An individual approach to intraoperative parathyroid hormone measurement during total thyroidectomy.

PURPOSE: Hypocalcemia is a common complication of thyroidectomy. Measurement of the intraoperative serum parathyroid hormone (PTH) levels became an established technique but it requires further improvements. We aimed to assess intraoperative PTH level testing results against the hypothesis that the PTH assay may be performed almost immediately after thyroid gland removal. METHODS: A retrospective cohort study. During total thyroidectomy surgery, the patients had PTH levels measured at the cutting time and again immediately after the thyroid gland is removed. Post-operatively, serial total blood calcium levels were obtained twice daily and recorded. RESULTS: Among 63 enrolled patients, 39 had multinodular goiter, 15 thyroid carcinoma, and nine had Graves' disease. The mean age was 59.8 ± 15.3 years, 43 females. The mean PTH level before surgery was 45.8 ± 22.0 pg/mL. Post-operatively, 11/63 patients developed hypocalcemia with serum calcium levels <8 mg/dL. Four patients with ≥50 % decrease in PTH concentration were normocalcemic a day after surgery and were discharged early. Four patients with ≥70 % PTH decrease were treated accordingly during prolonged hospitalization and did not suffer from permanent hypocalcemia. The cut-off value of 70 % decrease after the gland removal was able to predict postoperative hypocalcemia with a sensitivity of 100 %, specificity 82.9 %, PPV 60.0 % and NPV 100 %. CONCLUSION: Measurements of intraoperative PTH may not be performed at fixed time intervals but after 1-2 min after removal of the thyroid gland. Defining those not at risk would allow the majority of patients to be waived from post-operative blood calcium testing and safely discharged early after surgery.

Comparative analysis of approaches to the Wharton's duct during surgery of the submandibular gland: A retrospective case-control study.

INTRODUCTION: We investigated complications and recurrence rates after surgical techniques for sialolith removal with intact and resected Wharton's duct of the submandibular gland. METHODS: The retrospective case-control analysis of a series analysed 271 surgical operations (2003-2022) for sialolithiasis performed at a hospital department of Otolaryngology-Head and Neck Surgery. The study compared two approaches: (1) pure endoscopic technique or pinpoint stone removal with Wharton's duct left intact and (2) transoral duct dissection or pinpoint stone removal technique, after which the duct was shortened. While choosing the surgical option, the size of the stone, the location of the stone, and the presence of multiple stones were taken into account. The rates of complications (lingual nerve paraesthesia, duct stenosis, drooling, and sialoadenitis), the incidence of foreign bodies, and the rate of recurrence during follow-up of ≥18 months were compared. RESULTS: 323 sialoliths were removed from 271 patients. Of these 323 calculi, 150 were removed by the first approach and 173 by the second approach. The calculi varied in diameter from 2 to 38 mm with an average diameter of 8.2 mm. For all 271 patients, the rate of recurrence was 4.8%, but 11 recurrent cases (8.7%) appeared after the first approach surgeries and 2 cases (1.4%) after the second approach surgeries (p = .03). Other variables did not show statistically significant differences. CONCLUSIONS: Surgical removal of the submandibular calculi, ending with shortening of Wharton's duct, reduces the recurrence rate for sialolithiasis but does not affect the rate of postsurgical complications.

The association between Helicobacter pylori and chronic otitis media with effusion.

PURPOSE: Chronic otitis media with effusion (COME) is a common condition in children and a leading cause for hearing loss and ventilation tubes (VT) insertion. Among other risk factors, it is suggested that Helicobacter pylori (H. pylori) infection may have a role in the pathogenesis of COME. Previous studies have reached different results, and therefore, there is a need for further data on the relationship between H. pylori infection and COME development in children. Our objective is to investigate the presence of H. pylori in the middle-ear fluid (MEF) from children with COME. METHODS: A Comparative cross-sectional study. Children ≤ 18 years were included. The study group included children diagnosed with COME and required VT insertion. The control group included children with acute otitis media (AOM) who required myringotomy in the emergency room. Middle-ear fluid samples were sent for both culture and bacterial identification using polymerase chain reaction (PCR) testing. RESULTS: A total of 43 children were included. Eighteen with COME (median age 4 years, IQR 3-6), and 25 with AOM (median age 1 year, IQR 1-2). All samples were cultured for H. pylori. Twenty-two samples underwent H. pylori PCR testing of them, 12 samples from children with COME, and 10 from children with AOM. All cultures and PCR tests results were negative for H. pylori. CONCLUSIONS: Our results suggest that H. pylori does not have a role in the pathogenesis of COME. Future larger studies are needed to investigate whether H. pylori has a role in the pathogenesis of COME.

The impact of eustachian tube function on intra-tympanic steroid administration.

OBJECTIVES: This study investigated the impact of eustachian tube (ET) function (ETF) on therapeutic success on candidates for intra-tympanic administration of steroids (ITAoS), due to idiopathic sudden sensorineural hearing loss (ISSNHL). METHODS: Medical chart review in two university-affiliated medical centers was performed. Included were consecutive adult patients diagnosed with unilateral ISSNHL between 2012 and 2019 who were treated with ITAoS due to incomplete or no recovery following systemic steroidal therapy. ETF was assessed by means tympanometry, before the initiation of ITAoS. The cohort was divided into an ET dysfunction group (ETD(+)) and a functioning ET group (control: ETD(-)). The audiologic response to treatment was recorded at the last follow-up. RESULTS: A total of 64 suitable patients [median (interquartile, IQR) age 49 (38-63) years] were enrolled. The ETD(+) group included 20 patients and the remaining 44 patients served as controls. Demographic and clinical parameters were not significantly different between the two groups at presentation. Hearing thresholds were improved significantly better, at frequencies 250, 500, 1, 2, 4, and 8 kHz (p = 0.001-0.040) in the ETD(+) group. CONCLUSION: ETD(+) is associated with better efficacy of ITAoS.

Caustic Ingestion in Children: The Otolaryngologist Perspective.

OBJECTIVES: Caustic ingestion in children is a significant cause of morbidity despite preventive measures. Upon arrival to the emergency department, these children are often initially seen by the otolaryngologist and later on by the gastroenterologist. This study aimed to determine which otolaryngological and gastrointestinal signs and symptoms can better predict abnormal findings on imaging, esophagogastroduodenoscopy (EGD), and complications development. METHODS: We performed a retrospective chart review of children 18 years or younger admitted because of caustic ingestion between January 2007 and November 2019. RESULTS: Forty-one children with a median age of 4.2 years (interquartile range, 1.7-16.7 years) were included; of them, 22 (53.6%) were males. Nineteen children (46.3%) underwent EGD, which revealed no pathology in 13 cases (68.4%). Most ingested substances were in the form of liquid (82.9%), accidentally ingested (82.9%), and with an alkaline pH (57.5%). Stridor, dyspnea, drooling, abnormal oral cavity findings, dysphagia, and vomiting were significantly associated with pathological findings on imaging and/or EGD and/or complications development ( P = 0.028, P = 0.028, P = 0.022, P = 0.02, P < 0.001, and P = 0.01 respectively). Laryngopharyngeal group of findings (dyspnea, stridor, hoarseness, sore throat, and/or drooling) predicted a higher risk for complications development than the gastrointestinal group (dysphagia, abdominal pain, vomiting, or abdominal swelling and/or tenderness) ( P = 0.011, P = 0.31 respectively). CONCLUSIONS: In children, after caustics ingestion, laryngopharyngeal signs and symptoms may predict a higher risk for complications development in comparison with gastrointestinal signs and symptoms. We therefore stress the importance of otolaryngological examination upon arrival to the emergency department.

Clinical parameters predicting tonsillar malignancy.

PURPOSE: Tonsillectomy is indicated in unilateral tonsillar enlargement (UTE) to rule out malignancy, which eventually is found in about 1.4% of the patients. The aim of this study was to evaluate the presenting symptoms of patients who underwent tonsillectomy for UTE and identify parameters that are associated with an increased risk for malignancy, for better assessment and refinement of current management protocols. METHODS: A retrospective chart review of adult patients with UTE who underwent tonsillectomy between 1/1/2006 and 31/12/2016 was conducted. RESULTS: Forty-one patients with a median age of 53 years were included. There were 20 (49%) females and 21 (51%) males. Sixteen (39%) patients were diagnosed as having tonsillar malignancy. Patients with malignancy were older than those in the benign group (p = 0.001), had a previous malignancy (p = 0.006), and were less likely to present as an incidental finding (p < 0.001). Lymphadenopathy, throat pain, suspicious appearance of tonsillar mucosa, and hard consistency were also found to be statistically significant findings in the malignancy group (p = 0.017, p = 0.001, p = 0.01 and p = 0.018, respectively). Multivariable regression showed age, appearance and adjacent tissue involvement to be independently with malignancy. CONCLUSIONS: UTE alone, as an incidental finding, should not be regarded as an indication for tonsillectomy, as the risk for malignancy is low and the morbidity is significant. We suggest integrating the above-mentioned clinical parameters in the decision-making process, which were found to be significantly more frequent in the malignant group.

The significance of tissue biopsy for fungi in necrotizing otitis externa.

INTRODUCTION: The conventional treatment for necrotizing otitis externa (NOE) is prolonged anti-pseudomonas therapy, with surgical treatment in non-responsive patients. The aim of the present study is to describe the course of management of patients with non-responsive NOE undergoing hyperbaric oxygen therapy (HBOT), and to investigate the importance of tissue biopsy for fungi in this group of patients. MATERIALS AND METHODS: A retrospective study conducted between January 2010 and December 2013 at an Otolaryngology Head and Neck Surgery Department. Included were all 52 patients with NOE referred to our Medical Centre for further treatment including HBOT. RESULTS: Fifty-two consecutive patients, 29 men and 23 women, with a mean age of 70.6 years, were included in our study. Twenty seven (51.9%) underwent surgical debridement. No significant difference was found between the group having surgical intervention, and those who did not, with regard to sex, age, comorbidities, cranial nerve involvement or laboratory results. However, those who had surgical intervention had a statistically significant higher rate of fungal infection (P = 0.049). After completing 7 weeks of HBOT, a significantly lower WBC count was observed in the fungus-infected group (7000 vs 7.800, P = 0.03), and a tendency towards lower CRP levels in the fungus-infected group (16 vs 58, P = 0.087). CONCLUSION: Patients with NOE should have a comprehensive surgical intervention when delayed healing is observed, because proper fungal culturing might change the course of treatment and improve prognosis. LEVEL OF EVIDENCE: 4.

Indicators for imaging in periorbital cellulitis secondary to rhinosinusitis.

PURPOSE: Our objective was to identify the clinical indicators for subperiosteal orbital abscess (SPOA) among patients who present with periorbital cellulitis secondary to rhinosinusitis, and to evaluate the need for performing a computerized tomography (CT) scan. METHODS: A retrospective cohort study of all patients admitted to our tertiary care emergency department between 2006 and 2014 was conducted. Included were healthy patients with acute periorbital cellulitis secondary to rhinosinusitis. Variables analyzed included age, gender, duration of symptoms, previous antibiotic therapy, highest recorded temperature, physical examination findings, ophthalmologist's examination results, laboratory results, and interpretation of imaging studies, when performed. RESULTS: Of the 123 identified patients, 78 (63%) were males, with a mean age of 4 years (range 1-70). 68 patients were categorized as Chandler's 1 disease, 2 as Chandler's 2, and 53 as Chandler's 3. 68 patients underwent a CT scan, of those 53 had SPOA. Proptosis and ophthalmoplegia were strongly associated with the presence of an abscess (P < 0.001). However, 14 patients with no ophthalmoplegia or proptosis who underwent a CT scan were older (mean age, 10 years; P < 0.028), and had higher neutrophil count of 78 versus 59% (P = 0.01). This group of patients had a clinically rapidly progressive disease, receiving wider broad-spectrum antibiotics or had their antibiotic treatment replaced to broader spectrum antibiotics through their course of treatment (48.2% compared to only 6.1%). CONCLUSIONS: We confirmed that patients with proptosis and/or limitation of extraocular movements are at high risk for developing SPOA, yet many do not have these predictors. Other features can identify patients who do not have proptosis and/or limitation of extraocular movements but do have significant risk of SPOA, and in these cases performing an imaging study is strongly suggested.

The efficacy of extended Draf IIb procedure by partial nasal septectomy: long-term follow up.

Draf IIb procedure is mostly used in a very narrow frontal recess and in a revision frontal sinus surgery. In most cases, the contralateral sinus is not involved. In order to avoid Draf III procedure's reported disadvantages we have commenced the use of the extended Draf IIb procedures in our center. Patients treated with extended Draf IIb procedure at our center between the years 1997 and 2012 were retrospectively evaluated. This procedure includes further widening of the frontal ostium and recces by excising the adjacent most superior nasal septum. Included in our study were patients who have failed previous Draf IIb procedure or had a small and narrow frontal sinus. Collected data included demographics, prior sinus pathology, previous surgical treatment, surgical complications and further treatment if required. All were evaluated by the SNOT-22 questioner pre and post-operatively and all were endoscopically evaluated during the follow up period. 15 patients and 18 frontal sinuses were included in our study, eight males and seven females with a mean age of 50.3 years. The mean pre-operative SNOT-22 fell from 46 to 24 and all patients improved clinically. No surgical complications were reported except for one case of postoperative maxillary sinusitis. Only one patient required further surgical intervention. In most cases the patients had a patent frontal sinus ostium after a follow up of 3-8 years. Extended Draf IIb procedure is less traumatic, safe and effective in the treatment of persistent frontal sinus disease, without surgically involving the healthy contralateral frontal sinus, and may obviate the need for Draf III procedure.

Gender differences in the bacteriology of rhinosinusitis.

Evaluating gender differences in pathogens involving sinonasal tract disease in patients undergoing nasal surgery for chronic and recurrent rhinosinusitis (C/R RS). Retrospective analysis of 164 positive sinonasal swab cultures taken during endoscopic sinonasal surgery between the years 2006 and 2013. Study population included 79 (48.8%) female patients and 84 (51/2%) males with a mean age of 47.3 (13-88) years. Positive Staphylococcal growth was found in 38 (23.2%) patients, positive anaerobic growth in 25 (15.2%) patients and 67 (40.9%) patients had polymicrobial growth. Staphylococcal growth in the male population was significantly higher compared to the female population (p = 0.04). Odds ratio for a polymicrobial infection in males over 60 years old compared to females was 2.17 (CI 0.63-8.08, 95%). Anaerobes were found to be more frequent in males (17.9%) than in females (12.5%). Species of Streptococci showed no difference between gender and age groups. The results obtained suggest a difference between the causing pathogens in C/R RS between females and males. In the male population, staphylococcal species were found to be significantly more common with a greater tendency to polymicrobial pathogens and higher rates of anaerobes. These results might suggest different management protocols perioperatively in males and females.

Management of superior subperiosteal orbital abscess.

A superior subperiosteal orbital abscess (SSPOA) is a collection of purulent material between the periorbit and the superior bony orbital wall, and is typically a complication of frontal sinusitis. SSPOA is characteristically managed by classic external surgical drainage. The aim of our study was to assess the role of surgical intervention in SSPOA. A retrospective medical chart review of patients diagnosed with SSPOA secondary to rhinosinusitis between the year 2005 and 2013 was conducted. Collected data included age, gender, co-morbidity, clinical presentation, prior antibiotic management, CT scans, surgical approach, outcome and complications. Six patients were included in our study, three males and three females with a mean age of 22.8 (range 9-58). Two patients were treated with amoxicillin clavulanic acid for 3 days prior to admission. Only the youngest patient with the smallest abscess responded successfully to conservative treatment, while the rest were managed surgically: three patients were treated successfully by the endonasal endoscopic approach and two patients were treated by utilizing the combined endonasal endoscopic and external approach. In patients who underwent the combined approach, the abscess was located in a more antero-lateral position than those treated endonasal endoscopically only. The location of a SSPOA dictates the surgical approach. The most antero-lateral SSPOAs should be drained by the combined approach, while more posterior abscesses should be approached endoscopically. Furthermore, a small SSPOA is first to be reported to resolve with conservative treatment. Level 4 (case series).

Hyperbaric oxygen therapy as an alternative to surgery for non-healing pharyngocutaneous fistula.

The aim of the study is to examine the utilization of hyperbaric oxygen treatment (HBOT) as an alternative to surgical treatment for non-healing postoperative phayngocutaneous fistula (POPCF). A retrospective study was conducted between 2012 and 2014 of referred patients who had failed conservative treatment for POPCF at other medical centers. Reevaluation at our department was followed by therapeutic management including daily HBOT. Eight male patients with a mean age of 62.3 years were included. The average period of conservative treatment was 1 month before admittance to our department. All patients were managed with HBOT and local debridement. Closure of the POPCF was proved by a barium swallow test in seven patients (87.5 %). HBOT is recommended for patients who have failed conservative treatment for POPCF post-laryngectomy, due to a high rate of successful (87.5 %) closure and should be considered as an alternative to surgical treatment.

Bacteriology of peritonsillar abscess in patients over 40 years--a neglected age group.

The clinical presentation of peritonsillar abscess (PTA) in patients over 40 years is scarcely reported. Since older patients present differently than younger patients, our aim was to investigate possible correlation between illness severity in the older age group and their bacteriologic studies. A retrospective study on all cases of PTA admitted between June 1996 and June 2003 was carried out. Details regarding sex and age were obtained. Bacteriologic studies were analyzed for gram stain, aerobic and anaerobic culture results. Two hundred and eighty-two patients (143 male and 139 female) had 311 hospitalizations due to PTA with known results of the microbiologic studies. Mean age was 29.6 (range 4-80 years). Sixty-five adults over 40 of age were found comprising 23 % of our cohort. Aerobic growth in the older group was found to be significantly lower (P < 0.05). Anaerobic growth was identified in 44.7 % of the positive pathogen growth. The older age group also showed a tendency to higher rates of anaerobic bacterial growth (57.1 % compared to 41 % in the young age group; P = 0.09, OR = 1.91). Older population with PTA presents with significant lower rates of aerobic bacteria and a tendency towards higher rates of anaerobic growth. The dangerous combination of the latter with the higher reported rates of comorbidities and less prominent symptoms and signs compared to the younger patients might clarify the need for prompt and aggressive surgical and antibiotic treatment.

Unfolding the role of PET FDG scan in the management of thyroid incidentaloma in cancer patients.

Thyroid incidentaloma detected on FDG-PET scan has been reported repeatedly in the last several years, though conflicting data are reported. Our aim is to identify the incidence and outcome of incidental FDG-PET detected thyroid lesions in patients undergoing FDG-PET scan for other primary malignancies and to suggest a management algorithm. This is a retrospective review of all patients who had a FDG-PET detected incidental thyroid lesion between January 2002 and December 2009 at Peter MacCallum Cancer Center. Demographics, data relating to PET scan findings, FNA diagnoses, operative details, and histopathology were reviewed. Of the 1,034 subjects who underwent the FDG-PET study, 51 (4.9%) were identified as having thyroid incidentaloma, 31 females and 20 males with a mean age of 60 years. Thyroid malignancy was noted in 39.5% (19/48 patients) who underwent FNAB. Sixteen underwent thyroidectomy. The histopathology revealed 12 patients with papillary carcinoma, 5 with follicular carcinoma and 2 with medullary carcinoma. The high rates are in concordance with analysis of the rates published in the literature. In patients with thyroid PET incidentaloma, the incidence of primary thyroid malignancy is very high as reported in our study and based on analysis of published data, necessitating further investigation. If assessment of these incidentalomas suggests malignancy, then appropriate surgical management may be warranted according to the patient's medical condition.

Complications following powered endoscopic sinus surgery: an 11 year study on 1190 patients in a single institute in Israel.

BACKGROUND: Over the past 20 years, advances in endoscopic sinus surgery (ESS) techniques have led to widespread applications of this technology in both adult and pediatric populations with better results and lower morbidity. OBJECTIVES: To update data regarding the rate of minor and major complications following ESS procedures that used powered instrumentation. METHODS: We retrospectively reviewed the charts of all patients who, with general anesthesia, underwent ESS utilizing powered instrumentation between January 1996 and December 2006. Age, gender, indication for surgery, length of hospitalization, and type and rate of surgical complications were recorded. RESULTS: A total of 1190 patients were included in our study (1309 surgeries). The male:female ratio was 1.7:1.0 and the average age was 39 years (range 4-86 years). The most common indication for surgery was chronic rhinosinusitis. The rate of major complications was 0.31% and that of minor complications 1.37%. The only major complication that occurred was cerebrospinal fluid leak. The minor complications included epistaxis, periorbital emphysema, ecchymosis and mucocele formation. CONCLUSIONS: Compared to previously published series, the rate of major and minor complications in our study was low. The results indicate that the use of powered instruments during ESS is safe.

The Safety, Tolerability, and Efficacy of DL-Lactic Acid Syrup (Tonsitin) in Children With Recurrent Tonsillitis: A Pilot Study.

To evaluate Tonsitin (10% DL-lactic acid) safety, tolerability, and efficacy, as a treatment for recurrent tonsillitis (RT) in children. This is a clinical prospective, randomized, double blind pilot study, to evaluate the safety, tolerability and efficacy of Tonsitin in healthy children with RT. Safety evaluated in terms of adverse events (AEs), tolerability in terms of compliance, and efficacy in terms of tonsils' size and frequency of tonsillitis, and quality of life. The study included 51 children. The treatment regimen was tolerable among the participants. Six children experienced AEs, but mostly mild. Tonsil size declined in both groups, but these results did not reach statistical significance. Tonsillitis episodes' frequencies were random and not significant. Tonsitin treatment was found to be feasible in the clinical setup and was well tolerated, and appears to be safe. Study efficacy results did not reach statistical significance.

Role of computerized dynamic posturography in evaluating sinugenic vertigo.

OBJECTIVES: Vertigo associated with rhinosinusitis has seldom been reported, and the pathophysiologic mechanism is still vague. Our aim was to evaluate sinugenic vertigo with computerized dynamic posturography (CDP) and suggest a possible pathophysiologic mechanism. METHODS: We conducted a prospective study of 16 patients with a clinical and radiologic diagnosis of rhinosinusitis made between January 2007 and December 2008. All patients underwent CDP on the first 2 days after diagnosis. Patients with abnormal CDP results and/or complaints of vertigo underwent follow-up CDP when healthy. RESULTS: Five patients complained of a new onset of vertigo. The CDP demonstrated a combined disorder in 3 of them, even though the vestibular signs were intact. On follow-up examination, all 3 patients were asymptomatic, and the follow-up CDP values were normal. CONCLUSIONS: We report a surprising 20% prevalence of sinugenic vertigo associated with abnormal results on CDP. Our results might possibly indicate that the somatosensory system of the paranasal sinuses plays a major role in the pathophysiologic mechanism of sinugenic vertigo.

Accuracy of ultrasonography versus computed tomography scan in detecting parapharyngeal abscess in children.

OBJECTIVE: Significant morbidity and rarely mortality have been described in parapharyngeal space infections in children; hence, the decision on the timing of surgical intervention might be crucial. The aim of this study was to compare the accuracy of plain x-rays, ultrasonography (US), and contrast-enhanced computed tomography (CT) in demonstrating a parapharyngeal abscess. METHODS: A retrospective study on all patients with parapharyngeal abscess admitted and operated on from January 1996 to December 2000 was carried out. Charts were reviewed for patients' demographics, symptoms and signs, details of workup, intraoperative findings, and culture results. The CT scans were reviewed for the presence of a rim enhancement, a presence of a definable wall, and fluid-fluid level and were correlated with the plain x-rays and US results and intraoperative findings. RESULTS: Eighteen patients with proven parapharyngeal infection were included: 10 with proven abscess and 8 with cellulitis. The sensitivity and specificity of lateral neck radiograph and US were low compared with a specificity of 87.5 while evaluating fluid-fluid level seen on the CT scan, sensitivity of 58.3% for the presence of a definable abscess wall, and a sensitivity of 100% for the presence of a prominent wall. CONCLUSIONS: Our study demonstrates good rates of accuracy of CT scan for diagnosing a parapharyngeal abscess. Our study suggest that it is appropriate to obtain a CT scan upon presentation in all children with suspected parapharyngeal abscess and that a CT scan is proven to be a useful diagnostic tool in establishing a treatment plan.

Extended High Frequency Audiometry for Revealing Sudden Sensory Neural Hearing Loss in Acute Tinnitus Patients.

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

Intravital staining with methylene blue in tympanoplasty.

Objective of the study is to investigate usefulness of the methylene blue staining for the operation of tympanoplasty in surgical training process with randomized, controlled trial. Two hospitals were involved: Department of Otolaryngology, Assaf Harofeh Medical Center, and Department of Otolaryngology Head and Neck Surgery, Soroka University Medical Center. Tympanoplasty with graft placement was performed by young surgeons on 30 patients (30 ears) with anterior perforations using intraoperative staining of tympanoplasty grafts with methylene blue (Group 1). The same number of patients/ears was operated by the young surgeons without intraoperative staining (Group 2). 76 patients operated without staining by experienced surgeons served as a control group. Results showed tympanic membrane healing (graft take) in 30 (100%) cases in Group 1 and in 26 (86.66%) cases in Group 2. The pure-tone audiogram testing revealed significant improvement of hearing in all successful cases (p < 0.05). No side immediate or postponed effects were detected. We conclude that intravital staining with methylene blue in tympanoplasty simplifies the operation and could assist in better visualization and proper placement of the graft. This technique could be most useful in a training process for resident surgeons.