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.

Effectiveness of conventional versus virtual reality-based vestibular rehabilitation exercises in elderly patients with dizziness: a randomized controlled study with 6-month follow-up

Abstract Objectives: To investigate the effect of vestibular rehabilitation exercises supported with virtual reality containing real-life environments on dizziness, static and dynamic balance, functional mobility, fear of falling, anxiety, and depression in elderly patients with dizziness. Methods: In this prospective randomized controlled study, 32-patients aged 65-years and older who applied to the otorhinolaryngology clinic with dizziness complaint randomly assigned to 2 groups. In Group 1 (n = 16), vestibular rehabilitation program, supported with virtual reality, and in Group 2 (n = 16), conventional vestibular rehabilitation program was applied 30-min a day, 5 sessions per week, 15 sessions in total for 3 weeks. Subjects were evaluated with The Vertigo Symptom Scale (VSS), Dizziness Handicap Inventory (DHI), Berg Balance Test (BBT) and Timed Up & Go Test (TUG), Falls Efficacy Scale-International (FES-I), Postural Stability Test (PST), Geriatric Depression Scale (GDS), Hamilton Anxiety Scale (HAS) at baseline, at the end of the treatment and 6-months after the treatment. Results: Statistically significant improvements were seen in the DHI emotional subscale and TUG in Group 1 compared to Group 2 at the end of the treatment in elderly with dizziness (p<0.05). Also, there were significant improvements in the VSS, all DHI subgroups, and total scores, BBT, HAS in Group 1 compared to Group 2 at the 6-months after the treatment (p<0.05). Conclusion: The application of vestibular rehabilitation in a virtual reality environment can lead to additional improvements especially in dizziness symptoms, disability, balance, and mobility in the elderly with chronic dizziness.

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.

Effectiveness of conventional versus virtual reality-based vestibular rehabilitation exercises in elderly patients with dizziness: a randomized controlled study with 6-month follow-up.

OBJECTIVES: To investigate the effect of vestibular rehabilitation exercises supported with virtual reality containing real-life environments on dizziness, static and dynamic balance, functional mobility, fear of falling, anxiety, and depression in elderly patients with dizziness. METHODS: In this prospective randomized controlled study, 32-patients aged 65-years and older who applied to the otorhinolaryngology clinic with dizziness complaint randomly assigned to 2 groups. In Group 1 (n=16), vestibular rehabilitation program, supported with virtual reality, and in Group 2 (n=16), conventional vestibular rehabilitation program was applied 30-min a day, 5 sessions per week, 15 sessions in total for 3 weeks. Subjects were evaluated with The Vertigo Symptom Scale (VSS), Dizziness Handicap Inventory (DHI), Berg Balance Test (BBT) and Timed Up & Go Test (TUG), Falls Efficacy Scale-International (FES-I), Postural Stability Test (PST), Geriatric Depression Scale (GDS), Hamilton Anxiety Scale (HAS) at baseline, at the end of the treatment and 6-months after the treatment. RESULTS: Statistically significant improvements were seen in the DHI emotional subscale and TUG in Group 1 compared to Group 2 at the end of the treatment in elderly with dizziness (p<0.05). Also, there were significant improvements in the VSS, all DHI subgroups, and total scores, BBT, HAS in Group 1 compared to Group 2 at the 6-months after the treatment (p<0.05). CONCLUSION: The application of vestibular rehabilitation in a virtual reality environment can lead to additional improvements especially in dizziness symptoms, disability, balance, and mobility in the elderly with chronic dizziness.

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.

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.

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.

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.

Detecting Intralabyrinthine Pressure Increase by Postural Manipulation with Wideband Tympanometry and Distortion Product Otoacoustic Emissions.

OBJECTIVE: Intracranial pressure increase is known to affect inner ear pressure through the cochlear and vestibular aqueducts. This finding forms a good model for inner ear pressure studies. Standard techniques used to detect this pressure increase are neither reliable nor easily repeatable or cheap. Studies with immitancemetry and otoacoustic emissions have been giving hopeful results. This study aims to confirm the results in the literature with wideband tympanometry and add a new parameter of otoacoustic emissions to inner ear pressure testing. METHODS: Wideband tympanometry (WBT) and distortion product otoacoustic emissions (DPOAE) tests were applied to 40 healthy participants in sitting, supine, and Trendelenburg positions. DPOAE were measured under ambient or peak pressure. Resonance frequency, tympanic peak pressure, 1000, 1500, 2000, 3000, 4000, and 6000 Hz frequencies in DPOAE were measured. RESULTS: The increase in the tympanic peak pressure and the decrease in resonance frequency (RF) due to position change were found statistically significant (p<0.01). Signal noise ratio (SNR) decrease at 1 kHz frequency and SNR increase at 2, 3, 6 kHz in the normal protocol, SNR decrease at 1 kHz in the pressurized protocol were found statistically significant (p<0.01). CONCLUSION: RF in WBT and 1 kHz DPOAE SNR parameters were found useful in supporting the diagnosis in pathologies that increase intracranial pressure and inner ear pressure. Future research may ease their widespread use in clinical practice as they are non-invasive and rapidly applicable.

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.

Prevalence of allergic rhinitis among the adult population in Turkey.

CONCLUSION: The prevalence of self-reported and physician-diagnosed allergic rhinitis (AR) exhibits significant variability across the seven geographical regions in Turkey. Our findings may contribute to the formulation of public health policy and development of preventive and therapeutic strategies for AR in Turkey. OBJECTIVE: The purpose of this study was to assess the prevalence of AR in the Turkish adult population, with emphasis on descriptive parameters in seven distinct geographical regions in Turkey. METHODS: The volunteers were evaluated with a custom-designed questionnaire for AR. Sample size for the study was calculated by allowing for 2% error in prevalence along with a 95% confidence interval (CI). At the end of the study, we reached 4125 volunteers. The data were analyzed with chi(2), ANOVA, and Tukey (post hoc) tests. RESULTS: A total of 4125 volunteers participated in the study; 2200 were female and 1925 were male. On the basis of self-reporting, 23.1% of the study population was considered to have AR (males 22.3%, females 23.8%). On the other hand, the prevalence of physician-diagnosed AR was 20.1% (males 19.7%, females 20.4%). The prevalence of self-reported AR was 23.8% in the urban and 18.4% in the rural areas.

Does tonsillectomy reduce the risk of being a habitual or severe snorer?

We assessed the relationship between tonsillectomy and being a habitual or severe snorer. Volunteers were asked to provide their age and sex, a detailed snoring history covering the frequency and intensity of snoring, and their smoking and alcohol intake habits. After oral and nasal examinations, the tonsil size scores, Mallampati index scores, and nasal obstructions of the volunteers were recorded. Body heights and weights were measured, and body mass indexes were calculated. Being male, aging, an increase in body mass index and tonsillectomy were identified as independent risk factors for being a habitual and severe snorer. Although a nasal obstruction was found to be an independent risk factor for being a habitual snorer, an obstructive tongue base was identified as an independent risk factor for being a severe snorer. Tonsillectomy reduces the risk of being both a habitual and severe snorer. This reduced incidence and intensity of snoring following tonsillectomy could be accepted as a long-term beneficial side effect of the operation.

Provocation of endolymphatic hydrops with a prick test in Meniere's disease.

This study was conducted to test the hypothesis that antigenic challenge is an important stimulative factor for an episode of endolymphatic hydrops. The study was held in a tertiary care center for patients with probable or definite Meniere's disease. The prick test, which included dietary and inhalant allergens, was applied to all patients with a Multi-Test Applicator (Lincoln Diagnostics, Decatur, Ill). Patients were tested with electrocochleography before and after the prick test. The positive allergen was diluted in 1/10 of a prick test dose, and patients were provoked and tested again. A negative summating potential/action potential (SP/AP) amplitude ratio greater than 0.5 was used as the main outcome measure. Pretest, posttest, and postprovocation SP/AP amplitude ratios were compared. A total of 80 diseased and 16 normal ears of 48 patients with Meniere's disease were assessed. All patients were found to be atopic, but none had allergic symptoms. No symptom like vertigo or fullness was seen after the prick test was performed. In all, 30 patients had tinnitus and fullness in the diseased ear, and 6 patients had vertigo after the provocation. The SP/AP ratio was greater than 0.50 in 23 diseased (29%) and 3 normal (19%) ears before the prick test. After the prick test, 62 diseased (78%) and 13 normal (81%) ears had endolymphatic hydrops. These numbers did not change much after the provocation. Results reported here support the role of antigenic stimulation for episodes of Meniere's disease. Endolymphatic hydrops was the atopic reaction that occurred in most study patients.

Does corticosteroid usage in rhinoplasty cause mood changes?

In this study, the psychological effects of single-dose corticosteroids administered to patients who had undergone rhinoplasty were assessed. A total of 30 rhinoplasty patients were included in the study and were randomly assigned to 1 of 2 groups. Preoperatively, patients completed the Bech Rafaelsen Mania Scale and the Beck Depression Inventory. Dexamethasone 10 mg was given intravenously just before surgery to the first group, but no medication was administered to the second group. On the first postoperative day, patients were seen again, and the Bech Rafaelsen Mania Scale and the Beck Depression Inventory were again completed. Periorbital edema and ecchymosis were graded, and psychological well-being was measured on a standard visual analog scale. All patients and physicians were blinded to treatment until the end of the study. Results show that administration of a single-dose of dexamethasone 10 mg caused neither euphoria nor depression. No significant differences were observed between steroid and control groups in terms of patients' psychological well-being. With single-dose dexamethasone, periorbital edema was significantly reduced on the first 2 postoperative days, and upper eyelid ecchymosis was significantly decreased only on the first postoperative day. However, reoperative steroid administration had no influence on ecchymosis of the lower eyelid. The authors conclude that single-dose dexamethasone 10 mg can be used safely to reduce periorbital edema and ecchymosis in rhinoplasty patients.

Impact of multiple etiology on dizziness handicap.

OBJECTIVE: Our aim was to find the ratio of multiple diagnosis in dizziness patients and to evaluate the effect of multiple etiologies on handicap level of the patient. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. INTERVENTION: The data of 703 patients (178 men and 525 women) were included in the study. Diagnoses of the patients were made in a multiple-specialty environment including otolaryngology, neurology, cardiology, internal medicine, and rehabilitation medicine. MAIN OUTCOME MEASURES: All patients filled the dizziness handicap inventory and pointed the severity of dizziness on a 10-point visual analog scale. RESULTS: Four hundred thirty-three patients (61.6%) have only one diagnosis, whereas 183 (26%) had two. Three diseases have been found in 34 patients (4.8%), and four diseases were present in eight patients (1.1%). The mean number of diagnosis in one patient was 1.32 +/- 0.71. There was a significant difference between two sexes on the number of disease. There was no correlation between age and the number of diagnosis. There was no significant difference in functional scale, but the statistically significant increases are present in both physical (p < 0.05) and emotional (p < 0.01) scales. There was no correlation between age and handicap levels. CONCLUSION: Multiple diagnoses were important factors on physical and emotional handicaps. It was also found that this problem is not limited with older age group.

[The prevalence of allergic rhinitis in the adult urban population of Denizli]. / Denizli il merkezindeki eriskin nüfusta alerjik rinit görülme sikligi.

OBJECTIVES: We investigated the prevalence of allergic rhinitis in the adult urban population of Denizli. STUDY DESIGN: A survey study was conducted to cover 1010 adults above 19 years of age, representing the urban population of Denizli district, Turkey. A questionnaire was designed to collect data on sociodemographic features, symptoms of allergic rhinitis, duration of symptoms, and any prior diagnosis of allergic rhinitis made by a physician. Interviews were made with randomly chosen adults from three socioeconomically different urban areas. RESULTS: Interviews were completed for 951 adults with ages ranging from 19 to 65 years (414 males, mean age 36.3+/-12 years; 537 females, mean age 35.2+/-12 years). The frequency of self-reported allergic rhinitis was 10.8%, and 5.2% had allergic rhinitis diagnosed by a physician. Two or more symptoms of allergic rhinitis were found in 7.2%. The prevalence of allergic rhinitis was higher in females. There was no relationship between the frequency of allergic rhinitis and age. CONCLUSION: The prevalence of allergic rhinitis in the adult urban population of Denizli is between 5% to 10%, with a higher frequency in females.

[The prevalence of snoring in adult population]. / Eriskin nüfusta horlama yayginligi.

OBJECTIVES: This study aimed to investigate the prevalence of habitual snoring in adult population and the relationship between habitual snoring and accompanying factors. PATIENTS AND METHODS: A cross-sectional, epidemiological study was conducted to evaluate snoring and accompanying factors. Data of 1245 persons (629 females, 616 males; mean age 45.0+/-12.2) were evaluated. A questionnaire was administered to draw information on their sociodemographic data, the incidence of snoring, the presence of witnessed apnea during sleep, the severity of snoring and its changes depending on the body position, their willingness to receive treatment for snoring, the presence of alcohol or cigarette consumption, and hypertension and coronary disease. Height and weight measurements were performed to calculate body mass index. The results were evaluated using the chi-square test and a multiple regression analysis. RESULTS: The prevalence of habitual snoring was 8.9% in females and 29.5% in males. Multivariate analyses showed that male sex, age over 40 years, obesity, smoking, and the use of alcohol were significant risk factors for habitual snoring. Hypertension and coronary heart disease were statistically more common in individuals with habitual snoring. The severity of snoring was high enough in 2.1% of females and in 9.4% of males to force their roommates to leave the room, making 1.1% of females and 3.4% of males to show willingness to receive medical attention. CONCLUSION: Habitual snoring is a frequent complaint in our country. Inquiry into the presence of habitual snoring is necessary in adults and patients should be subjected to a detailed examination for respiratory disorders during sleep.

Subjective visual vertical and subjective visual horizontal measures in patients with chronic dizziness.

OBJECTIVES: We aimed to find the frequency of otolith organ pathologies in the clinical picture of common dizziness etiologies in the chronic stage. METHOD: Subjective visual vertical and subjective visual horizontal measures were assessed in patients who had persistent or recurrent dizziness at least 2 months after the acute period. Every patient was tested in three head positions: neutral, right, or left deviation in the roll plane. Test results were compared with those of the control group. RESULTS: Seventy-three patients and 18 controls were examined. Fifty-eight of the patients had peripheral vestibular disease; 15 of them had central vestibular disease. Left subjective visual horizontal (SVH) and right SVH measures of the peripheral group were significantly different from those of the control group (p < .01). There was no difference in any test between the peripheral and central groups. When we put a cut off point for abnormality (0, 1) according to mean +/- 2 SD of the control group, the peripheral and central groups had very high significant differences from the control group. Approximately 25 to 50% of our patients had pathologic subjective visual vertical or SVH measures according to test type. CONCLUSION: These results showed that the otolith system must be evaluated in the chronic period of dizziness, especially in patients who frequently visit their physician, and modifications in treatment programs must be conducted.

Does creating a subperiosteal tunnel influence the periorbital edema and ecchymosis in rhinoplasty?

PURPOSE: The study goal was to determine whether creating a subperiosteal tunnel before lateral osteotomy had an effect on postoperative periorbital edema, ecchymosis, and subconjunctival ecchymosis. PATIENTS AND METHODS: Eighteen consecutive patients who underwent septorhinoplasty were included in the study. In all patients lateral osteotomies were carried out bilaterally, after creating a subperiosteal tunnel on a randomly chosen side and without creating a subperiosteal tunnel on the other side. The patients were seen on the second postoperative day, and a different surgeon who was unaware of the side with the periosteal tunnel determined the side of the face with more edema and ecchymosis. Subconjunctival ecchymosis was evaluated and recorded, as well. RESULTS: Creating subperiosteal tunnels before lateral osteotomy statistically increased periorbital ecchymosis. Although there was no statistically significant difference, creating subperiosteal tunnels also increased development and severity of subconjunctival ecchymosis and edema. CONCLUSIONS: We suggest performing lateral osteotomy without creating subperiosteal tunnels.