Comparison of the Reliability of the House- Brackmann, Facial Nerve Grading System 2.0, and Sunnybrook Facial Grading System for the Evaluation of Patients with Peripheral Facial Paralysis.

BACKGROUND: To compare the reliability of the House-Brackmann (HB), Facial Nerve Grading System 2.0 (FNGS 2.0), and Sunnybrook Facial Grading System (SB) which are widely used in the evaluation of peripheral facial paralysis (PFP) patients. METHODS: Thirty-five video-recorded adult PFP patients were included in the study. The evaluators comprised 6 physicians. Evaluations were conducted twice independently, utilizing video recordings. Simultaneously, the evaluators were asked to keep time during the evaluation. For the analysis of reliability, Fleiss' kappa coefficient was used for the HB, and the intraclass correlation coefficient (ICC) was used for the FNGS 2.0 and SB. RESULTS: The mean evaluation time of 1 patient was found to be 1.06 ± 0.24, 1.47 ± 0.23, and 2.32 ± 0.41 minutes for the HB, FNGS 2.0, and SB, respectively. For interrater reliability, Fleiss' kappa for the HB was 0.495 and 0.403; ICC for the FNGS 2.0 was 0.966 and 0.958; ICC for the SB was 0.960 and 0.967 for the first and second measurements, respectively. For intrarater reliability, Fleiss' kappa for the HB was 0.391, 0.446, 0.564, 0.502, 0.626, and 0.455; ICC for the FNGS 2.0 was 0.87, 0.982, 0.966, 0.929, 0.933, and 0.948; ICC for the SB was 0.935, 0.96, 0.895, 0.941, 0.96, and 0.94 for the 6 raters, respectively. CONCLUSION: In the present study, statistically high intra- and interrater correlations were found for the FNGS 2.0 and SB, while a moderate correlation was found for the HB. Although the HB seems to be more practical, it has been concluded that the FNGS 2.0 and SB are more reliable.

The effect of face mask usage on the allergic rhinitis symptoms in patients with pollen allergy during the covid-19 pandemic.

PURPOSE: The study aims to evaluate the use of face masks on allergic rhinitis symptoms in pollen allergy patients who were compulsorily using face masks due to the covid-19 pandemic. MATERIALS AND METHODS: A 15-item questionnaire was developed following the study goals by a team experienced in allergic rhinitis. Then the records of patients who underwent allergy tests in our hospital between 2013 and 2019 were retrospectively analyzed. Fifty participants with isolated pollen allergy were included in the study. Patients who agreed to participate in the research answered the questions over the phone. RESULTS: Of the 50 participants, 30 (60%) were female and 20 (40%) were male, with a mean age of 34.34 ± 9.41 years. While the rate of participants who defined their nasal symptoms as severe-moderate in the pre-pandemic period was 92% (46 patients), this rate decreased to 56% (28 patients) during the pandemic when they used face masks. In ocular symptoms, the same rate decreased from 60% (30 patients) to 32% (16 patients). A statistically significant decrease was found in both nasal and ocular symptoms of patients after mask use (p < 0.001). The most regression in allergy symptoms was observed in sneezing (p = 0.029) and nasal discharge (p = 0.039). CONCLUSIONS: This study observed that the use of face masks reduced both nasal and ocular allergic rhinitis symptoms in individuals with pollen allergy. These results support the hypothesis that the use of face masks would reduce the severity of allergic rhinitis symptoms.

Bilateral choanal atresia in a 60-year-old man: A case report and review of the literature.

Choanal atresia is a congenital condition referring to the blockage of the posterior nasal cavity. As bilateral choanal atresia (BCA) causes complete nasal congestion, it usually results in death due to asphyxia in the newborn if no emergency intervention is performed. Therefore, it is very rare to see a patient with BCA who has reached an advanced age. There are only 11 adult cases reported in the recent literature. Here, we report a case of a 60-year-old man diagnosed with BCA and we discuss the clinical presentation and treatment modalities with a review of the literature.

Effectiveness of the Epley maneuver versus Cawthorne-Cooksey vestibular exercises in the treatment of posterior semicircular canal benign paroxysmal positional vertigo (BPPV): A randomized controlled trial.

OBJECTIVE: Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo that mainly affects the posterior semicircular canal. Studies suggest that Epley maneuver could improve balance of patients, but Cawthorne-Cooksey vestibular exercises are still scarce. This study aimed to observe the effects of Cawthorne-Cooksey vestibular exercises applied after the Epley maneuver on balance, vertigo symptoms, and quality of life in posterior semicircular canal BPPV. METHODS: Thirty-six patients with posterior semicircular canal BPPV were randomly assigned into Epley maneuver (EpleyM) and Epley maneuver and exercise (EpleyM&Exe) groups. All patients were treated with the Epley maneuver, while Cawthorne-Cooksey vestibular exercises were given to the EpleyM&Exe group as home exercises for 6 weeks. Their static and dynamic balance, vertigo symptoms, and quality of life were assessed at pre-, post-intervention (1st, 3rd and 6th weeks). RESULTS: Thirty-two patients completed the study (mean age: 46.91 ± 9.78 years). Epley maneuver applied alone and combined with Cawthorne-Cooksey vestibular exercises, was found to be effective in 25 patients (78.1%), 6 patients (18.8%) and 1 patient (3.1%) at the 1st, 3rd and 6th weeks, respectively. After 6 weeks, both groups had gained significant improvements in balance, vertigo symptoms, and quality of life (p < 0.001); however, there were no significant differences between the groups, except for the static dominant leg balance test (p = 0.022). CONCLUSIONS: The Epley maneuver can be considered as the first option compared to Cawthorne-Cooksey vestibular exercises. Exercises do not appear to have any additional effects in improving posterior semicircular canal BPPV symptoms.

Risk analysis in persistent cervical lymphadenopathies: Malignant or benign?

OBJECTIVE: The objective of the study was to determine the parameters that can be used to predict malignancy in persistent cervical lymphadenopathies. METHODS: We retrospectively reviewed the files of 162 patients diagnosed with persistent cervical lymphadenopathy who underwent an excisional biopsy in our department between January 2011 and October 2019. Patient demographics and the size, side, duration, and localization of lymphadenopathy were recorded, and their relationship with histopathological results was investigated. Multiple regression analysis was used to determine the relationship between clinical parameters and malignancy. RESULTS: Of the 162 patients, 91 (56.2%) were male and 71 (43.8%) were female, and the mean age was 45.40±20.41 (2-84) years. Male gender (OR=3.099; p=0.003), increasing age (OR=1.029; p=0.002), short duration of lymphadenopathy (OR=0.989; p=0.048), and neck level V (OR=2.604; p=0.031) patients had a statistically significantly higher risk of malignancy. There was no statistically significant relationship between the side and size of the lymph node and the risk of malignancy (p>0.05). CONCLUSION: In our study, male gender was determined to be the most predictive risk factor for malignancy in patients with cervical lymphadenopathy, followed by lymph node neck level, increased age, and duration of the disease.

Allergy Practices in Otorhinolaryngology Residency Programs in Turkey: Quo Vadis?

OBJECTIVE: The aim of this study was to investigate how allergy practices in the otorhinolaryngology (ORL) residency departments in Turkey have changed over the last 20 years and to examine the current status in ORL residency training. METHODS: A 17-item questionnaire was developed following the study goals by a team experienced in allergy practices. The questionnaire was sent via e-mail to the program directors of all the 95 ORL residency departments in Turkey. RESULTS: A total of 60 (63.2%) program directors completed the questionnaire. We found that allergy testing and immunotherapy had been performed in 70% and 28.3%, respectively, at any time to date. The most common reason for discontinuing in allergy practices over time was "the changes introduced by the Turkish Social Security Institute as stated in the healthcare implementation communiqué" and "the difficulties in obtaining vaccine supplies from companies". Of all departments, allergy testing, immunotherapy, nasal smear, and nasal provocation tests were performed only by 35%, 8.3%, 28.3%, and 1.7%, respectively. CONCLUSION: Allergy practices have been increasingly used, especially in the 2000s, but came to a standstill upon the changes introduced by the Turkish Social Security Institute as stated in the healthcare implementation communiqué. These findings suggest that allergy training, in the recent years, has remained in the background in ORL residency programs in Turkey. To achieve standardization in allergy training in ORL residency programs, professional associations and authorities should develop solutions in cooperation with legislators.

Prevalence of oropharyngeal high-risk human papillomavirus in tumor-free tonsil tissue in adults.

PURPOSE: To determine the prevalence of oropharyngeal high-risk human papillomavirus (HPV) in patients undergoing tonsillectomy by detection of high-risk HPV in tonsil tissues using the in situ hybridization (ISH) technique. MATERIALS AND METHODS: The patients who underwent tonsillectomy between 2014 and 2018 were examined retrospectively. The pediatric cases and patients who underwent tonsillectomy due to malignancy were excluded. The study included 270 adult cases selected by age and gender randomization. The tonsillar tissue of each case was re-examined by the pathology department, and the presence of high-risk HPV was investigated via the ISH technique. Multiple logistic regression models were used for predictions of different factors. RESULTS: The prevalence of high-risk HPV in the 270 patients (male: 154 [57%]; female: 116 [43%]; mean age: 36.44 ± 12.87 years) was found to be 6.7% (n = 18). The prevalence was found 8.4% in men and 4.3% in women; 8.9% in cases under the age of 40 and 2.9% in cases over the age of 40; and 10.9% in patients who underwent tonsillectomy for infectious indications and 2.3% for non-infectious indications. Multivariate analysis identified that the infectious indications for tonsillectomy were significantly associated with high-risk HPV positivity (OR 5.328; p = 0.009). CONCLUSIONS: The prevalence of oropharyngeal high-risk HPV was found to be 6.7% and higher in younger people and men. Additionally, the HPV positivity was found to be higher in patients who underwent tonsillectomy for infectious indications. To our knowledge, this is the first study that reports the correlation between recurrent tonsil infections and HPV positivity in tonsil tissue.

A 25-Year Bibliometric Analysis of Allergic Rhinitis Publications from Turkey.

OBJECTIVE: To analyze the change over the 25 years period in the number of publications on allergic rhinitis from Turkey, and to compare the data of the four major relevant specialties. METHODS: A search was conducted over 25-years between1994 and 2019 using the keywords "allergic rhinitis" and "Turkey" in PubMed®, and "allerji", "alerji" and "rinit" in TRDizin®. The articles were grouped by specialty; namely, "Otorhinolaryngology (ORL)," "Pediatrics," adult "Pulmonary disease" and adult "Allergy/immunology," based on the affiliation of the first author. The total number of publications in each specialty group within the 25-year period were compared using a significance test for a difference in two proportions within the statistical assessment. RESULTS: The 25-year results revealed 624 and 213 publications in the PubMed® and the TRDizin® databases, respectively. When the number of publications in a specific field in both databases was examined, the highest number of publications were identified in the ORL group, followed by the Pediatrics group. The number of publications in the ORL group was statistically higher than those in the "Pulmonary diseases" and "Allergy/immunology" groups in both the PubMed® and the TRDizin® databases (p=0.0001). CONCLUSION: The analysis of the number of 25-year allergic rhinitis publications from Turkey revealed that the academic interest of otolaryngologists in allergic rhinitis was unaffected, despite the challenges experienced in practice, with an increasing number of publications noted. When the number of 25-year publications was examined, ORL recorded the highest number of publications among all specialties.

A Novel Assessment Method With Ultrasound for Obstructive Tonsillar Hypertrophy in Children.

OBJECTIVES: To develop a new method for the objective evaluation of airway obstruction due to tonsillar hypertrophy using ultrasound (US) in children. METHODS: The oropharynx was examined in patients, and tonsil grades were evaluated according to the staging system of Brodsky et al (Int J Pediatr Otorhinolaryngol 1987; 13:149-156). The narrowest intertonsillar distance (ITD) and widest transverse length of the tongue base (TLTB) were then measured by US, and their ratio was calculated. The clinical value of US was investigated for the classification of tonsillar hypertrophies as nonobstructive or obstructive by matching the patients' clinical grades with the US data. RESULTS: A total of 102 patients (age range, 2-12 years) were included in the study. According to the Brodsky staging system, 44.1% and 55.9% of the patients were in nonobstructive (stages I and II) and obstructive (stages III and IV) tonsillar hypertrophy groups, respectively. The area under the curve was 0.991 (95% confidence interval, 0.977-0.999) according to a receiver operating characteristic curve analysis between the Brodsky staging and the ITD/TLTB ratio. The optimal cutoff value for the ITD/TLTB ratio for the diagnosis of obstructive tonsillar hypertrophy was found to be 0.3 or less, which had 96.5% sensitivity and 95.6% specificity. CONCLUSIONS: The degree of airway obstruction due to tonsillar hypertrophy can be objectively determined by US in children. An ITD/TLTB ratio of 0.3 or less was found to be compatible with obstructive tonsillar hypertrophy. This new and easily applicable evaluation method may provide considerable value and guidance for tonsillectomy decisions.

Salivary gland tumors: A 15-year experience of a university hospital in Turkey.

OBJECTIVE: To determine the demographic characteristics of benign and malignant salivary gland tumors in our department in the last 15 years. METHODS: In this study, the files of the patients who underwent salivary gland surgery between 2004 and 2019 in our department were analyzed retrospectively. A total of 366 patients whose diagnoses of salivary gland tumor histopathologically confirmed were included in this study. The demographic data of the patients and tumor localizations were recorded, and their relationships with histopathological results were examined. RESULTS: Of the 366 tumors, 292 (80%) of them was originated from the parotid gland, 52 (14%) from the submandibular gland, and 22 (6%) from the minor salivary gland. The male: female ratio was found as 1.2:1, and the mean age of the patients was 50.37 years. A total of 259 (70.8%) tumors were benign, and 107 (29.2%) were malignant. The most frequent benign tumor was pleomorphic adenoma, with 121 cases (46.7%). While pleomorphic adenomas constituted the majority of the benign tumors of the submandibular gland and minor salivary glands, Warthin tumor was detected more than pleomorphic adenoma in the parotid gland. The most common malignant tumor was mucoepidermoid carcinoma, with 26 cases (24.3%). CONCLUSION: The distribution of the salivary gland tumors detected in our department was found to be substantially similar to other worldwide series. Unlike the literature, we concluded that salivary gland tumors were seen slightly more in males, minor salivary gland tumors were relatively rare and Warthin tumors were more frequently detected in our region.

Validation of the Turkish Version of the Facial Nerve Grading System 2.0.

OBJECTIVE: We aimed to adapt the Facial Nerve Grading System 2.0 (FNGS 2.0) to Turkish and to investigate the validity and the reliability of the Turkish version. METHODS: The original FNGS 2.0 was translated into Turkish and validated by international standards. Six Turkish physicians, three specialists and three residents, independently rated the videos, two times each, of 40 adult facial palsy patients. Inter-rater and intra-rater reliability were assessed using the intraclass correlation coefficient (ICC) and Cronbach's alpha coefficient. As another indication of reliability, "generalizability" was also evaluated. For all analyses, a p value of <0.05 was considered statistically significant. RESULTS: ICC and Cronbach's alpha coefficients for the inter-rater reliability of the total score of the FNGS 2.0 were 0.970 and 0.979 for the first assessment, 0.973 and 0.979 for the second assessment, respectively. The intra-rater reliability ICC results for the total score of the FNGS 2.0 were 0.95, 0.976, 0.982, 0.956, 0.96 and 0.931 for the six raters, respectively. The generalizability coefficient was found as G=0.894. CONCLUSION: In this study, we adapted the FNGS 2.0 to Turkish, and confirmed its reliability and validity as a facial palsy scale. The Turkish version of the FNGS 2.0 can be safely used to assess.

Correlation between Surgical Outcome and Stage of Acquired Middle Ear Cholesteatoma: Revalidation of the EAONO/JOS Staging System.

OBJECTIVES: This study aimed to evaluate the intraoperative findings, recurrence rate, and hearing outcome of cholesteatoma surgery and correlate them with the newly proposed EAONO/JOS Joint Consensus Statement. MATERIALS AND METHODS: The records of 407 patients diagnosed with chronic otitis media and cholesteatoma between 2009 and 2017 were reviewed. After the exclusion of records with unsatisfactory surgical notes and anamnesis, 353 patients were included in the study. The 290 patients who had undergone primary surgery and 63 who had undergone revision surgery were evaluated separately. RESULTS: Total 162 of 290 (56%) patients had retraction pocket cholesteatoma and 128 of 290 (44%) patients had non-retraction pocket cholesteatoma. Eighty (28%) patients had stage I, 114 (39%) had stage II, 91 (31%) had stage III, and 5 (2%) had stage VI disease. The recurrence rate was 6.9% (20/290). The average age of these patients at the time of the second operation was 23.31±10.3 years. Twelve patients had (60%) recurrent cholesteatoma, and eight (40%) had residual cholesteatoma. Hearing outcome and surgical technique were significantly associated with the disease stage; however, the recurrence rate showed no such association. CONCLUSION: We concluded that the EAONO/JOS staging system is beneficial for estimating the postoperative hearing results and planning the surgical technique. However, there was no significant relationship between the recurrence rate and the EAONO/JOS staging system. We believe that additional factors, such as infection, ossicles, and invasion, predict the recurrence. Widespread use of the EAONO/JOS staging system will enable better evaluation of surgical outcomes and prognosis.

Validation of the Turkish version of the Sunnybrook facial grading system

Background/aim: To adapt the Sunnybrook facial grading system (SFGS) into Turkish and perform validation and reliability studies on the Turkish version. Materials and Methods: The original English version of the SFGS was translated into Turkish by performing a linguistic validity study based on international standards. The evaluators comprised 6 physicians. Evaluations were performed twice independently using the video recordings of 65 facial palsy patients. Synchronously, the House-Brackman facial grading system (HBFGS) was filled out to display concurrent validity. The intraclass correlation coefficient (ICC) and Cronbach's alpha was used for the examination of the inter- and intra-rater reliability. As another indication of reliability, the generalizability (G) was also examined. Results: The ICC for the inter-rater reliability for resting symmetry, symmetry of voluntary movement, synkinesis, and the composite score, which are 4 components of the SFGS, were determined, respectively, as 0.822, 0.956, 0.606, and 0.957 for the first evaluation, and 0.805, 0.965, 0.584, and 0.965 for the second evaluation. For the intra-rater reliability, the ICC were determined as 0.842, 0.956, 0.794, and 0.937, while the Cronbach's alpha coefficients were determined as 0.809, 0.956, 0.792, and 0.948, respectively. The G coefficient was determined as G = 0.772. For the concurrent validity, a strong correlation was found between the SFGS and HBFGS scores. Conclusion: The present study adapted the SFGS into Turkish, and demonstrated that the adapted scale was valid and reliable. The Turkish version can be used for the evaluation of facial palsy, the follow-up of treatment efficiency, and standardization in reporting outcomes with the international literature.

Assessment of Tonsil Volume With Transcervical Ultrasonography in Both Children and Adults.

OBJECTIVES: To investigate the success of ultrasonography (USG) in the objective measurement of palatin tonsil volume in both children and adults and to compare those results with clinical findings. METHODS: Eighty-five patients, who were scheduled to undergo tonsillectomy with the indications of recurrent tonsillitis and obstructive sleep apnea syndrome, were included in the study. The tonsil grades of the patients were recorded according to the Friedman tonsil grading. The tonsil size and volume were measured with transcervical USG. After tonsillectomy, the volumes of the tonsils were calculated by the displacement method. The correlation between the obtained data was evaluated. In all analyses, P < .05 was accepted as a statistical level of significance. RESULTS: Fifty children and 35 adults were included in the study. In children, the mean actual volume ± SD of 100 tonsils was measured as 3.5 ± 1.45 mL, and the USG volume was 3.67 ± 1.59 mL; a high correlation was found between both methods (r = 0.842; P < .05). In adults, the mean actual volume of 70 tonsils was measured as 5.15 ± 2.25 mL, and the USG volume was 5.71 ± 2.98 mL; a moderate correlation was found between the methods (r = 0.589; P < .05). In children, a moderate correlation was found between the Friedman grading and the USG (r = 0.532; P < .05), and actual (r = 0.549; P < .05) tonsil volumes. In adults, a low correlation was found between the Friedman grading and the USG (r = 0.363; P < .05) and actual (r = 0.384; P < .05) tonsil volumes. CONCLUSIONS: Ultrasonography is a useful, accessible, and noninvasive imaging method for objective measurement of tonsil volume in adults and children.

Adaptation of "Objective Structured Assessment of Technical Skills" for Adenotonsillectomy into Turkish: A Validity and Reliability Study.

OBJECTIVE: To adapt an objective surgical assessment tool (OSATS) for adenotonsillectomy/tonsillectomy to Turkish. METHODS: A prospective longitudinal validation study was planned. Adenoidectomy items were added to the tonsillectomy OSATS. Data were collected from 80 real-time observed surgical performances. To examine interrater reliability, 25 performances were simultaneously scored by two evaluators. In total, 105 test forms were filled, and reliability and validity studies were conducted. RESULTS: Regarding reliability, Cronbach's alpha values were found to be >0.95, indicating very high internal consistency. For interrater reliability, a statistically significant positive correlation was found between the two evaluators' task-specific checklist (TSC) (p=0.0001; r=0.969) and global rating checklist (GRC) (p=0.0001; r=0.957). Between the TSC and GRC, there was a statistically significant positive correlation (p=0.0001; r=0.951). A model was developed using the generalizability theory, and the highest variances belonged to surgical processes. Regarding validity, the trainers' scores were significantly higher than the trainees' scores (p=0.0001). As surgical experience increased, both the TSC and the GRC scores significantly increased (p=0.0001). A trainee's first-ever 34 adenotonsillectomy performances were scored. A scatter plot of the obtained data showed that the trainee had gained more scores as the number of operations increased. CONCLUSION: The results indicate that adenotonsillectomy OSATS is a reliable and valid tool for the assessment of residents' surgical skills. This is the first OSATS developed for adenotonsillectomy in the Turkish literature. It is ready to be used in the operating room to provide constructive feedback and monitor the development of trainees' surgical skills in adenotonsillectomy.

An Unusual Complication of Otitis Media: Luc's Abscess.

Luc's abscess is an extremely rare complication of otitis media, caused by the spread of the middle ear infection to the subperiosteal area and its accumulation beneath the temporal muscle. Unlike other subperiosteal abscesses relating to otitis media, infection may not be associated with mastoid bone involvement. Therefore, it is defined as a benign complication of otitis media. However, its rare occurrence may lead to delayed diagnosis and treatment. Here we report a case of an 11-year-old boy diagnosed with Luc's abscess with mastoid involvement. We discuss its clinical presentation and treatment with a review of the literature.

Direct Observation of Procedural Skills in Otorhinolaryngology Training.

OBJECTIVE: To assess the experience on using direct observation of procedural skills (DOPS) by trainees and trainers and to evaluate its use during the training process of Otorhinolaryngology (ORL) residency. METHODS: This study was designed as a prospective educational research. For the quantitative assessment, the "construct validity" of the assessment tool was examined. For the qualitative assessment, the trainees and trainers' experiences regarding the use of DOPS in training process were investigated. RESULTS: A total of 55 DOPS assessment forms were filled during the study. The mean observation time was 7.14±4.83 (range: 1-20) minutes, and the mean feedback time was 2.11±2.01 (range: 0.5-10) minutes. A significant difference was detected between the first year trainees and the older ones, whereas no significant difference was observed between the third, fourth, and fifth year trainees. A statistically significant, positive correlation was found between the years of education and the average score. According to the results of the qualitative assessment, the trainees stated that they realized their technical inadequacy in some procedures and it helped them to improve their skills during their residency training. The trainers confirmed that they gave feedback after each assessment. Both the trainers and trainees suggested that specific guidelines should be prepared for every procedure. CONCLUSION: DOPS is a useful, valid, and fair tool for assessing Otorhinolaryngology trainees. The data obtained from the DOPS forms can be used for demonstrating the success of a training clinic and to evaluate the training program.

Quantum molecular resonance-assisted phonomicrosurgery: preliminary experience.

The objective of this study was to evaluate the use of quantum molecular resonance (QMR) energy in phonomicrosurgery. Quantum molecular resonance energy (QMRE) is an innovative technology that provides low temperature cutting and coagulation of tissues and causes minimal tissue damage during the procedure. Because of these features, this technology may offer new possibilities in phonomicrosurgery. Twelve patients with vocal fold polyps underwent QMR-assisted phonomicrosurgery. The patients were evaluated before and after surgery at 1 and 3 months postoperatively by using the voice handicap index, laryngeal stroboscopy rating, acoustic voice analysis, and perceptual voice evaluation. The subjects were also evaluated by a patient self-assessment questionnaire at 3 months postoperatively. All parameters significantly improved after QMR-assisted phonomicrosurgery (P < .05). All of the patients also subjectively improved by self-rating. These results suggest that QMRE is a safe and potentially promising treatment in phonomicrosurgery. Yet, further studies should be conducted to confirm these results.

Aural myiasis: case report.

Myiasis is the infestation of live vertebrates with dipterous larvae. Aural myiasis involves infestation of the external ear and/or middle ear. It is a rare clinical state that usually occurs in patients who have mental or physical disabilities. Although myiasis is a self-limiting disease, it can be associated with fatal complications like penetration within the central nervous system. We present a 87-year-old patient suffering from Alzheimer's disease with aural myiasis and also discuss the clinical presentation and efective therapies with a review of the literature.