Follow-up clarifications concerning the authors' reply to the 'look at the elephant!' comment on 'prevalence of temporomandibular disorders in adult obstructive sleep apnoea patients: A cross-sectional controlled study'.

OSAS and TMDs represent multifactorial nosologic entities, whose central, functional and psycho-social aspects are gaining growing attention within the scientific community. In our previous commentary, we wanted to point out that structural aspects should not be forgotten in a clinical and research context. The inherent complexity of the matter could make it difficult to quantify the exact contribution of every single factor. The multifaceted nature of OSAS and TMDs pathophysiology could sustain several phenotypes in both conditions, and the anatomic parameters may assume different weights according to each phenotype, possibly justifying literature discrepancies. Thus, a patient with a co-existing OSAS and TMD (umbrella terms per se, each of them including different pathophysiological and clinical characteristics) represents an even greater challenge to researchers and practitioners. The scientific and therapeutic community should keep on looking for evidence to offer the best possible answers to such daring questions, in the most collaborative and fruitful way.

Oral splint therapy in patients with Menière's disease and temporomandibular disorder: a long-term, controlled study.

PURPOSE: To assess the effect of oral splint therapy on audio-vestibular symptoms in patients with Menière's disease (MD) and temporomandibular disorder (TMD). METHODS: Retrospective case-control study. Treatment group: 37 patients with MD and TMD who received gnatological treatment. CONTROL GROUP: 26 patients with MD and TMD who had never received gnatological treatment. The number of vertigo spells in 6 months (primary endpoint), pure-tone audiometry average (PTA), MD stage, functional level, Dizziness handicap Index (DHI), Tinnitus handicap Index (THI) and Aural Fullness Scale (AFS) were compared at baseline and after 24 months according to groups. Analysis of Covariance was used to determine the treatment effect. RESULTS: Groups were comparable for demographic, clinical data, baseline PTAs and the number of vertigo spells. Analysis of covariance showed a significant effect of gnathological treatment on number of vertigo spells ([Formula: see text] = 0.258, p < 0.001), PTA ([Formula: see text] = 0.201, p < 0.001), MD stage ([Formula: see text] = 0.224, p < 0.001), functional level ([Formula: see text] = 0.424, p < 0.001), DHI ([Formula: see text] = 0.421, p < 0.001), THI ([Formula: see text] = 0.183, p < 0.001), but not for AFS ([Formula: see text] = 0.005, p = 0.582). The treatment group showed vertigo control of class A in 86.5% and class B in 13.5% of patients. In the control group, vertigo control was of class A in 19.2% of patients and class B in 11.5%, class C in 30.8%, class D in 11.5%, class E in 19.2% and class F in 7.7%. Classes of vertigo control differed significantly (X2 test, p < 0.001). CONCLUSIONS: Oral splint therapy could represent a viable treatment in patients with TMD and uncontrolled MD disease. The effects are maintained at least after 2 years.

Human papillomavirus infection and non-oropharyngeal head and neck cancers: an umbrella review of meta-analysis.

OBJECTIVE: The causative and prognostic roles of human papillomavirus (HPV) in non-oropharyngeal squamous cell carcinoma of the head and neck are uncertain. This umbrella review assessed the strength and quality of evidence and graded the evidence derived from published meta-analyses on this subject. DATA SOURCES: MEDLINE, Embase, and the Cochrane Library were searched. Meta-analyses of observational studies and randomized trials were included. REVIEW METHODS: Evidence of association was graded according to the established criteria: strong, highly suggestive, suggestive, weak, or not significant. RESULTS: 15 meta-analyses were evaluated. The association with HPV was highly suggestive of oral (OR = 2.40, [1.87-3.07], P < 0.00001) and nasopharyngeal cancers (OR = 17.82 [11.20-28.35], P < 0.00001). Improved survival emerged only in hypopharyngeal carcinoma and was confirmed in studies in which only p16 + cancers were considered. CONCLUSION: HPV infection may increase the risk of oral cavity and nasopharyngeal cancer. However, the prognosis was not influenced, except in hypopharyngeal carcinoma.

Comparison of different treatments for HPV+ oropharyngeal carcinoma: a network meta-analysis.

INTRODUCTION: Treatment of human papillomavirus (HPV)-related head and neck squamous cell carcinoma (HNSCC) is rapidly evolving. Despite either surgery or radiotherapy (RT), with or without chemotherapy (CT), being acceptable in intermediate and locally advanced diseases, there is uncertainty regarding the best treatment option for these patients. Therefore, we performed a network meta-analysis (NMA) to compare the relative efficacy of different treatments for HPV+ oropharyngeal carcinoma. MATERIAL AND METHODS: Randomized clinical trials that enrolled adults with non-metastatic HPV+ oropharynx cancer and provided data about overall survival (OS) and/or progression-free survival (PFS) and/or locoregional control and distant metastases (LRC and DM) were included. Fixed- or random-effects models were fit using a Bayesian approach to NMA. Between-group comparisons were estimated using hazard ratios (HRs) with 95% credible intervals (CrIs). The primary outcome was OS. RESULTS: A total of 844 citations were screened; 11 randomized clinical trials were included (HPV+ stage III-IV cancer, mainly oropharynx carcinomas). Nine treatment arms were compared. Radiotherapy (altered or standard fractionation) + triweekly cisplatin (HR 3.8; 95% CrIs 0.29-65 and 0.3; 95% CrIs 0.03-2.51) was superior to RT in term of OS (P score = 0.42 and 0.16). Radiotherapy with low and high cisplatin doses appeared similar (HR 1.57; 95% CrIs 0.19-12.72). Altered fractionation or standard RT + 3-weekly cisplatin are the 2 highest-ranked options in terms of PFS (P score = 0.35 and 0.34). CONCLUSIONS: This meta-analysis confirms the role of cisplatin added to RT as the best option for HPV+ oropharyngeal carcinoma. RT+ 3-weekly cisplatin is likely to be the best radical treatment in terms of OS and PFS.

Look at the elephant! Commentary on 'Prevalence of temporomandibular disorders in adult obstructive sleep apnoea patients: A cross-sectional controlled study'.

The relationship between obstructive sleep apnoea (OSA) and temporomandibular disorders (TMDs) is complex. Research has shown controversial evidence. The recent study by Bartolucci et al. titled 'Prevalence of temporomandibular disorders in adult obstructive sleep apnoea patients: A cross-sectional controlled study' reported no clear associations between the two conditions. However, it does not take into account the occlusal and mandibular features of the patients, which may justify the hypothetical coexistence of OSA and TMD in a subset of cases. In this letter, we discuss these aspects and possible biases that could have impaired the results.

Self-reported smell and taste recovery in coronavirus disease 2019 patients: a one-year prospective study.

PURPOSE: The aim of the present study was to estimate the 1 year prevalence and recovery rate of self-reported chemosensory dysfunction in a series of subjects with previous mild-to-moderate symptomatic COVID-19. METHODS: Prospective study based on the SNOT-22, item "sense of smell or taste" and additional outcomes. RESULTS: 268/315 patients (85.1%) completing the survey at baseline also completed the follow-up interview. The 12 months prevalence of self-reported COVID-19 associated chemosensory dysfunction was 21.3% (95% CI 16.5-26.7%). Of the 187 patients who complained of COVID-19 associated chemosensory dysfunction at baseline, 130 (69.5%; 95% CI 62.4-76.0%) reported complete resolution of smell or taste impairment, 41 (21.9%) reported a decrease in the severity, and 16 (8.6%) reported the symptom was unchanged or worse 1 year after onset. The risk of persistence was higher for patients reporting a baseline SNOT-22 score ≥ 4 (OR = 3.32; 95% CI 1.32-8.36) as well as for those requiring ≥ 22 days for a negative swab (OR = 2.18; 95% CI 1.12-4.27). CONCLUSION: A substantial proportion of patients with previous mild-to-moderate symptomatic COVID-19 characterized by new onset of chemosensory dysfunction still complained on altered sense of smell or taste 1 year after the onset.

Temporomandibular Joint and Otitis Media: A Narrative Review of Implications in Etiopathogenesis and Treatment.

Otitis media (OM) and its recurring (rAOM), effusive (OME), and chronic forms, represent a frequent clinical challenge. The middle ear, the mandible, and the temporomandibular joint (TMJ) share several embryological and anatomical connections. Despite that, the role of mandibular malposition and TMJ dysfunction is frequently overlooked in the management of otitis media. In this narrative review, we present current evidence supporting the etiopathogenetic role of a dysfunctional stomatognathic system in the onset of OM and the effectiveness of orthognathic treatment in preventing rAOM and OME. In particular, a focus on the influence of TMJ on Eustachian tube function is provided.

Disposable chlorine dioxide wipes for high-level disinfection in the ENT department: A systematic review.

BACKGROUND: Nasopharyngoscope reprocessing methods should be effective, rapid and reproducible with moderate cost. Tristel Trio Wipes system (TTWS) is a manual reprocessing method based on chlorine dioxide that has lately emerged in ENT department. This review aims to collect evidence on this system. METHODS: The PubMed, Web of Science and Cochrane Library databases were searched for all the studies on TTWS or one of its components. Data were grouped according to the study type. RESULTS: Ten articles were included in the review. TTWS ensured high-level disinfection in laboratory and clinical setting. Although the limitations of the manual systems, TTWS proved to be faster than automated endoscope reprocessing (AER) and safe for patients and health-care workers. TTWS represented cheaper system than AER or sheaths in low- and medium-volume centers. CONCLUSION: TTWS could be a valid, safe and fast HLD method for nasopharyngoscopes, with reasonable costs for medium-low reprocessing volumes.

The predictive role of PD-L1 in head and neck cancer: A systematic review and meta-analysis.

This systematic review and meta-analysis investigates the predictive and prognostic role of PD-L1 expression in treating head and neck squamous cell carcinoma (HNSCC). Recognizing the importance of PD-L1 in patient response to treatment, the main objective was to assess its impact on overall survival and progression-free survival in HNSCC patients. A thorough search of databases such as PubMed, Scopus, and Web of Science from 2010 to 2022, along with relevant articles and references, yielded 120 studies. Of these, 7 met the criteria focusing on HNSCC patients, PD-L1 expression evaluation, and treatment with PD-1 or PD-L1 inhibitors. Data extraction followed PRISMA guidelines and involved independent review and consensus for discrepancies. The primary outcomes analyzed were overall survival and progression-free survival in relation to PD-L1 expression levels in patients undergoing immunotherapy.Theseven randomized controlled trials selected had a total of 4,477 participants. Results showed that patients with positive PD-L1 expression experienced improved overall survival when treated with PD-1 or PD-L1 inhibitors, particularly those with high PD-L1 expression. However, PD-L1 expression did not significantly affect progression-free survival. These findings suggest that PD-L1 expression can be a predictive marker for better overall survival in HNSCC patients treated with immunotherapy. However, its influence on progression-free survival remains unclear, indicating the need for further research.

HPV impact on oropharyngeal cancer radiological staging: 7th vs 8th edition of AJCC TNM classification.

PURPOSE: To evaluate the agreement between pathological and radiological staging in oropharyngeal cancer by comparing the 7th and the 8th edition of the AJCC TNM system. METHODS: This retrospective cohort study included 57 cases of oropharyngeal cancer with lymph node metastases staged with the 7th and 8th editions of the AJCC TNM system. Comparison between clinical and radiological features and differences in agreement rates were calculated between radiological and pathological staging for the primary tumor (T) and lymph nodes (N) in HPVpos and HPVneg cases. RESULTS: Comparison of HPVpos and HPVneg revealed a significantly different distribution between early and advanced stages in the 8 th edition, with a relevant number of HPVpos patients redefined from advanced stages whit the 7 th ed. to early stages with 8 th ed. (p < 0.01); no significant differences were found when comparing all diagnostic methods for T and N. CONCLUSIONS: The 8th edition of the AJCC TNM seems to lead to better pretreatment staging. For both HPVpos and HPVneg, the agreement between pretreatment radiological and pathological staging.

Prognostic role of EAONO/JOS, STAMCO, and ChOLE Staging for Exclusive Endoscopic and Endoscopic-Microscopic Tympanoplasty.

OBJECTIVE: The aim of the study is to evaluate cholesteatoma's surgical outcomes in patients treated with endoscopic ear surgery (EES) or a combined endoscopic-microscopic approach (cEMA) according to STAM, STAMCO, ChOLE, and EAONO/JOS system (EJS) classifications and staging. STUDY DESIGN: Retrospective study. SETTING: Monocentric study in a tertiary referral center. METHODS: One-hundred sixty-eight patients who underwent EES or cEMA for cholesteatoma between 2010 and 2018 were classified according to the abovementioned classification and staging. Data on cholesteatoma's recurrence and residual rates were collected. Inferential statistical analysis was performed to evaluate surgical outcomes and the prognostic value of classifications and staging. RESULTS: The recurrence rate was significantly lower in cholesteatomas classified in EJS stage 1 (2.6%) and STAM stage 1 (0%). A comparison of the different stages of the disease showed a significantly lower recurrence only for stage 1 versus the superior stages of both classifications. Involvement of mastoid bone was associated with a higher risk of recurrence (odds ratio [OR]: 4.12; p = .031). Attical involvement was associated with a higher risk of residual cholesteatoma (OR: 1.165; p = .046). CONCLUSION: EES or cEMA represents an effective treatment for middle ear cholesteatoma. The STAM classification and the EJS have shown a prognostic value, with STAM 1 and EAONO-JOS 1 stages associated with a better prognosis. Mastoid involvement represents a risk factor for recurrence. Attic localization is associated with residual disease. Localization at difficult access sites did not implicate a higher risk for recurrence or residual. ChOLE classification, Ossicular chain status, and complication status did not provide prognostic information regarding recurrence or residual cholesteatoma.

COVID-19 and Deafness: Impact of Face Masks on Speech Perception.

BACKGROUND: The COVID-19 pandemic has made wearing face masks a common habit in public places. Several reports have underlined the increased difficulties encountered by deaf people in speech comprehension, resulting in a higher risk of social isolation and psychological distress. PURPOSE: To address the detrimental effect of different types of face masks on speech perception, according to the listener hearing level and background noise. RESEARCH DESIGN: Quasi-experimental cross-sectional study. STUDY SAMPLE: Thirty patients were assessed: 16 with normal hearing [NH], and 14 hearing-impaired [HI] with moderate hearing loss. DATA COLLECTION AND ANALYSIS: A speech perception test (TAUV) was administered by an operator trained to speak at 65 dB, without a face mask, with a surgical mask, and with a KN95/FFP2 face mask, in a quiet and in a noisy environment (cocktail party noise, 55 dB). The Hearing Handicap Index for Adults (HHI-A) was administered twice, asking subjects to complete it for the period before and after the pandemic outburst. A 2-way repeated-measure analysis of variance was performed. RESULTS: The NH group showed a significant difference between the no-mask and the KN95/FFP2-mask condition in noise (p = 0.01). The HI group showed significant differences for surgical or KN95/FFP2 mask compared with no-mask, and for KN95/FFP2 compared with surgical mask, in quiet and in noise (p < 0.001). An increase in HHI-A scores was recorded for the HI patients (p < 0.001). CONCLUSION: Face masks have a detrimental effect on speech perception especially for HI patients, potentially worsening their hearing-related quality of life.

Italian validation of the Neck Dissection Impairment Index questionnaire.

Objective: The Neck Dissection Impairment Index (NDII) questionnaire is a useful and validated Quality of Life (QoL) evaluation instrument in patients undergoing major head-neck surgery. Its English version has been used in several studies in the last years. The aim of this work is to validate the NDII in Italian for both patient assessment and future studies. Materials and methods: Cross-cultural adaptation of the NDII was performed using standard techniques. Items of the original NDII were translated into Italian by a professional translator and two bilingual investigators. A final consensus version was obtained and given to two professional translators to produce a literal translation into English. The two translators and an expert committee synthesised the results of the translations in an English back-translated version that was compared with the original to check that they had the same semantic value. Results: Finally, a total of 42 patients completed both copies of the translated questionnaires. Internal consistency proved to be excellent, with Cronbach's alpha = 0.95. Conclusions: The NDII was successfully translated into Italian and its use was easy for patients. The translation of the NDII can represent a useful tool for individual patient assessment and future research.

NBI utility in oncologic surgery: An organ by organ review.

The main aims of the oncologic surgeon should be an early tumor diagnosis, complete surgical resection, and a careful post-treatment follow-up to ensure a prompt diagnosis of recurrence. Radiologic and endoscopic methods have been traditionally used for these purposes, but their accuracy might sometimes be suboptimal. Technological improvements could help the clinician during the diagnostic and therapeutic management of tumors. Narrow band imaging (NBI) belongs to optical image techniques, and uses light characteristics to enhance tissue vascularization. Because neoangiogenesis is a fundamental step during carcinogenesis, NBI could be useful in the diagnostic and therapeutic workup of tumors. Since its introduction in 2001, NBI use has rapidly spread in different oncologic specialties with clear advantages. There is an active interest in this topic as demonstrated by the thriving literature. It is unavoidable for clinicians to gain in-depth knowledge about the application of NBI to their specific field, losing the overall view on the topic. However, by looking at other fields of application, clinicians could find ideas to improve NBI use in their own specialty. The aim of this review is to summarize the existing literature on NBI use in oncology, with the aim of providing the state of the art: we present an overview on NBI fields of application, results, and possible future improvements in the different specialties.

pT3 N0 Laryngeal Squamous Cell Carcinoma: Oncologic Outcomes and Prognostic Factors of Surgically Treated Patients.

OBJECTIVES/HYPOTHESIS: To assess the disease control, survival rates, and prognostic factors of exclusive surgical treatment for patients with pT3 N0 laryngeal squamous cell carcinoma (LSCC). STUDY DESIGN: Multicentric retrospective cohort study. METHODS: Multicentric retrospective case series of previously untreated patients with pT3 R0N0 LSCC, who received exclusive surgery between 2011 and 2019. Tumor location; subsite involvement; grading; and lymphatic, vascular, and perineural invasion were reported. Overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were measured. RESULTS: Fifty-four patients (mean age 67.1; male sex 83.3%; mean follow-up period 37 months) underwent total laryngectomy (48.1%) or partial laryngectomy (51.9%). Ipsilateral or bilateral neck dissection was performed in 46 (85.2%) cases. Perineural invasion was more frequent in case of supraglottic involvement than glottic involvement (85.7% vs. 14.3%, P = .03). Five (9.3%) patients experienced recurrence (3 local recurrences, 1 nodal recurrence, 1 distant recurrence). Rate of recurrence differed between glottic (0%), supraglottic (80%), and transglottic (20%) tumors (P = .01), with a lower risk yielded by glottic involvement (odds ratio [OR], 0.05, 95% confidence interval [95% CI], 0.01-0.56, P = .01). A higher risk was recorded in case of perineural invasion (OR, 66.0, 95% CI, 1.41-3085.3, P = .03). The OS, DSS, and DFS were 79.6%, 96.3%, and 90.7%, without differences regarding the type of surgery. The DFS was lower in case of supraglottic involvement when compared to purely glottic LSCC (83.9% vs. 100%, P = 0.02). CONCLUSIONS: Exclusive surgery is a safe option for patients with pT3 R0N0 LSCC. Adjuvant treatments or closer follow-up monitoring might be considered in case of supraglottic involvement or perineural invasion. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2262-2268, 2021.

COVID-19 in the tonsillectomised population.

OBJECTIVE: Interactions between SARS-CoV-2 and pharyngeal associated lymphoid tissue are thought to influence the manifestations of COVID-19. We aimed to determine whether a previous history of tonsillectomy, as a surrogate indicator of a dysfunctional pharyngeal associated lymphoid tissue, could predict the presentation and course of COVID-19. METHODS: Multicentric cross-sectional observational study involving seven hospitals in Northern and Central Italy. Data on the clinical course and signs and symptoms of the infection were collected from 779 adults who tested positive for SARS-CoV-2, and analysed in relation to previous tonsillectomy, together with demographic and anamnestic data. RESULTS: Patients with previous tonsillectomy showed a greater risk of fever, temperature higher than 39°C, chills and malaise. No significant differences in hospital admissions were found. CONCLUSIONS: A previous history of tonsillectomy, as a surrogate indicator of immunological dysfunction of the pharyngeal associated lymphoid tissue, could predict a more intense systemic manifestation of COVID-19. These results could provide a simple clinical marker to discriminate suspected carriers and to delineate more precise prognostic models.

Primary Adenoid Cystic Carcinoma of the Frontal Sinus: Case Description of a Previously Unreported Entity and Literature Review.

Sinonasal adenoid cystic carcinoma is a rare malignant epithelial tumor characterized by slow growth, multiple local recurrences, and perineural invasion; surgery followed by radiotherapy provides the best overall survival by means of an endoscopic, craniofacial, or combined approach. We present a previously undescribed case of frontal sinus adenoid cystic carcinoma involving the subcutaneous tissue and the dura mater treated with an open technique, free flap reconstruction, and hadron therapy together with a summary of the state of the art.