were included. Mean age was 61.04 years (range: 21-88 years). The mean score of VHI, before and after voice therapy, was statistically different (P < .001) with a lower score after therapy. The score of VHI was not influenced by age (P = .717). However, for each 10-year increase in age, the score of VHI, before and after voice therapy, increased 1.91 and 2.86 units, respectively. As concerns endoscopic findings, 80% of patients exhibited better glottis closure after voice therapy (P < .001), and this was not influenced by age. Nevertheless, for each 10-year increase in age, the chance of endoscopic improvement reduced 3%. CONCLUSIONS: A clear and significant improvement was visible in the endoscopic and self-assessment ratings after rehabilitation by isolated voice therapy. Despite possible anatomical and physiological aging changes in the phonatory system, age did not compromise the successful rate obtained by voice therapy.

Shaved Cartilage Gel Versus Diced Cartilage on Final Dorsal Camouflage: Prospective Study of 200 Patients.

Importance: Diced cartilage (DC) is a reported technique that has been used for dorsal camouflage after reduction rhinoplasty. Nevertheless, there are certain issues regarding its use on nasal dorsum, especially its variable resorption rate and risk of graft distortion or migration, especially in thin-skinned patients. Recently, regenerative medicine protocols have been used to overcome drawbacks of methods based on DC. Thus, cartilage embedded in platelet-rich fibrin (PRF) has been described as a promising and reliable alternative to existing procedures. Objective: To compare long-term aesthetic outcomes of two different techniques for dorsal camouflage: DC versus shaved cartilage plus platelet-rich fibrin (SC+PRF)-shaved cartilage gel. Design, Setting, and Participants: This is a prospective, interventional, and longitudinal study at an academic tertiary medical center. Participants were 200 consecutive patients undergoing primary reduction rhinoplasty by spare roof technique (SRT) or component dorsal reduction (CDR). Materials and Methods: The inclusion criteria were primary rhinoplasty, in Caucasian patients with dorsal hump, and camouflage of the dorsum by DC or SC+PRF. Exclusion criteria were ≤18 years of age, revision rhinoplasty and reconstructive rhinoplasty for neoplasic or severe traumatic nasal deformities. The "Utrecht Questionnaire for outcome assessment in aesthetic rhinoplasty" was used. Patients answered it before and after surgery (3 and 12 months after). Results: The study population included 200 patients divided into two groups considering the type of dorsal camouflage: DC (n = 132) and shaved cartilage gel (n = 68). The mean age at the time of surgery was 35.44 years (standard deviation ±9.78) and the study population included 130 females (65.0%) and 70 males (35.0%). Regarding aesthetic outcomes, analyses of postoperative means showed a significant improvement, in both groups, over time. However, self-assessment, based on the visual analogue scale (VAS), at 12 months postsurgery, was higher for patients with SC+PRF than with DC (p = 0.004). Twelve months after surgery, patients with thin skin had better aesthetic outcome with SC+PRF than with DC (p = 0.001). For both reduction rhinoplasty techniques, aesthetic outcomes, based on the VAS at 12 months after surgery, were significantly better for patients with SC+PRF (SRT: p = 0.016; CDR: p = 0.004). For both rhinoplasty approaches, either open or closed, aesthetic outcomes, based on the VAS at 12 months after surgery, were significantly better for patients with SC+PRF (closed approach: p = 0.046; open approach: p = 0.017). Conclusions: SC+PRF provides better long-term aesthetic outcomes, not only for thin-skinned patients, but also for patients who had undergone rhinoplasty by a structured or preservation technique, or by an open or closed approach, for dorsal hump reduction.

Swallowed by the bone - Is skin reaction the "tip of the iceberg"?

The most frequent complications of osseointegrated implantation include implant-site infections, soft tissue overgrowth and failure of osseointegration. Bone overgrowth is also a complication at the abutment site and infrequently reported. We describe a rare case of difficult control and exuberant bone overgrowth, with total implant involvement, in a short period of time never before described in the literature. Bone growth around the implant is frequently underestimated and can be the cause of difficult control of skin reactions, that in some cases is just the "tip of the iceberg". Timely surgical review with removing excess bone may lead to implant preservation and control of skin reaction and healing.

Craniodiaphyseal dysplasia: A Rare And Successful Bone-Anchored Hearing Aid Implantation.

Craniodiaphysial dysplasia is an extremely rare genetic disorder characterized by a severe form of bone dysplasia and a distinctive facial dysmorphisms, as a result of a massive generalized hyperostosis and sclerosis, primarily involving the facial bones and the skull. We present a 10-years-old girl referred to an otolaryngology consultation with complaints of progressive hearing loss. The clinical aspects, pathogenesis and management of this disease are also review in this paper. Furthermore, we describe the first case of craniodiaphysial dysplasia rehabilitated with Bone-Anchored Hearing Aid, despite the concerns inherent to the involvement of the skull bone that characterizes the disease.

DOOR syndrome: A case report and its embryological basis.

DOOR syndrome is an extremely rare genetic disorder. "DOOR″ is an acronym to describe the combination of: deafness, onychodystrophy, osteodystrophy and mental retardation. We present a patient, with all of the above-mentioned main symptoms, that was rehabilitated with convencional hearing aids. The presented case suggested that every case of deafness and abnormal nails and phalanges in the hands and feet should have a clinical diagnosis of possible DOOR syndrome. Based on embryological process, congenital abnormal nails or phalanges highlights the importance for detailed hearing screening.

Endoscopic management of sinonasal hemangiopericytoma: case report and literature review

ABSTRACT Introduction: Hemangiopericytoma is a rare vascular tumor of the sinonasal region, associated with epistaxis and nasal obstruction as the main symptoms. When located in this region, it has special clinical characteristics that differentiate it from others. Case presentation: The following paper reports the case of a 43-year-old female patient presenting with right nasal obstruction and 6 months of evolution associated with mucopurulent rhinorrhea and recurrent right side epistaxis. Physical examination showed a right obstructive mass originating from the cribriform plate. Computed tomography of the paranasal sinuses revealed a complete blockage of the right nasal cavity by a homogeneous content, with soft tissue density and no evident contrast enhancement. The lesion extended superiorly to the cribriform plate but without intracranial or orbital extension. The patient was treated with endoscopic surgery and anatomopathological study revealed sinonasal hemangiopericytoma. The patient had complete remission and subsequent 3-year follow-up without recurrence. Conclusion: The recommended treatment for hemangiopericytoma is total surgical excision with free margins. The results are generally good and the risk of recurrence seems to be associated with incomplete tumor excision. A literature review is presented and its main characteristics are discussed.

RESUMEN Introducción: El hemangiopericitoma es un tumor vascular poco frecuente en la región nasosinusal que se asocia con epistaxis y obstrucción nasal como principales síntomas. Cuando se presenta en esta región, tiene características clínicas especiales que lo hace diferente de otras localizaciones. Presentación del caso: A continuación se presenta el caso de una paciente de 43 años de edad, con síntomas de obstrucción en fosa nasal derecha y 6 meses de evolución asociados con rinorrea mucopurulenta y epistaxis recurrente del lado derecho. El examen físico mostró una masa obstructiva en el lado derecho con origen en la placa cribriforme. Una tomografía computarizada de los senos paranasales reveló un bloqueo completo de la cavidad nasal derecha por un contenido homogéneo, con densidad de partes blandas, sin captación de contraste evidente. La lesión se extendía hacia el lado superior de la placa cribriforme, sin extensión intracraneal u orbitaria. La paciente fue tratada con cirugía endoscópica y el estudio anatomopatológico reveló un hemangiopericitoma sinonasal. La paciente tuvo remisión completa y se realizó seguimiento por 3 años sin recurrencia. Conclusión: El tratamiento recomendado para el hemangiopericitoma es la escisión quirúrgica total con márgenes libres, cuyos resultados son generalmente buenos. El riesgo de recurrencia parece estar asociado con una escisión tumoral incompleta. Se presenta una revisión de literatura, así como comentarios sobre sus características principales.