A new halitosis screening tool: halitosis finding score derivation and validation.

OBJECTIVE: The lack of a valid and appropriate halitosis screening survey prompted us to develop and validate a simple, 15-item questionnaire to be used as a screening tool to score halitosis for the daily practise. METHODS: After calculating the sample size, 200 participants were included in the study. All participants filled a 15-item questionnaire with the subsequent measurements of halitosis through the organoleptic scoring system and a halimeter. The application of questionnaire and the halitosis measurements were repeated 15 days after the first control. RESULTS: Mann-Whitney's U test was statistically significant between the halimeter measurements and Halfins scores (p=.000, p<.05). ROC curve is drawn due to halitometer analyses. The cut-off point was determined such as Halfins scores greater than 14 indicated halitosis (65.75 sensitivity, 66.04 specificity). The content validation and concurrent validity were proven successful. CONCLUSIONS: A new halitosis-specific screening tool called Halfins was proven as a valid diagnostic tool for measuring halitosis in the present study. Nevertheless, we believe this questionnaire could be used as complementary tool for the diagnosis of halitosis, seeing as its use alone is not able to firmly conclude the presence of halitosis in all cases, an organoleptic test or VSC assessment would still be necessary.

Adenoid cystic carcinoma located on the lower lip.

Adenoid cystic carcinoma is a relatively rare epithelial tumor of the major and minor salivary glands that makes up less than 1% of head and neck neoplasms. The typical clinical and pathological findings of this neoplasm include slow growth, perineural invasion, multiple local recurrences, and distant metastasis. Herein, we report a patient with adenoid cystic carcinoma located to the lower lip which is quite uncommon.

The effect of platelet-rich fibrin (PRF) on wound healing, adhesion, and hemostasis after endoscopic sinus surgery in patients with nasal polyposis.

PURPOSE: Chronic rhinosinusitis (CRS) is one of the most common chronic diseases seen worldwide. Endoscopic sinus surgery (ESS) has become a widely accepted procedure for medically refractory chronic rhinosinusitis and nasal polyps. Prevention of revision surgery often depends on good wound healing and less adhesion formation. In recent years, the effects of platelet-rich fibrin (PRF) on tissue healing have been addressed in many surgical branches, especially for dental implant surgery and plastic surgery. METHODS: This prospective study was conducted with 50 patients who underwent endoscopic sinus surgery for the diagnosis of nasal polyposis. While the middle meatus in one nasal cavity was filled with PRF and supported with Nasopore, only Nasopore was used in the other nasal cavity middle meatus. The patients were followed up clinically at weeks 1, 2, 3, 4, 8, and 12 postoperatively. The assessor determined the presence of adhesion, crusting, bleeding, frontal ostium stenosis, granulation, and infection, and if present, the grades of these complications were scored according to a questionnaire. RESULTS: In our study, adhesion, infection, bleeding, granulation, and frontal ostium stenosis were less common in the PRF group, and a statistically significant difference was found between the groups. CONCLUSION: In our study, better results were obtained in terms of adhesion, infection, bleeding, granulation, and frontal ostium stenosis after ESS as a result of the effects of PRF on wound healing. The application of PRF is an inexpensive and easy procedure. PRF can be a good alternative to other types of tampons after ESS.

Analysis of snoring to determine the site of obstruction in obstructive sleep apnea syndrome.

BACKGROUND: The aim of this study was to integrate the physical findings of drug-induced sleep endoscopy with snoring sound analysis in patients with obstructive sleep apnea/hypopnea syndrome (OSAS) and to compare the findings with previously published data. METHODS: This was a prospective, non-randomized study. Participants were all candidates for surgical treatment of OSAS and formed three groups, retropalatal (RP) obstructions, retrolingual (RL) obstructions, and multilevel (ML) obstructions. At the time of DISE, recordings of concurrent snoring sounds were made. Mean pitch frequency, peak sound frequency, and fundamental frequency (Fo) components were determined. RESULTS: A total of 55 participants had mean age 46.2 ± 7.3 years, mean BMI 30.0 ± 3.7 kg/m2, and included 11 women (20%). Differences in mean pitch frequency, Fo, and peak sound frequency were all statistically significant between the RP and RL (p = 0.001), between ML and RL (p = 0.025) but were not significantly different between RP and ML. Mean pitch frequency of RP was lower than RL, and ML frequency was between RL and RP. The sound analysis graphics revealed RP waves with sharp peaks and lower frequencies and RL with smooth curves and higher frequencies. ML showed irregular patterns. Mean pitch frequency of RL was always above 400 Hz, whereas RP was below this value. CONCLUSIONS: It is feasible to apply sound analysis to determine the site of obstruction during DISE. Combining the data may help surgeons make more accurate assessments of the pattern of the disease.

Comparison of the Olfactory Functions in Conventional Endoscopic Sinus Surgery to the Balloon Sinuplasty in Frontal Sinus Surgery.

OBJECTIVE: Balloon sinuplasty is being used worldwide, however the olfactory functions after balloon sinuplasty are underestimated. The authors aimed to study the effects of conventional endoscopic sinus surgery (ESS) compared to the balloon sinuplasty on olfactory function. MATERIALS AND METHODS: Forty-four subjects were randomly divided into 2 groups as ESS and balloon sinuplasty. The olfactory functions of each subject were recorded preoperatively and at the 1st, 3rd, 6th, and 12th months postoperatively. RESULTS: The initial assessments of olfaction were the same in both groups. After the surgery, the olfactory functions were significantly better in those of ESS group (P < 0.05). CONCLUSION: The olfactory function is preserved better in the conventional surgery compared to the balloon catheter dilation of the frontal sinus.

Impact of Upper Airway Collapse and Sleep Parameters on Daytime Sleepiness and Sleep Quality.

OBJECTIVE: Standard overnight polysomnography (PSG) scores only the apneahypopnea index (AHI) as a predictor of sleep apnea. It is proven that the arousals also contribute especially to the daytime symptoms of obstructive sleep apnea syndrome (OSA). The authors aimed to search the relevance of arousals and obstruction site in the upper airway with the sleep parameters, daytime sleepiness and the sleep quality. MATERIALS AND METHODS: A total number of 118 subjects were recruited. All of them received a full-night attended PSG and a thorough otolaryngologic examination to identify the site of obstruction in the upper airway and 2 different sleep questionnaires to present the daytime sleepiness and the sleep quality. RESULTS: The level of nasal airway blockage had no impact on AHI, daytime sleepiness and the sleep quality. The increase in level of tonsillar hypertrophy had a negative impact on oxygen desaturation index (ODI) only (P = 0.021). The level of retrolingual obstruction worsen ODI (P = 0.022), AHI (P = 0.041), daytime sleepiness (P = 0.047) and sleep quality (P = 0.033). CONCLUSION: Arousals during sleep deserve better attention in scoring PSG events, as they reliably reflect daytime somnolence and sleep quality. Retrolingual obstruction was the main contributor for cortical arousals. It is imperative to cure retrolingual obstruction properly which may be easily detected in sleep endoscopy.

A simple method to reduce halitosis; tongue scraping with probiotics.

OBJECTIVE: We aimed to assess the effects of probiotic implantation to the dorsum of the tongue against halitosis. MATERIALS AND METHODS: 100 participants were randomly divided into three groups as tongue back scraping (TS), probiotic implantation to the dorsum of the tongue (PB) and mouthwash alone as the control group (MW). Measurements were taken before the treatment, after the first month of treatment and one month after the cessation of treatment. RESULTS: Halimeter, winkel and woodlight scores were evaluated initially, in the first month and after the cessation of the treatment. All of MW measurements showed no difference throughout the study. All of TS measurements decreased significantly in the first month (p < 0.05) but rose again in the final count. All of PB measurements significantly decreased in the first month and kept their low levels after the cessation of the treatment (p < 0.05). CONCLUSION: Probiotics and tongue scraping are widely used against halitosis but they are not intended to be used together. In this study, we proposed and proved an effective method of probiotic implantation by tongue scraping and showed that halitosis did not recur after the cessation of the treatment.

Preservation of Autogenous Septal Cartilage for Revision Surgery.

The aim of this study is to find the ideal solution and the optimum temperature to protect the viability of the cartilage graft. This randomized prospective study consists of 30 patients with septal deviation. All patients had septoplasty operation for chronic nasal obstruction. Ten strips of cartilages were prepared from each excised septum and then immersed in formalin, alcohol (96%), saline (0,9%), gentamicin (80 mg), and cefazolin sodium (Cezol 1gr) solutions in a total of 300 vials. Those vials were stored for 6 months at both +4°C and -18°C temperatures. Two groups were compared with each other. 22 cases were male (73%) and 8 patients were female (7%). The age range was between 20 and 48 (average 25.34 ±â€Š4.09 years). Parameters at +4°C; the cartilage volume was not significantly different among the solutions (P >0.05). Necrosis was significantly lower in the alcohol (46.7%) compared to other solutions (P = 0.001). Calcification was lower in the gentamicin group (56.7%). The loss of metachromasia was lower in the alcohol solutions (P = 0.000). Parameters at -18°C; the loss of metachromasia was higher in the gentamicin group (56.7%) than the other solutions (P = 0.003). The authors observed no significance in the rates of necrosis, calcification, metaplasia, inflammation, vascularity, or fibrosis among the solutions (P >0.05). Less necrosis and metachromosis loss in the alcohol solution indicated that alcohol was more suitable for preservation of the cartilage. In addition, temperature degree for the preservation of the cartilage did not show any significant differences.

The value of ultrasound elastography-guided fine-needle aspiration biopsy of thyroid nodules in reducing nondiagnostic results.

Fine-needle aspiration biopsy (FNAB) is an important tool for diagnosing thyroid nodules; however, nondiagnostic results are a problem with FNAB. We evaluated the optimal targeting area of thyroid nodules for FNAB by using ultrasound elastography (USE) to reduce nondiagnostic results. Between December 2008 and November 2010, 96 consecutive prospective subjects scheduled to undergo FNAB were included in the study. Initially, the dominant nodule was evaluated with ultrasound, after which USE was performed. FNABs were performed from both the red (hard foci) and the green (soft foci) color-coded areas using the same technique according to the USE maps. The cellularity of all the specimens was evaluated cytopathologically. Nondiagnostic results from the red and green color-coded areas were compared by Chi-square test. In the red color-coded regions on USE images, the diagnostic rate was 76.0 % and the nondiagnostic rate was 24.0 %. In the green color-coded regions on USE images, the diagnostic rate was 53.1 % and the nondiagnostic rate was 46.9 %. Seven nodules were malignant and 89 were benign. Nondiagnostic results were significantly fewer in red color-coded regions (P = 0.0001). USE can help to enhance the cellularity of biopsy of thyroid nodules to reduce the nondiagnostic results if the red color-coded (less elastic or hard) areas are preferred.

Effects of soft palate implants on acoustic characteristics of voice and articulation.

OBJECTIVE: To evaluate the effects of soft palate implants on voice and articulation. STUDY DESIGN: Prospective case series. METHODS: Male subjects (n=23) diagnosed with mild obstructive sleep apnea and/or habitual snoring underwent acoustic analysis with the Multidimensional Voice Program (Kay Multi-Speech Model 3700 Advanced Version; Kay Elemetrics [KayPentax], Lincoln Park, NJ) before and 8 weeks after insertion of palatal implants to determine the effects of soft palate implants on voice and articulation. Sustained vowels (/a/e/u/o/i/) and phonetically balanced carrier sentences were used for acoustic analyses. Parameters measured were fundamental frequency (F0), jitter, shimmer, noise-to-harmonics ratio, Voice Turbulence Index, Soft Phonation Index, degree of voiceless, degree of voice breaks and peak amplitude variation, first formant (F1) and second formant (F2) frequencies, and voice onset time (VOT). F1 and F2 for each vowel were determined using linear predictive analysis on a spectrogram. VOT was measured for the palatal consonant /k/ and the dental consonant /t/ on a wideband spectrogram from a carrier sentence segment that contained a syllable with a stop consonant. RESULTS: No statistically significant difference was detected in F0, F1, F2, or other MDVP parameters before and after implantation. Average VOT values measured for /t/ were not significantly different. On the other hand, average VOT values of /k/ were found to be significantly shorter. CONCLUSIONS: Implant insertion had no significant effect on MDVP parameters, F0, F1, or F2. On the other hand, articulation as a function of velar region seemed to be affected because VOT values of velar /k/ were changed.

Transcervical tongue base reduction with hyoepiglottoplasty: long-term results.

Aims To evaluate the long term results of tongue base reduction with hyoepiglottoplasty as a surgical option in the treatment of severe obstructive sleep apnea. Material and Method Severe obstructive sleep apnea patients diagnosed as upper airway narrowing at the tongue base level were treated with transcervical tongue base reduction with hyoepiglottoplasty. Seven years after single stage multilevel surgery, the patients were reevaluated clinically, radiologically and polysomnographic records were taken. Preoperative, early postoperative and long-term postoperative parameters were compared to determine the success rate of the surgical technique. Results In the postoperative long-term follow-up Epworth sleepiness scale (ESS) scores were reduced to 4 and 6 respectively 2 months after surgery despite the initial values of 17 and 15. BMI were decreased from 29.7 and 27.9 kg/m(2) respectively to 26 and 24 kg/m(2). The apnea/hypopnea index (AHI) were reduced to 14.1 and 16.2 respectively from 68.6 and 83.83. O(2) nadir was 55 and 66% respectively and improved to 86 and 89%. Flexible nasopharyngoscopy revealed competent airway in both retropalatal and retroglossal level. Bed partners scored snoring as 2/10 and 4/10 corresponding to very mild and moderate. Daytime somnolence and witnessed apneic periods were completely disappeared in both patients. Conclusion Open tongue base resection with hyoepiglottoplasty is effective among all other surgical corrections of sleep apnea even after 7 years postoperatively.

Interexaminer agreement of Friedman tongue positions for staging of obstructive sleep apnea/hypopnea syndrome.

OBJECTIVE: To determine if strong interexaminer agreement exists in identifying Friedman tongue positions (FTPs) for staging of obstructive sleep apnea/hypopnea syndrome (OSAHS). STUDY DESIGN AND METHODS: Twenty-six digital video clips of oropharyngeal examinations were prepared to demonstrate FTPs I through IV. Specific parameters for each FTP were provided to 126 examiners (otolaryngology residents, attendings, and fellows). The video clips were then presented to the examiners to determine the FTP. Kappa statistical analysis was used to evaluate the degree of intergrader agreement or disagreement. RESULTS: A generalized kappa statistic of 0.8 is considered the upper limits of substantial agreement. Thus, the overall kappa value (0.82) as well as all the subgroup kappa values for attendings (0.84), fellows (0.87), and residents (0.84) represented "very good" agreement. CONCLUSION: The strong interexaminer correlation of FTP demonstrated by this study indicates that FTP may be a useful adjunct in describing hypopharyngeal anatomy in patients with OSAHS.

Evaluation of submucosal minimally invasive lingual excision technique for treatment of obstructive sleep apnea/hypopnea syndrome.

OBJECTIVE: Submucosal minimally invasive lingual excision (SMILE) is a novel approach to address hypopharyngeal obstruction. This study compares the efficacy, morbidity, and complications of this technique to radiofrequency reduction of the tongue base (RFBOT), the current standard in minimally invasive tongue base reduction. STUDY DESIGN: Retrospective analysis of data extracted from a prospective database. METHODS: Ninety-six patients who underwent SMILE (n=48) or RFBOT (n=48) were studied. Efficacy and safety of the procedures were compared on the basis of polysomnography results, morbidity measures, and complications. RESULTS: Patients in both groups demonstrated a significant reduction in the apnea/hypopnea index. Success rates for SMILE and RFBOT were 64.6 percent and 41.7 percent, respectively (P=0.024). SMILE, however, was associated with increased morbidity and complications. CONCLUSION: In a comparable surgical protocol for obstructive sleep apnea-hypopnea syndrome, SMILE technique for tongue base reduction demonstrated increased efficacy over RFBOT but resulted in more complications. Additional experience with the procedure may reduce complications and increase overall efficacy.

The efficacy of multilevel surgery of the upper airway in adults with obstructive sleep apnea/hypopnea syndrome.

OBJECTIVE: Many patients with obstructive sleep apnea/hypopnea syndrome (OSAHS) are incapable of using continuous positive airway pressure. These patients therefore turn to surgical options as a salvage treatment. Early studies and reviews focused on the efficacy of uvulopalatopharyngoplasty, a single-level procedure for the treatment of OSAHS. Since OSAHS is usually caused by multilevel obstructions, the true focus on efficacy should be on multilevel surgical intervention. The purpose of this paper is to provide an overview of the literature on multilevel surgery for OSAHS patients. STUDY DESIGN: Systematic review of the literature and meta-analysis focusing on subjective and objective outcomes of patients with OSAHS treated with multilevel surgery of the upper airway. METHODS: We searched PubMed, the Cochrane database, and MEDLINE bibliographic databases up to March 31, 2007, for studies dealing with multilevel surgical modification of the upper airway for the treatment of OSAHS. Additional studies were identified from their reference lists. Articles were included only if the surgical intervention involved at least two of the frequently involved anatomic sites: nose, oropharynx, and hypopharynx. RESULTS: After applying specific inclusion criteria, 49 multilevel surgery articles (58 groups) were identified. There were 1,978 patients included in the study. The mean minimal follow-up time was 7.3 months (range, 1 to 100 months). A meta-analysis was performed to redefine the success rate to be consistent with the commonly agreed upon criteria, namely "a reduction in the apnea/ hypopnea index (AHI) of 50% or more and an AHI of less than 20." "Success" implies an improved condition and is not meant to imply cure. The recalculated success rate was 66.4%. The overall complication rate was 14.6%. The evidence-base medicine (EBM) level of these 49 studies revealed that only one study was EBM level 1, two papers were EBM level 3, and the other 46 papers were ranked as level 4 evidence. CONCLUSIONS: Multilevel surgery for OSAHS is obviously associated with improved outcomes, although this benefit is supported largely by level 4 evidence. Future research should focus on prospective and controlled studies.

Guidelines for radioguided parathyroid surgery.

OBJECTIVE: To confirm or refute the notion that only parathyroid adenomas have radioactivity higher than 20% of background. DESIGN: Retrospective analysis of a prospective patient data set. SETTING: Tertiary care referral center. PATIENTS: Forty-six patients (9 men and 37 women; mean +/- SD age, 53.7 +/- 12.1 years) underwent thyroid and parathyroid surgery between December 2005 and December 2006 to collect data on ex vivo radioactivity percentages on a variety of tissues. INTERVENTIONS: Patients were injected with 296 to 925 MBq of technetium Tc 99m sestamibi 1(1/2) to 3(1/2) hours before surgery. Biopsy specimens were taken of normal parathyroid glands, normal thyroid tissue, and lymph nodes and ex vivo radioactivity was recorded. Hyperplastic parathyroid glands and adenomatous glands were excised. Finally, some enlarged glands were cut into segments, and radioactivity counts were recorded and compared with the weight of the tissue. MAIN OUTCOME MEASURES: All counts were compared with radioactivity percentages in the surrounding tissues, and results were expressed as a function of these background radioactive counts. RESULTS: The mean +/- SD ex vivo background radioactivity of parathyroid adenomas was 148.5% +/- 83.1% of background activity (range, 40.1%-388.9% but never less than 40%). The mean +/- SD ex vivo background radioactivity of hyperplastic parathyroid glands was 74.6% +/- 18.0% (range, 49.5%-109.1% but never less than 40%). A significant difference was found in ex vivo background radioactivity between pathologic parathyroid tissue and the other tissue specimens studied (normal parathyroid glands [2.4% +/- 1.8%], thyroid tissue [4.5% +/- 2.8%], lymph nodes [1.6% +/- 0.8%], and fat [0.4% +/- 0.3%]). CONCLUSIONS: Ex vivo radioactivity percentages can differentiate hyperactive parathyroid tissue from any other tissue, but they cannot differentiate adenoma from hyperplasia and thus are not helpful in ruling out multiglandular disease. Interpretation of ex vivo radioactivity percentages should take into consideration the size of the specimen.

Impact of treatment of gastroesophageal reflux on obstructive sleep apnea-hypopnea syndrome.

OBJECTIVES: We test the hypothesis that treatment of gastroesophageal reflux disease (GERD) can improve obstructive sleep apnea-hypopnea syndrome (OSAHS). METHODS: One hundred forty-six patients with OSAHS underwent a complete history-taking, physical examination, and laboratory testing, including questions related to GERD symptoms. Full-night attended polysomnography, 24-hour wireless pH study at the upper esophagus, snoring level evaluation, Epworth Sleepiness Scale, and quality-of-life surveys were completed for each patient. Patients who tested positive for GERD were treated with esomeprazole magnesium 40 mg once daily for 2 to 12 months. The 24-hour pH study was repeated, and those patients with elimination of GERD were reevaluated by polysomnography, snoring level evaluation, Epworth Sleepiness Scale, quality-of-life surveys, and subjective data collection. RESULTS: Forty-one patients completed single-dose treatment with esomeprazole, but the repeat 24-hour pH study showed that 9 patients had persistent GERD. In the 29 patients who completed phase 2 with normal pH study findings, the snoring level decreased from 9.7 +/- 0.5 to 7.9 +/- 1.3 (p < .0001), the Epworth Sleepiness Scale score decreased from 14.2 +/- 2.5 to 11.1 +/- 2.4 (p < .0001), the apnea-hypopnea index decreased from 37.9 +/- 19.1 to 28.8 +/- 11.5 (p = .006), and the minimum saturation of oxygen increased from 84.1% +/- 7.8% to 86.9% +/- 5.0% (p = .055). CONCLUSIONS: Treatment of GERD had a significant impact on the reduction of the apnea-hypopnea index, snoring, and daytime sleepiness. Elimination of GERD should be part of a comprehensive treatment plan for patients with OSAHS.

Minimally invasive single-stage multilevel treatment for obstructive sleep apnea/hypopnea syndrome.

OBJECTIVES: To assess subjective and objective improvement after single-stage multilevel minimally invasive treatment for obstructive sleep apnea/hypopnea syndrome (OSAHS). STUDY DESIGN: A retrospective review of a prospective dataset of patients treated in a tertiary care referral center. METHODS: Charts of 145 patients with mild/moderate OSAHS treated with a single-stage multilevel minimally invasive technique were reviewed to abstract pre- and posttreatment symptoms and polysomnographic data. One hundred twenty-two patients had minimum follow-up of 6 (range, 6-23) months and complete data available for analysis. All patients studied had three-level treatment that included nasal surgery, palatal stiffening by Pillar implant technique, and radiofrequency volume reduction of the tongue base. Primary outcomes included change from baseline in apnea/hypopnea index (AHI). Secondary outcomes included change in Epworth Sleepiness Scale (ESS) and bed-partner assessed snoring visual analogue scale (VAS, 0-10), pain levels, narcotic use, and complications. RESULTS: Mean AHI decreased from 23.2 +/- 7.6 preoperatively to 14.5 +/- 10.2 postoperatively (P < .0001). Classical "cure" was achieved in 54 (47.5%) patients. Mean ESS decreased from 9.7 +/- 3.9 preoperatively to 6.9 +/- 3.3 postoperatively (P < .0001). Mean snoring VAS decreased from 9.4 +/- 0.9 preoperatively to 3.2 +/- 2.4 postoperatively (P <. 0001). CONCLUSION: Polysomnographic respiratory parameters, ESS, and snoring VAS significantly improved in patients with mild/moderate OSAHS treated with single-stage multilevel minimally invasive surgery. Multilevel minimally invasive single-stage surgery is a valid option for selected patients with mild/moderate OSAHS with the understanding that they may require secondary treatment.

The effects of incisional myringotomy and CO2 laser myringotomy on rat tympanic membranes.

OBJECTIVE: The purpose of this study was to compare closure rates and histopathological findings of carbon dioxide (CO(2)) laser myringotomies to those of incisional myringotomy. STUDY DESIGN: We performed CO(2) laser round myringotomy on left ears and incisional round myringotomy on the right ears of 34 rats on the same day. The incisions were 2mm in size on both ears. Examination was made with otoendoscope on days 1, 3, 5, 7, 9, 11, 13, 15, 17, 19, 21, 25, 30, 35, 40, 45, 50 with videorecording. Two rats were sacrificed every 2 days for 25 days and every 5 days thereafter, randomly. The tympanic membranes (TM) were excised and hyalinization, fibrosis and inflammation were assessed with light microscope. RESULTS: Most of the CO(2) laser myringotomies healed after day 15, and all of them healed by day 50. Three of the incisional myringotomy perforations were closed at day 3, and the rest by day 15. Patency of CO(2) laser myringotomies was significantly longer than that of incisional myringotomies. Hyalinization, fibrosis and inflammation of the incisional myringotomy group were significantly less than those of the laser myringotomy group. CONCLUSIONS: CO(2) laser myringotomies remain patent for a longer period of time than the incisional procedure, however, they cause more tissue inflammation. We believe that CO(2) laser myringotomy is an effective method, however, additional studies are needed to identify its complications.