The Frontal Sinus and Frontal Recess: Anatomical, Radiological and Surgical Concepts

Abstract Introduction The frontal sinus (FS) is the most complex of the paranasal sinuses due to its location, anatomical variations and multiple clinical presentations. The surgical management of the FS and of the frontal recess (FR) is technically challenging, and a complete understanding of its anatomy, radiology, main diseases and surgical techniques is crucial to achieve therapeutic success. Objectives To review the FS and FR anatomy, radiology, and surgical techniques. Data Synthesis The FS features a variety of anatomical, volumetric and dimensional characteristics. From the endoscopic point of view, the FR is the point of greatest narrowing and, to have access to this region, one must know the anatomical limits and the ethmoid cells that are located around the FR and very often block the sinus drainage. Benign diseases such as chronic rhinosinusitis (CRS), mucocele and osteomas are the main pathologies found in the FS; however, there is a wide variety of malignant tumors that can also affect this region and represent a major technical challenge to the surgeon. With the advances in the endoscopic technique, the vast majority of diseases that affect the FS can be treated according to Wolfgang Draf, who systemized the approaches into four types (I, IIa, IIb, III). Conclusion Both benign and malignant diseases that affect the FS and FR can be successfully managed if one has a thorough understanding of the FS and FR anatomy, an individualized approach of the best surgical technique in each case, and the appropriate tools to operate in this region.

The Frontal Sinus and Frontal Recess: Anatomical, Radiological and Surgical Concepts.

Introduction The frontal sinus (FS) is the most complex of the paranasal sinuses due to its location, anatomical variations and multiple clinical presentations. The surgical management of the FS and of the frontal recess (FR) is technically challenging, and a complete understanding of its anatomy, radiology, main diseases and surgical techniques is crucial to achieve therapeutic success. Objectives To review the FS and FR anatomy, radiology, and surgical techniques. Data Synthesis The FS features a variety of anatomical, volumetric and dimensional characteristics. From the endoscopic point of view, the FR is the point of greatest narrowing and, to have access to this region, one must know the anatomical limits and the ethmoid cells that are located around the FR and very often block the sinus drainage. Benign diseases such as chronic rhinosinusitis (CRS), mucocele and osteomas are the main pathologies found in the FS; however, there is a wide variety of malignant tumors that can also affect this region and represent a major technical challenge to the surgeon. With the advances in the endoscopic technique, the vast majority of diseases that affect the FS can be treated according to Wolfgang Draf, who systemized the approaches into four types (I, IIa, IIb, III). Conclusion Both benign and malignant diseases that affect the FS and FR can be successfully managed if one has a thorough understanding of the FS and FR anatomy, an individualized approach of the best surgical technique in each case, and the appropriate tools to operate in this region.

Accuracy of a portable breath meter test for the detection of halitosis in children and adolescents

OBJECTIVES: This study aimed to determine the accuracy of the Breath-Alert™ portable breath meter (BA) for the detection of halitosis in children and adolescents, considering the organoleptic test (OT) as the gold standard in this assessment. METHODS: A cross-sectional study was conducted on 150 children (aged 6-12 years). OT was performed by three independent examiners on a single occasion, obtaining three scores of 0-5 points on the Rosenberg's organoleptic scale. The median of the three evaluations for each child was used for analysis. BA was used according to the manufacturer's instructions, with breath odor scored from 0-5 points. Scores ≥2 on both tests were considered indicative of halitosis. RESULTS: A total of 26 (17.3%) and 23 (15.3%) children were detected with halitosis on the OT and BA tests, respectively. The sensitivity and specificity of the BA scores for the detection of halitosis were 80.76% and 98.38%, respectively. The positive and negative predictive values for BA were 91.3% and 96.06%, respectively. CONCLUSION: In the present study involving children, who require fast, practical examinations, BA proved to be an auxiliary tool to OT for the detection of halitosis in the practice of pediatric dentistry, demonstrating high sensitivity and specificity.

P3 Cognitive Potential in Cochlear Implant Users

Abstract Introduction The P3 cognitive evoked potential is recorded when a subject correctly identifies, evaluates and processes two different auditory stimuli. Objective to evaluate the latency and amplitude of the P3 evoked potential in 26 cochlear implant users with post-lingual deafness with good or poor speech recognition scores as compared with normal hearing subjects matched for age and educational level. Methods In this prospective cohort study, auditory cortical responses were recorded from 26 post-lingual deaf adult cochlear implant users (19 with good and 7 with poor speech recognition scores) and 26 control subjects. Results There was a significant difference in the P3 latency between cochlear implant users with poor speech recognition scores (G-) and their control group (CG) (p= 0.04), and between G- and cochlear implant users with good speech discrimination (G+) (p= 0.01). We found no significant difference in the P3 latency between the CG and G+. In this study, all G- patients had deafness due to meningitis, which suggests that higher auditory function was impaired too. Conclusion Post-lingual deaf adult cochlear implant users in the G- group had prolonged P3 latencies as compared with the CG and the cochlear implant users in the G+ group. The amplitudes were similar between patients and controls. All G- subjects were deaf due to meningitis. These findings suggest that meningitis may have deleterious effects not only on the peripheral auditory system but on the central auditory processing as well.

Endoscopic sinus surgery dissection courses using a real simulator: the benefits of this training / Cursos de dissecção de cirurgia endoscópica nasossinusal em simulador real - os benefícios deste treinamento

ABSTRACT INTRODUCTION: Endonasal surgeries are among the most common procedures performed in otolaryngology. Due to difficulty in cadaver acquisition and the intrinsic risks of training residents during operations on real patients, nasosinusal endoscopic dissection courses utilizing real simulators, such as the Sinus Model Otorhino Neuro Trainer are being developed as a new technique to facilitate the acquisition of better anatomical knowledge and surgical skill. OBJECTIVE: To evaluate the efficacy of nasosinusal endoscopic dissection courses with the Sinus Model Otorhino Neuro Trainer simulator in the training of otolaryngology surgeons. METHODS: A prospective, longitudinal cohort study was conducted with 111 otolaryngologists who participated in a theoretical and practical course of endoscopic surgery dissection using the Sinus Model Otorhino Neuro Trainer simulator, with application of questionnaires during and after the course. RESULTS: From the ten procedures performed utilizing the simulator, the evaluation revealed mean scores from 3.1 to 4.1 (maximum of 5). Seventy-seven participants answered the questionnaire six months after the end of the course. 93% of them reported that they could perform the procedures more safely following the course, 98% reported an improvement in their anatomical and clinical knowledge, and 85% related an improvement in their surgical ability. After the course, the number of endoscopic surgeries increased in 40% of the respondents. CONCLUSION: Endoscopic sinus dissection courses using the Sinus Model Otorhino Neuro Trainer simulator proved to be useful in the training of otolaryngologists.

RESUMO INTRODUÇÃO: Cirurgias endonasais são as cirurgias mais realizadas na otorrinolaringologia. Devido à dificuldade de adquirir cadáveres e ao risco inerente em realizar treinamento em pacientes reais, cursos de dissecção endoscópica nasossinusal em simuladores reais, como o sinus model otorhino - neuro trainer - S.I.M.O.N.T, são uma nova proposta de aquisição de maior conhecimento anatômico e habilidades cirúrgicas. OBJETIVO: Avaliar a eficácia dos cursos de dissecção de cirurgia endoscópica nasossinusal com simulador S.I.M.O.N.T. no treinamento de cirurgiões otorrinolaringologistas. MÉTODO: Estudo de coorte contemporâneo longitudinal com 111 otorrinolaringologistas que participaram de curso teórico - prático de dissecção endoscópica nasossinusal em simulador real S.I.M.O.N.T., com aplicação de questionários durante e após a realização do curso. RESULTADOS: Dos dez procedimentos realizados no simulador, a avaliação apontou para médias de notas que variaram de 3,1 a 4,1 (máximo de 5). Setenta e sete participantes responderam a avaliação 6 meses após o curso. Declararam que houve aumento da segurança após o curso, 93% dos mesmos; 98% disseram ter aumentado o conhecimento anátomo-clinico e 85% declararam um aumento da habilidade cirúrgica. Quarenta por cento aumentaram o número de cirurgias endonasais após o curso. CONCLUSÃO: Cursos de dissecção de cirurgia endonasais com simulador real S.I.M.O.N.T. mostraram ser úteis para o treinamento de otorrinolaringologistas.

Endoscopic sinus surgery dissection courses using a real simulator: the benefits of this training.

INTRODUCTION: Endonasal surgeries are among the most common procedures performed in otolaryngology. Due to difficulty in cadaver acquisition and the intrinsic risks of training residents during operations on real patients, nasosinusal endoscopic dissection courses utilizing real simulators, such as the Sinus Model Otorhino Neuro Trainer are being developed as a new technique to facilitate the acquisition of better anatomical knowledge and surgical skill. OBJECTIVE: To evaluate the efficacy of nasosinusal endoscopic dissection courses with the Sinus Model Otorhino Neuro Trainer simulator in the training of otolaryngology surgeons. METHODS: A prospective, longitudinal cohort study was conducted with 111 otolaryngologists who participated in a theoretical and practical course of endoscopic surgery dissection using the Sinus Model Otorhino Neuro Trainer simulator, with application of questionnaires during and after the course. RESULTS: From the ten procedures performed utilizing the simulator, the evaluation revealed mean scores from 3.1 to 4.1 (maximum of 5). Seventy-seven participants answered the questionnaire six months after the end of the course. 93% of them reported that they could perform the procedures more safely following the course, 98% reported an improvement in their anatomical and clinical knowledge, and 85% related an improvement in their surgical ability. After the course, the number of endoscopic surgeries increased in 40% of the respondents. CONCLUSION: Endoscopic sinus dissection courses using the Sinus Model Otorhino Neuro Trainer simulator proved to be useful in the training of otolaryngologists.

The impact of acute loss of weight on eustachian tube function.

Introduction The eustachian tube is one of the key structures responsible for the functional balance of the middle ear. Some clinical conditions associated with tubal malfunction can cause extremely unpleasant symptoms. These symptoms could be triggered by acute loss of weight, for example, after bariatric surgery. Objective To evaluate the frequency and intensity of auditory tube dysfunction symptoms in obese patients after bariatric surgery. Methods Nineteen patients with accepted formal indications for bariatric surgery underwent a hearing evaluation (otoscopy, tonal and vocal audiometry, and impedanceometry) and a hearing questionnaire before, at the time of, 3 months after surgery (first postoperative evaluation), and 6 months (second postoperative evaluation) after surgery. Patients with a history of ear disease or ear surgery were excluded. Results None of the patients reported tubal dysfunction symptoms before surgery. Postsurgical results showed that 5 (26.3%) patients presented symptoms related to dysfunction of the eustachian tube at the first postoperative evaluation. After the 6-month follow-up, 9 (47.3%) patients reported symptoms of tubal dysfunction. Conclusion This study suggests that bariatric surgery can cause symptoms of eustachian tube dysfunction, probably due to rapid weight loss and the consequent loss of peritubal fat.

The Impact of Acute Loss of Weight on Eustachian Tube Function

Introduction The eustachian tube is one of the key structures responsible for the functional balance of the middle ear. Some clinical conditions associated with tubal malfunction can cause extremely unpleasant symptoms. These symptoms could be triggered by acute loss of weight, for example, after bariatric surgery. Objective To evaluate the frequency and intensity of auditory tube dysfunction symptoms in obese patients after bariatric surgery. Methods Nineteen patients with accepted formal indications for bariatric surgery underwent a hearing evaluation (otoscopy, tonal and vocal audiometry, and impedanceometry) and a hearing questionnaire before, at the time of, 3 months after surgery (first postoperative evaluation), and 6 months (second postoperative evaluation) after surgery. Patients with a history of ear disease or ear surgery were excluded. Results None of the patients reported tubal dysfunction symptoms before surgery. Postsurgical results showed that 5 (26.3%) patients presented symptoms related to dysfunction of the eustachian tube at the first postoperative evaluation. After the 6- month follow-up, 9 (47.3%) patients reported symptoms of tubal dysfunction. Conclusion This study suggests that bariatric surgery can cause symptoms of eustachian tube dysfunction, probably due to rapid weight loss and the consequent loss of peritubal fat...

Olfactory neuroepithelium in the superior and middle turbinates: which is the optimal biopsy site?

INTRODUCTION: Olfactory neuroepithelium (ON) biopsy has several therapeutic applications for both disorders of olfaction and neurodegenerative diseases. Successful collection of ON is still anything but routine due to a dearth of studies on the distribution of ON in the superior and middle turbinates. AIM: To determine the location in which ON is most likely to be present in endoscopically removed cadaver superior and middle turbinates as well as the influences of gender, age, and naris side on the presence of ON and the extent to which it is present. METHODS: We conducted a prospective anatomical study. The superior and middle turbinates on both sides endoscopically removed from 25 fresh cadavers (less than 12 h post-mortem). The turbinates were halved into anterior and posterior segments for a total of 200 specimens, which were analyzed after hematoxylin and eosin and immunohistochemical staining. Hematoxylin and eosin-stained slides were subjected to blind examination by 3 independent pathologists, and the presence of ON was graded on a 5-point scale from 0 to 4. Kappa measurement was used to determine the agreement between pairs of observers. RESULTS: ON was present in 82.9% of superior turbinate samples and in 17.1% of middle turbinate samples. Immunohistochemistry detected ON in superior turbinates only by S-100 staining and only in 15 fragments. Gender, age, and naris side had no statistically significant effects on the presence of ON. CONCLUSION: When biopsying ON, the posterior portion of the superior turbinate should be targeted whenever possible because it has the highest concentration of ON among the nasal structures.

Short and long term impact of adenotonsillectomy on the immune system.

UNLABELLED: Palatine and pharyngeal tonsils are immune reactive lymphoid organs that manifest specific antibodies and B/T-cell activity to respond to a variety of antigens. They perform humoral and cellular immune functions. The possible effects of adenotonsillectomy upon the immune system remain controversial. OBJECTIVE: To study the short and long-term impacts of tonsillectomy upon the cellular and humoral immunity of children. METHOD: This longitudinal prospective study included 29 children referred to adenotonsillectomy for adenotonsillar hypertrophy. Serum IgA, IgM, and IgG and lymphocyte counts were analyzed at three points in time: before surgery, 1-2 months after surgery (short term), and 12-14 months after surgery (long term). RESULTS: TCD4+ cell counts were significantly increased shortly after surgery. IgA and IgG values were significantly reduced in the long run, but were within normal ranges for this age group. CONCLUSION: This study indicated that adenotonsillectomy does not pose negative short or long term impacts upon the cellular and humoral immunity of children submitted to the procedure.

Repercussão da adenotonsilectomia sobre o sistema imune a curto e longo prazo / Short and long term impact of adenotonsillectomy on the immune system

As tonsilas palatinas e faríngea são órgãos linfoides imunologicamente reativos, que manifestam anticorpos específicos e atividade de células B e T em resposta a uma variedade de antígenos, desempenhando funções de imunidade humoral e celular. Os possíveis efeitos imunológicos da adenotonsilectomia ainda permanecem controversos. OBJETIVO: O propósito desse estudo foi investigar o impacto da tonsilectomia na imunidade celular e humoral em crianças a curto e longo prazo. MÉTODO: Desenho do estudo: longitudinal prospectivo. Foram incluídas 29 crianças com indicação de adenotonsilectomia por hipertrofia adenoamigdaliana. IgA, IgM e IgG séricas e contagem de linfócitos foram analisados em 3 períodos: antes, 1 a 2 meses (curto prazo) e 12 a 14 meses (longo prazo) após o procedimento cirúrgico. RESULTADOS: Houve aumento estatisticamente significante de linfócitos TCD4+ a curto prazo após adenotonsilectomia. Os valores de IgA e IgG apresentaram diminuição significante a longo prazo, mas permaneceram dentro dos parâmetros de normalidade para a faixa etária. CONCLUSÃO: Os resultados do presente estudo indicam que a adenotonsilectomia, tanto a curto como a longo prazo, não apresenta repercussão negativa sobre a imunidade celular e humoral das crianças submetidas a este procedimento.

Palatine and pharyngeal tonsils are immune reactive lymphoid organs that manifest specific antibodies and B/T-cell activity to respond to a variety of antigens. They perform humoral and cellular immune functions. The possible effects of adenotonsillectomy upon the immune system remain controversial. OBJECTIVE: To study the short and long-term impacts of tonsillectomy upon the cellular and humoral immunity of children. METHOD: This longitudinal prospective study included 29 children referred to adenotonsillectomy for adenotonsillar hypertrophy. Serum IgA, IgM, and IgG and lymphocyte counts were analyzed at three points in time: before surgery, 1-2 months after surgery (short term), and 12-14 months after surgery (long term). RESULTS: TCD4+ cell counts were significantly increased shortly after surgery. IgA and IgG values were significantly reduced in the long run, but were within normal ranges for this age group. CONCLUSION: This study indicated that adenotonsillectomy does not pose negative short or long term impacts upon the cellular and humoral immunity of children submitted to the procedure.

Olfactory neuroepithelium in the superior and middle turbinates: which is the optimal biopsy site?

INTRODUCTION: Olfactory neuroepithelium (ON) biopsy has several therapeutic applications for both disorders of olfaction and neurodegenerative diseases. Successful collection of ON is still anything but routine due to a dearth of studies on the distribution of ON in the superior and middle turbinates. AIM: To determine the location in which ON is most likely to be present in endoscopically removed cadaver superior and middle turbinates as well as the influences of gender, age, and naris side on the presence of ON and the extent to which it is present. METHODS: We conducted a prospective anatomical study. The superior and middle turbinates on both sides endoscopically removed from 25 fresh cadavers (less than 12 h post-mortem). The turbinates were halved into anterior and posterior segments for a total of 200 specimens, which were analyzed after hematoxylin and eosin and immunohistochemical staining. Hematoxylin and eosin-stained slides were subjected to blind examination by 3 independent pathologists, and the presence of ON was graded on a 5-point scale from 0 to 4. Kappa measurement was used to determine the agreement between pairs of observers. RESULTS: ON was present in 82.9% of superior turbinate samples and in 17.1% of middle turbinate samples. Immunohistochemistry detected ON in superior turbinates only by S-100 staining and only in 15 fragments. Gender, age, and naris side had no statistically significant effects on the presence of ON. CONCLUSION: When biopsying ON, the posterior portion of the superior turbinate should be targeted whenever possible because it has the highest concentration of ON among the nasal structures.

Metástases pituitárias / Pituitary metastases

Introdução: Tumores metastáticos para a glândula pituitária são uma complicação incomum das metástases sistêmicas de neoplasias primárias com outros focos de origem, geralmente vistos em pacientes idosos com doença maligna difusa. Apenas 1% de todas as cirurgias da glândula pituitária é realizada para tratar tumores metastáticos. Apesar de raros, devem ser sempre considerados, uma vez que podem ser a primeira manifestação de um tumor primário oculto. Objetivo: O objetivo deste estudo é relatar e discutir casos de metástase pituitária e correlacionar o diagnóstico diferencial para este problema. Metodologia: Descrever e discutir a apresentação clínica, diagnóstico, tratamento e resultado em quatro pacientes com neoplasias primárias de pulmão, próstata, cólon e rim que apresentaram metástase pituitária ao longo da evolução clínica da doença. Resultados: O diagnóstico diferencial entre metástases na região hipotálamo hipofisária e adenoma pituitário pode ser difícil, porém as manifestações clínicas e achados de neuroimagem podem ajudar no diagnóstico diferencial. Normalmente,o prognóstico desses pacientes é pobre. Conclusão: As metástases hipofisárias são raras, mas devem ser consideradas no diagnóstico diferencial para pacientes idosos, pacientes com história de malignidade e em pacientes com sintomas de diabetes insipidus ou oftalmoplegia. Embora o prognóstico seja pobre por causa da doença sistêmica não controlada, pode haver um papel importante na ressecção do tumor em um seleto grupo de pacientes, a fim de se aliviar os sintomas e melhorar a qualidade de vida.

Voice feature characteristic in morbid obese population.

BACKGROUND: Morbid obesity is highly prevalent in the Western World, and its consequences present a real public health challenge. Voice alterations can represent one of these consequences and represent an opportunity for interference with therapeutic methods. This particularly features of the individual's voice was the goal of the present study. METHODS: A group of 45 adult volunteers of both sexes with a BMI greater than 35 Kg/m(2) was selected among patients of the Obesity Ambulatory of the Digestive Surgery Division. The control group consisted of volunteers matched by sex, age (±1 year), and smoking habits, but with a BMI below 30 Kg/m(2). All subjects were submitted to laryngoscopic examination, audio perceptive analysis, and voice acoustics determination. Examinations were always performed by the same doctor, and diagnoses were provided by two different physician specialists in laryngology and voice. RESULTS: Obese individuals exhibit the following modifications in voice feature: hoarseness, murmuring, vocal instability, altered jitter and shimmer, and reduced maximum phonation times as well the presence of voice strangulation at the end of emission. CONCLUSION: The voices of individuals with morbid obesity are different of the voice of nonobese people and demonstrate significant changes in vocal characteristics.

Evaluation of inverted papilloma and squamous cell carcinoma by nasal contact endoscopy.

BACKGROUND: Contact endoscopy (CE) was initially described as a method used in the analysis of uterine and vocal folds histology. The first nasal cavity CE studies achieved promising results regarding its use for the differentiation between benign and malignant lesions, considering that biopsy might cause some complications, especially bleeding. This study described and compared the findings of CE on inverted papilloma and nasosinusal squamous cell carcinoma (SCC) and tested the effectiveness of this exam as a noninvasive method for in vivo differentiation between these tumors. METHODS: The patients included in this study were divided into group A, patients diagnosed with inverted papilloma, and group B, patients diagnosed with SCC. CE results were compared among themselves. CE images were presented to examiners not experienced with the method. RESULTS: Twenty-two patients were examined, 13 in group A and 9 in group B. The main relevant differences in CE findings between those two groups were corkscrew vessels, presence of mitoses, keratinization and nuclear pleomorphism in carcinoma, and vacuolated cells in papilloma. The examiners were capable of defining the diagnosis of these nasal tumors only based on CE images. CONCLUSION: CE may be a useful noninvasive exam to be used in the in vivo diagnosis of inverted papilloma and nasosinusal SCC, which may enable better preoperative planning.

Avaliação da dor e amnésia intra-operatórias com anestesia local e sedação em pacientes submetidos a rinoseptoplastias / Pain and intra-operative amnesia evaluation with local anesthesia and sedation in patients subjected to rhinosseptoplasties

Introdução: A prática da anestesia local e sedação para rinoplastia e outros procedimentos estéticos da face são cada vez mais frequentes. No Brasil o Conselho Federal de Medicina o define e regulamenta sua prática. Objetivo: Analisar a eficácia da analgesia e amnésia intraoperatórios através de escalas análogo-visual e subjetiva nas rinosseptoplastias realizadas sob anestesia local e sedação, buscando associações com as quantidades médias de medicações utilizadas. Método: Estudo retrospectivo baseado em relatórios referentes a 158 rinoplastias estético-funcionais. O cirurgião registrava em protocolo dados referentes ao uso de anestésicos locais e sedativos (incluindo concentrações e quantidades utilizadas) bem como efeitos adversos. No primeiro retorno pós-cirurgia o paciente quantificar a dor sentida no intraoperatório utilizando-se uma escala análogo-visual conforme descrito por HASEN e colaboradores. Amnésia considerada ideal quando paciente referia lembrar-se "nada" ou "pouco" do procedimento. Resultados: Amostra constituída de 80 (73,4%) mulheres e 29 (26,6%) homens, idade média de 29,3 ± 9,5 anos. A mediana da dor pela escala análogo-visual foi de 0,05; 80% inferior a 3,35. A amnésia foi ideal em 51 (46,8%) cirurgias. O midazolam foi usado em todas cirurgias, fentanil em 32 (29,4%) e petidina em 77 (70,6%). Não houve diferenças estatisticamente significantes entre as quantidades de medicações utilizadas entre o grupo de pacientes com amnésia ideal quando comparados com os que não obtiveram amnésia satisfatória. Conclusão: Anestesia local e sedação em rinoplastias são confortáveis e seguras na quase totalidade das vezes, mesmo sem haver amnésia satisfatória.

Introduction: The local anesthesia practice and sedation to rhinoplasty and others aesthetics procedures of the face are each time more frequents. In the Brazil, the Federal Council of Medicine defines it and regulate its practice. Objective: To analyze the analgesia' effectiveness and of the intro operative amnesia through analogous visual and subjective scales in the rhinosseptoplasties performed under local anesthesia and sedation, looking for associations with the medium quantities of medication utilized. Method: A retrospective study based in reports relatives to 158 aesthetic-functional rhinoplasties. The surgeon recorded in a protocol the data relatives to the use of local anesthetics and sedatives (including concentration and quantities utilized) as well as the side effects. In the first return post surgery the patient quantifies the pain that he felt in the intra operative utilizing a analogous visual scale as described by Hasen and collaborators. The Amnesia considered ideal when the patient referred to remind "nothing" or "a few of the procedure. Results: The sample constituted of 80 (73,4%) women and 29 )26,6%) men, average of age of 29,3 ± 9,5 years. The median of the pain by the analogous visual scale was 0,05; 80% under 3,35. The amnesia was ideal in 51 (46,8%) surgeries. The midazolam was utilized in all the surgeries. Fentanyl in 32 (29,4%) and, pethidine in 77 (70,6%). Had not statistically significants differences between the quantities of medication utilized between the groups of patients with ideal amnesia when compared with those that do not obtained satisfactory amnesia. Conclusion: Local anesthesia and sedation in rhinoplasties are comfortable and secures in the majority of the cases, even without have a satisfactory amnesia.

Laryngeal manifestations in atypical recurrent aphthous stomatitis / Manifestações laríngeas da Estomatite Aftoide Recorrente Atípica

Recurrent aphthoid stomatitis is characteristically observed in children and adolescents in the form of painful relapsing ulcers in the oral mucosa unaccompanied by evidences of systemic disease. The ulcers appear every one or two weeks for at least one entire year. Some patients suspected for recurrent aphthoid stomatitis develop lesions in atypical sites - mainly in the larynx - concurrently to the ones found in the oral mucosa. AIM: this study aims to describe a series of recurrent aphthoid stomatitis patients with atypical laryngeal injuries. Study design: this is a case series study. MATERIALS AND METHOD: patients diagnosed with recurrent aphthoid stomatitis with oral mucosa ulcers and laryngeal symptoms without altered lab test results and no evidence of systemic disease underwent fibroscopic examination, oral and laryngeal biopsies, followed by specimen evaluation by direct immunofluorescence. RESULTS: all six patients in this series had acute and chronic inflammatory processes according to pathology studies and negative direct immunofluorescence test results. CONCLUSION: laryngeal involvement in recurrent aphthoid stomatitis is rare. Therefore, during diagnostic examination thorough clinical history and meticulous physical examination accompanied by fibroscopic examination are necessary. When atypical lesions are found, biopsies for histological evaluation and direct immunofluorescence tests are required.

A Estomatite Aftoide Recorrente é definida como úlceras recorrentes e dolorosas na mucosa oral, de aparecimento na infância e adolescência, sem evidências de doenças sistêmicas, presentes quinzenal ou mensalmente por um período mínimo de um ano. No entanto existem quadros sugestivos de Estomatite Aftoide Recorrente que mostram lesões em localizações atípicas, principalmente em laringe, concomitantes àquelas localizadas na mucosa oral. OBJETIVO: Descrever uma série de portadores de Estomatite Aftoide Recorrente com apresentação atípica em laringe. Forma do Estudo: Estudo de uma série de casos. MÉTODO: Pacientes com diagnóstico clínico de Estomatite Aftoide Recorrente, com lesões em mucosa oral e sintomas laríngeos, sem alterações nos exames laboratoriais e sem evidências de doenças sistêmicas, foram submetidos a exame fibroscópico e a biópsia oral e laríngea, complementadas com Imunofluorescência Direta. RESULTADOS: Todos os seis pacientes desta série apresentaram como resultados histopatológicos processo inflamatório agudo e crônico e Imunofluorescência Direta negativas. CONCLUSÃO: O acometimento laríngeo na Estomatite Aftoide Recorrente é raro, por isso durante o diagnóstico faz-se necessária uma boa história clínica e um adequado exame físico, incluindo os exames fibroscópicos. Diante de lesões atípicas, faz-se necessário uso de biópsia para estudo histológico e de Imunofluorescência Direta.

Caracterização da voz do indivíduo portador de obesidade mórbida / Morbid obesity and it´s relationship to voice alterations

RACIONAL: A obesidade é doença crônica e grave com crescimento alarmante em todo o mundo e de interesse na saúde pública. Existe alteração no comportamento vocal destes pacientes e ele é pouco estudado. OBJETIVO: Caracterizar prospectivamente a voz de indivíduos portadores de obesidade mórbida comparando-a com a de não obesos. MÉTODOS: Estudo prospectivo de 45 indivíduos adultos voluntários, 14 homens e 31 mulheres com idade média de 43 anos variando de 20 a 63 anos. Todos apresentavam IMC acima de 35 Kg/m2 constituindo o grupo em estudo (GO) Para cada indivíduo do GO foi selecionado também um indivíduo adulto voluntário, proveniente da população geral do ambulatório de otorrinolaringologia com IMC abaixo de 30 Kg/m2, constituindo o grupo controle (GN). Os critérios de exclusão foram diagnóstico de lesões neoplásicas malignas em cabeça e pescoço ou operações prévias da região orofaríngea. Fooram submetidos a exame laringológico e à gravação da voz. Também submeteram-se à avaliação subjetiva perceptivo-auditiva da qualidade vocal, através da escala GIRBAS e a aspereza, o estrangulamento no final das. A análise acústica foi realizada objetivamente utilizando os softwares Vox Metria versão 4.0.47 e PRAAT, fornecendo a frequência fundamenta, jitter, shimmer, ruído e tempo máximo fonatório. RESULTADOS: Observou-se que os grupos foram homogêneos em relação ao sexo, idade, tabagismo e altura, mas significativamente diferentes em relação ao peso e IMC (P<0,001). Os achados laringoscópicos em ambos os grupos mostraram que 26,7% dos obesos tinham laringoscopia alterada contra 13,3% dos não obesos. Sinais laríngeos sugestivos de RLF foram significativos para o GO (P<0,042). A análise perceptivo-auditiva revelou que o grau da disfonia, a instabilidade, a rouquidão, a soprosidade, a astenia, a tensão e a aspereza tiveram alterações altamente significantes para o GO (P=0,001 ou 002)...

BACKGROUND: Obesity is a chronic disease with public health interest. Voice disturbance is common in this group. AIM: To compare the voice between the morbid obese patients with the non obese. METHODS: Prospective trial with 45 adult volunteers with 43 years old median age with BMI>35 Kg/m2 as study group and a control group in the same number but with BMI<30 Kg/m2. Exclusion criteria were tumor in head and neck or previous operations in oropharynx. All had laryngoscopy and voice recording. They were submitted to GIRBAS score. Acoustic analysis was done based on Vox Metria software and PRAAT. RESULTS: Laryngoscopy showed alterations in 26,7% of the obese group and 13,3% in controls. The GIRBAS score was highly significant to the obese group. Acoustic alterations were also significant in the obese group. CONCLUSION: The patients with morbid obesity have significant alterations in voice caracteristics in comparison to the ones normal in weight.

Correlation between histocompatibility antigens and recurrent aphthous stomatitis in the brazilian population / Estudo da associação entre antígenos de histocompatibilidade e estomatite aftoide recorrente em população brasileira

Recurrent aphthous stomatitis is a common oral mucosa disorder that affects 20 percent of the world's population, characterized by recurring painful ulcers in the mouth. The diagnosis is primarily based on the patient's clinical history. Inheritance may pose as a risk factor for the disease; however, the studies available are inconclusive as to the results attained, and they vary according to the population studied. AIM: to typify class I and class II HLA molecules and to assess how frequent these molecules are present in the Brazilian population with Recurrent Aphthous Stomatitis, compared to healthy controls. MATERIALS AND METHODS: In this prospective, cross-sectional and investigative study, thirty one patients with diagnostic hypothesis of recurrent aphthous stomatitis were seen from February of 2004 to May of 2006. We obtained the DNA from those patients who matched the inclusion criteria and typified their HLA by PCR. RESULTS: In those patients with Recurrent Minor Aphthous Stomatitis we found statistically significant occurrences of HLA-A33 and HLA-B35. CONCLUSION: HLA-A33 and HLA-B35 may be associated with recurrent minor aphthous stomatitis in the Brazilian's population.

A Estomatite Aftoide Recorrente é uma doença oral com incidência em 20 por cento da população mundial, caracterizada por úlceras mucosas de caráter recidivante. O diagnóstico baseiase principalmente na história clínica do paciente. Hereditariedade pode ser um fator de risco para doença, entretanto, os estudos disponíveis não são conclusivos quanto aos resultados obtidos, variando segundo a população estudada. OBJETIVO: Tipificar moléculas HLA de classe I e de classe II e avaliar a frequência destas moléculas em pacientes brasileiros, portadores de Estomatite Aftoide Recorrente, comparando com grupo controle. MATERIAL E MÉTODO: Este trabalho possui um desenho prospectivo, transverso e investigativo. Foram estudados 31 pacientes com suspeita diagnóstica de Estomatite Aftoide Recorrente no período de fevereiro de 2004 a maio de 2006. Os pacientes foram submetidos a protocolo de exames e, daqueles que obedeceram aos critérios de inclusão, foi extraído o DNA e realizada a tipificação HLA por Reação de Polimerização em Cadeia. RESULTADO: Nos pacientes portadores de Estomatite Aftoide Recorrente do tipo minor encontramos as frequências HLA A33 e B35 estatisticamente significantes. CONCLUSÃO: As frequências HLA-A33 e HLA-B35 podem estar associadas à Estomatite Aftoide Recorrente minor na população brasileira.