Computed Tomography versus Sleep Endoscopy (DISE) to Predict the Effectiveness of Mandibular Advancement Devices in Adult Patients with Obstructive Sleep Apnea: A Protocol for Systematic Review.

Obstructive sleep apnea is a sleep disorder with a high prevalence in the world population. The mandibular advancement device is one of the options for treating obstructive sleep apnea. Neck computed tomography and drug-induced sleep endoscopy are complementary diagnostic tests that may help predict the effectiveness of mandibular advancement devices. This study aims to analyze the best method for predicting the effectiveness of mandibular advancement devices in the therapeutic approach to obstructive sleep apnea. PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science Core Collection databases will be comprehensively searched. We will include randomized clinical trials, non-randomized prospective or retrospective clinical studies, case controls, cohort studies, and case series. Two authors will independently conduct data extraction and assess the literature quality of the studies. The analysis of the included literature will be conducted by Revman 5.3 software. The outcomes that will be analyzed are craniofacial characteristics, cephalometric assessments, site and type of obstruction of the upper airway, mean values of the apnea-hypopnea index, and SaO2 verified in the initial and follow-up polysomnography. This study will provide reliable, evidence-based support for the clinical application of mandibular advancement devices for obstructive sleep apnea.

Upper airway assessment in obstructive sleep apnea patients: can computed tomography with lateral cephalometry replace drug-induced sleep endoscopy (DISE)? / Evaluación de la vía aérea superior en pacientes con apnea obstructiva del sueño: ¿puede la tomografía computarizada con cefalometría lateral reemplazar endoscopia del sueño inducida por fármacos por fármacos?

Objective To evaluate the association between results from drug-induced sleep endoscopy (DISE) and computed tomography with lateral cephalometry (CTLC) of the pharynx in obstructive sleep apnea (OSA) patients, regarding the same anatomic level, in order to understand if CTLC could replace DISE in selected patients. Study design Cross-sectional. Setting Tertiary hospital. Methods A total of 71 patients who attended the Sleep Medicine Consultation in the Otorhinolaryngology Department of Hospital CUF Tejo between 1.6.2019 and 30.9.2021, performed a polysomnographic sleep study and were elected to undergo DISE and CTLC of the pharynx for diagnostic purposes were selected. Obstructions at the same anatomic levels – tongue base, epiglottis and velum - were compared in both exams. Results Patients with reduction of epiglottis-pharynx space on CTLC had also a complete obstruction at epiglottis level on the VOTE classification of DISE (p = 0,027). Reduction of velum-pharynx space or tongue base-pharynx space were not related to complete obstruction of the velum (P = 0,623) or the tongue base (p = 0,594) found in DISE. Those with two or more space reductions had a tendency to multilevel obstruction observed in DISE (p = 0.089). Conclusion When evaluating the obstruction level(s) of an OSA patient, efforts should be made to perform DISE, since CTLC measures, though regarding at the same structures, don´t correlate completely with obstructions observed in DISE. (AU)

Objetivo Evaluar la asociación entre los resultados de la endoscopia del sueño inducida por fármacos (DISE) y la tomografía computarizada con cefalometría lateral (TCCL) de faringe en pacientes con apnea obstructiva del sueño (AOS), en el mismo nivel anatómico, para comprender si la TCCL podría reemplazar DISE en pacientes seleccionados. Diseño del estudio Transversal. Lugar Hospital de tercer nivel. Métodos Un total de 71 pacientes que acudieron a la Consulta de Medicina del Sueño en el Servicio de Otorrinolaringología del Hospital CUF Tejo entre el 1.6.2019 y el 30.9.2021, a los que se les había realizado un estudio polisomnográfico del sueño y fueron elegidos para realizar DISE y TCCL de faringe con fines diagnósticos, fueron seleccionados. Las obstrucciones en los mismos niveles anatómicos (base de la lengua, epiglotis y velo) se compararon en ambos exámenes. Resultados Los pacientes con reducción del espacio epiglotis-faringe en TCCL también tenían una obstrucción completa a nivel de epiglotis en la clasificación VOTE de DISE (p = 0,027). La reducción del espacio velo-faringe o base de la lengua-faringe no se relacionó con la obstrucción completa del velo (P = 0,623) o de la base de la lengua (p = 0,594) encontrada en DISE. Aquellos con dos o más reducciones de espacio presentaron tendencia a la obstrucción multinivel observada en DISE (p = 0,089). Conclusión Al evaluar el o los niveles de obstrucción de un paciente con AOS, se debe intentar realizar DISE, ya que las medidas de TCCL, aunque se refieren a las mismas estructuras, no se correlacionan completamente con las obstrucciones observadas en DISE. (AU)

Upper airway assessment in obstructive sleep apnea patients: can computed tomography with lateral cephalometry replace drug-induced sleep endoscopy (DISE)?

OBJECTIVE: To evaluate the association between results from drug-induced sleep endoscopy (DISE) and computed tomography with lateral cephalometry (CTLC) of the pharynx in obstructive sleep apnea (OSA) patients, regarding the same anatomic level, in order to understand if CTLC could replace DISE in selected patients. STUDY DESIGN: Cross-sectional. SETTING: Tertiary hospital. METHODS: A total of 71 patients who attended the Sleep Medicine Consultation in the Otorhinolaryngology Department of Hospital CUF Tejo between 1.6.2019 and 30.9.2021, performed a polysomnographic sleep study and were elected to undergo DISE and CTLC of the pharynx for diagnostic purposes were selected. Obstructions at the same anatomic levels - tongue base, epiglottis and velum - were compared in both exams. RESULTS: Patients with reduction of epiglottis-pharynx space on CTLC had also a complete obstruction at epiglottis level on the VOTE classification of DISE (p = 0,027). Reduction of velum-pharynx space or tongue base-pharynx space were not related to complete obstruction of the velum (P = 0,623) or the tongue base (p = 0,594) found in DISE. Those with two or more space reductions had a tendency to multilevel obstruction observed in DISE (p = 0.089). CONCLUSION: When evaluating the obstruction level(s) of an OSA patient, efforts should be made to perform DISE, since CTLC measures, though regarding at the same structures, don´t correlate completely with obstructions observed in DISE.

Audiological biomarkers of tinnitus in an older Portuguese population.

Tinnitus is a phantom sound perceived in the absence of external acoustic stimulation. It is described in a variety of ways (e.g., buzzing, ringing, and roaring) and can be a single sound or a combination of different sounds. Our study evaluated associations between audiological parameters and the presence or severity of tinnitus, to improve tinnitus diagnosis, treatment, and prognosis. Our sample included 122 older participants (63 women and 59 men), aged 55-75 years from the Portuguese population, with or without sensory presbycusis and with or without tinnitus. All participants underwent a clinical evaluation through a structured interview, Ear, Nose, and Throat observation, and audiological evaluation (standard and extended audiometry, psychoacoustic tinnitus evaluation, auditory brainstem responses, and distortion product otoacoustic emissions). The Tinnitus Handicap Inventory was used to measure tinnitus symptom severity. Our data confirmed that the odds of developing tinnitus were significantly higher in the presence of noise exposure and hearing loss. Also, participants who had abrupt tinnitus onset and moderate or severe hyperacusis featured higher odds of at least moderate tinnitus. However, it was in the ABR that we obtained the most exciting and promising results, namely, in wave I, which was the common denominator in all findings. The increase in wave I amplitude is a protective factor to the odds of having tinnitus. Concerning the severity of tinnitus, the logistic regression model showed that for each unit of increase in the mean ratio V/I of ABR, the likelihood of having at least moderate tinnitus was 10% higher. Advancing knowledge concerning potential tinnitus audiological biomarkers can be crucial for the adequate diagnosis and treatment of tinnitus.

Chronic nasopharyngeal and otitis media tuberculosis: diagnosis and management difficulties.

Nasopharyngeal and otitis media tuberculosis are rare extrapulmonary manifestations of Mycobacterium tuberculosis infection. We present a case of a middle-aged woman with manifestations of both conditions along with a description of the anatomical and temporal evolution of the disease. This case also highlights the difficulty of diagnosis and management of this condition, requiring a multidisciplinary approach. Extrapulmonary tuberculosis must be considered in the differential diagnosis of multiple head and neck conditions, including refractory chronic rhinosinusitis and otitis.

A finite element model to predict the consequences of endolymphatic hydrops in the basilar membrane.

Ménière's disease is an inner ear disorder, associated with episodes of vertigo, fluctuant hearing loss, tinnitus, and aural fullness. Ménière's disease is associated with endolymphatic hydrops. Clinical evidences show that this disease is often incapacitating, negatively affecting the patients' everyday life. The pathogenesis of Ménière's disease is still not fully understood and remains unclear. Previous numerical studies available in the literature related with endolymphatic hydrops, are very scarce. The present work applies the finite element method to investigate the consequences of endolymphatic hydrops in the normal hearing, associated with the Ménière's disease. The obtained results for the steady state dynamics analysis are in accordance with clinical evidences. The results show that the basilar membrane is not affected in the same intensity along its length and that the lower frequencies are more affected by the endolymphatic hydrops. From a clinical point of view, this work shows the relationship between the increasing of the endolymphatic pressure and the development of hearing loss.

Quality of Life and Psychological Distress in Portuguese Older Individuals with Tinnitus.

Tinnitus is the perception of a sound without an external source, often associated with adverse psychological and emotional effects leading to impaired quality of life (QoL). The present study investigated QoL and psychological distress in tinnitus patients and analysed the effects of associated comorbidities. Tonal and speech audiometry, tinnitus assessment, and clinical interviews were obtained from 122 Portuguese individuals (aged from 55 to 75). Portuguese versions of the Brief Symptoms Inventory (BSI), the Medical Outcomes Study Short Form Health Survey (MOS SF-36) and Tinnitus Handicap Inventory (THI) were used to evaluate psychological distress, health-related QoL, social difficulties and tinnitus severity. The presence of tinnitus was significantly associated with hearing loss. The increases in tinnitus severity were associated with decreases in QoL, particularly regarding MOS SF-36 subscales "perception of health", "social functioning", and "mental health". Regarding BSI, patients with greater tinnitus severity had more severe psychopathology symptoms, measured with scales "Obsessive-compulsive", "Depression", "Anxiety", "Hostility" and "Phobic Anxiety". Our study supports the notion of the negative impact of increased tinnitus severity on QoL and psychological distress in older adults. Presented data strengthen the importance of a multidisciplinary approach to tinnitus assessment and treatment.

Evidence for biological markers of tinnitus: A systematic review.

Subjective tinnitus is a phantom sound heard only by the affected person and may be a symptom of various diseases. Tinnitus diagnosis and monitoring is based on subjective audiometric and psychometric methods. This review aimed to synthesize evidence for tinnitus presence or its severity. We searched several electronic databases, citation searches of the included primary studies through Web of Science, and further hand searches. At least two authors performed all systematic review steps. Sixty-two records were included and were categorized according the biological variable. Evidence for possible tinnitus biomarkers come from oxidative stress, interleukins, steroids and neurotransmitters categories. We found conflicting evidence for full blood count, vitamins, lipid profile, neurotrophic factors, or inorganic ions. There was no evidence for an association between tinnitus and the remaining categories. The current review evidences that larger studies, with stricter exclusion criteria and powerful harmonized methodological design are needed. Protocol published on PROSPERO (CRD42017070998).

Evaluation of vocal changes after vestibular rehabilitation in patients with balance disorders.

BACKGROUND: Although there are articles and studies that associate postural changes with changes in vocal quality, to the best of our knowledge, this was the first study investigating the association between balance disorders and voice. OBJECTIVE: This study aimed to determine whether patients with balance disorders present any clinical, acoustic, or endoscopic vocal changes, and if the correction of balance impairments, such as through vestibular rehabilitation, lead to improvement in vocal quality. METHODS: This was a prospective cohort study that analyzed vocal differences (clinical, videoendostroboscopic, audio-perceptual, and acoustic vocal parameters) in a sample of 43 patients with vestibular dysfunction at three different time points (pre-treatment, post-treatment, and 3 months' post-treatment) diagnosed by videonystagmography with changes in computerized dynamic posturography who were treated with vestibular rehabilitation. RESULTS: In pre-treatment, all of the patients presented supraglottic hyperfunction during videoendoscopic examination and abnormal values in the audio-perceptual scale. After treatment for balance disorders, there was a statistically significant improvement in some parameters of the videoendoscopic and audio-perceptual measures. These improvements were detected immediately after treatment and remained present until at least three months after treatment. CONCLUSIONS: The results suggested that the treatment for balance disorders results in changes in posture and consequently in voice quality.

Evaluation of Postural Changes Using Dynamic Posturography after Speech Rehabilitation in Patients with Voice Disorders: A Longitudinal Study.

BACKGROUND: The association between voice and body posture is consensual across the scientific literature and seems to be established both ways. Any changes in normal posture can influence the mechanisms of vocal production; on the other hand, vocal rehabilitation can influence posture. OBJECTIVES: This study aimed to evaluate the postural pattern in subjects with organic voice disorders before and after speech rehabilitation, using computerised dynamic posturography (CDP). METHODS: In this prospective cohort study, 21 patients affected by dysphonia caused by benign vocal fold lesions, never treated with speech therapy/vocal training, were submitted to a posturographic analysis using CDP before and after vocal rehabilitation/therapy. Each patient underwent an accurate voice and ear, nose, and throat (ENT) anamnesis, a general ENT examination, a rigid and flexible laryngoscopy, a videolaryngostroboscopy, an acoustic voice analysis including aerodynamic evaluation, and a perceptual evaluation of voice using the Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) scale and the Voice Handicap Index (VHI) questionnaire, before and after vocal therapy. Fifteen healthy age- and sex-matched volunteers were also submitted to a posturographic analysis on the day of recruitment and 4 weeks later. RESULTS: All patients showed an improvement in voice quality after vocal training. The VHI decreased in all subjects, and the GRBAS scale showed a decrease in all parameters in each vowel (/a/, /i/, /e/) and in spontaneous speech (p < 0.001 for all). Posturographic results showed an improvement in equilibrium score, in conditions 2-6 and composite score. Strategic analysis results showed an improvement in conditions 1-6. CONCLUSIONS: The posturographic analysis showed a significant difference in the visual, vestibular, and proprioceptive component of posture after voice therapy. These results showed that dysphonic patients changed their postural patterns after an effective voice treatment, with an improvement in postural performance. It seems like modifications of breathing pattern and voice production techniques led to objective and measurable postural changes.

Tinnitus, hearing loss and inflammatory processes in an older Portuguese population.

Objective: Tinnitus is associated with various conditions such as presbycusis, infectious, autoimmune and many other diseases. Our study aims to identify an association between inflammatory markers and the presence of tinnitus or hearing loss (HL).Design: Exploratory study including a structured interview, complete ENT observation, audiological and inflammatory markers evaluation.Study Sample: Sixty women and 54 men (55 to 75 years) from the Portuguese population, with or without sensory presbycusis and/or tinnitus.Results: IL10 levels were significantly lower in participants with tinnitus than in those without tinnitus. Moreover, TGF-ß was lower in older participants (p = 0.034), IL1α was higher in participants with tonal tinnitus (p = 0.033), and IL2 was lower in participants who reported partial or complete residual inhibition (p = 0.019). Additionally, we observed a negative correlation between tinnitus duration and IL10 levels (r= -.281), and between HSP70 levels and tinnitus loudness (r= -.377). TNF-α and HSP70 levels appears to be sensitive to the time when samples were collected (morning or afternoon).Conclusions: The results of our study showing fluctuations in inflammatory markers along the hearing loss process, reinforce the idea that inflammatory mechanisms are involved in hearing loss pathogenesis but also in tinnitus. IL10 levels appear significantly altered in tinnitus but not in hearing loss.

Effect of Water Precautions on Otorrhea Incidence after Pediatric Tympanostomy Tube: Randomized Controlled Trial Evidence.

OBJECTIVES: Tympanostomy with ventilation tube insertion is the most common otologic surgery. Many surgeons recommend water precautions, although its utility is questioned. We aimed to investigate if water precautions reduce the rate of otorrhea after transtympanic tube insertion. STUDY DESIGN: Multicenter randomized controlled trial. SUBJECTS AND METHODS: A total of 244 children aged 2 to 10 years undergoing their first set of Shepard tubes for otitis media with effusion and concomitant adenoidectomy were randomized to 2 groups: 1 with ear protection during water exposure (ear plugs and headbands, n = 130) and 1 without (n = 114). Bathing or swimming with unprotected ears was considered the exposure event and incidence of otorrhea, the primary outcome. Outcomes were assessed during the 6-month follow-up period. RESULTS: In the water precaution group, 32% had at least 1 episode of otorrhea as compared with 22% in the unprotected group, which was not statistically significant (P = .09). Only 37% of the episodes of otorrhea in the protected group and 36% in the unprotected group had a temporal relation to water exposure (no difference, P = .81). Respectively, 56% and 52% of the episodes of otorrhea were in the context of upper respiratory tract infection. Global quality of life improved significantly, irrespective of whether water protection was prescribed. CONCLUSION: The incidence of otorrhea was not different with or without prescription of ear protection during water exposure among children with tympanostomy tubes, which supports current guideline recommendations that routine water precautions are unnecessary in this population.

Pathophysiology of Subjective Tinnitus: Triggers and Maintenance.

Tinnitus is the conscious perception of a sound without a corresponding external acoustic stimulus, usually described as a phantom perception. One of the major challenges for tinnitus research is to understand the pathophysiological mechanisms triggering and maintaining the symptoms, especially for subjective chronic tinnitus. Our objective was to synthesize the published literature in order to provide a comprehensive update on theoretical and experimental advances and to identify further research and clinical directions. We performed literature searches in three electronic databases, complemented by scanning reference lists from relevant reviews in our included records, citation searching of the included articles using Web of Science, and manual searching of the last 6 months of principal otology journals. One-hundred and thirty-two records were included in the review and the information related to peripheral and central mechanisms of tinnitus pathophysiology was collected in order to update on theories and models. A narrative synthesis examined the main themes arising from this information. Tinnitus pathophysiology is complex and multifactorial, involving the auditory and non-auditory systems. Recent theories assume the necessary involvement of extra-auditory brain regions for tinnitus to reach consciousness. Tinnitus engages multiple active dynamic and overlapping networks. We conclude that advancing knowledge concerning the origin and maintenance of specific tinnitus subtypes origin and maintenance mechanisms is of paramount importance for identifying adequate treatment.

Water protection after tympanostomy (Shepard) tubes does not decrease otorrhea incidence - retrospective cohort study / Proteção contra a água após colocação de tubos de ventilação (Shepard) não diminui a incidência de otorreia - estudo retrospectivo de coorte

Abstract Introduction Myringotomy for tube insertion is the most common otologic surgery. Otorrhea is a frequent complication of this procedure and, to prevent it, most surgeons strongly recommend avoiding contact with water as this is thought to adversely impact on post-operative quality of life. Objective To understand the benefit of this recommendation. Methods Observational study - retrospective cohort study comparing the incidence of post-operative otorrhea and its impact on patients' quality of life, in two groups of patients comprising children under 10 years of age who underwent bilateral myringotomy and tube placement for chronic otitis media with effusion between May 2011 and May 2012. One group received water protection care after surgery, the other did not. Data was collected through telephonic interview, after one year of follow up (one year after the procedure). Water exposure without protection was considered the exposure event. Incidence of otorrhea and perceived impact on quality of life were the outcome measures. Results were compared after logistic regression. Results We included 143 children: 116 were not exposed to water without protection and 27 were exposed. In the not exposed group 36.2% had at least one episode of otorrhea, compared to 40.0% of the exposed group. Odds ratio for otorrhea on exposed was 1.21 (95% CI 0.51-2.85, p = 0.6). Negative impact on quality of life was reported by parents of 48.2% on the not exposed children, compared to 40.7% on the exposed group. This difference was not significant (p = 0.5). Conclusion We found that recommending water protection did not have beneficial effect on the incidence of otorrhea after myringotomy with tubes on chronic otitis media with effusion. However, such measures did not appear to have a negative impact on quality of life. This is a populational observational study with few cases (143 cases); these final statements would be better stated by a very large populational study with another large control group.

Resumo Introdução A miringotomia para inserção de tubo de ventilação é a cirurgia otológica mais comum. Otorreia é uma complicação frequente deste procedimento e, para evita-la, a maioria dos cirurgiões recomenda evitar o contato com a água, pois acredita-se que isso possa afetar negativamente a qualidade de vida pós-operatória. Objetivo Verificar o benefício dessa recomendação. Método Estudo observacional - estudo de coorte retrospectivo, comparando a incidência de otorreia pós-operatória e seu impacto na qualidade de vida dos pacientes, em dois grupos de pacientes com crianças menores de 10 anos submetidas à miringotomia bilateral e colocação de tubo de ventilação para o tratamento de otite média crônica com efusão, entre maio de 2011 e maio de 2012. Um grupo recebeu cuidados de proteção contra a água após a cirurgia, o outro não. Os dados foram coletados através de entrevista telefônica, após um ano de seguimento (um ano após o procedimento). A exposição à água sem proteção foi considerada o evento de exposição. A incidência de otorreia e o impacto percebido na qualidade de vida foram as medidas de resultado. Os resultados foram comparados após a regressão logística. Resultados Incluímos 143 crianças: 116 não foram expostas à água sem proteção e 27 foram expostas. No grupo não exposto, 36,2% apresentaram pelo menos um episódio de otorreia, em comparação com 40,0% do grupo exposto. A razão de chances (odds ratio) para otorreia no grupo exposto foi de 1,21 (IC 95%: 0,51-2,85, p = 0,6). O impacto negativo na qualidade de vida foi relatado pelos pais de 48,2% nas crianças não expostas, em comparação com 40,7% no grupo exposto. Essa diferença não foi significante (p = 0,5). Conclusão Não verificamos um efeito benéfico sobre a incidência de otorreia ao recomendar a proteção contra a água após colocação de tubos de ventilação para otite média com efusão. Entretanto, tais medidas não parecem ter tido um impacto negativo na qualidade de vida.

Including auditory tube function on models is relevant to assess water exposure after tympanostomy tubes-Multiphase computerized fluid dynamics model.

INTRODUCTION: Myringotomy with tympanostomy tube is the most common otologic surgery and some patients are still advised to avoid water. However, there is no evidence supporting this, with published papers questioning the need for this advice. METHODS: A Multiphase Computational Fluid Dynamics (CFD) model was created using computerized tomography images of a child's healthy ear. It was then used to study the flow of fluids through the external ear, tympanic cavity, and auditory tube, with and without submersion. RESULTS: The model accurately described the behavior of the air retained in the patient's nasopharynx and tympanic cavity. A simulated elevation of pressure in the external auditory canal without submersion, without increase of pressure in the nasopharynx, demonstrated that fluids promptly crossed the tympanostomy tube into the middle ear. However, simulated elevation of pressure in the external auditory canal with concurrent elevation of air pressure in the nasopharynx during submersion did not lead to passive tube opening nor to any detectable flow through the tympanostomy tube. CONCLUSIONS: In the model, submersion increases pressure in the nasopharynx which offsets the pressure in the external auditory canal. So, in the absence of a pressure gradient, no passive tubal opening took place, and no air or fluid flow was detected through the transtympanic tube. This model now includes the exhaust function of the auditory tube in the model and shows its relevance.

On ciprofloxacin concentration in chronic rhinosinusitis.

OBJECTIVE: Considering that all the evidence indicates that chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) are distinct entities, the aim of this study was to compare the concentrations obtained in plasma and in sinonasal mucosa with oral and nasal topical ciprofloxacin, in patients with and without nasal polyps, without evaluating the effectiveness of the use of an antibiotic. METHODS: Prospective clinical study with single-blind randomization. The population consisted of patients with chronic rhinosinusitis with eligible for endonasal surgery, over 18 years old. It took place between January 2010 and December 2014. A single preoperative dose of ciprofloxacin (oral or nasal topic- spray, gel or drops) was given and samples of plasma and nasal mucosa (inferior turbinate, middle turbinate, ethmoid and maxillary sinus) were collected prior to surgery. The plasma and mucosal ciprofloxacin concentrations were assayed with high performance liquid chromatography (HPLC) with fluorescence detection (FD). RESULTS: The oral ciprofloxacin achieved better mucosal concentrations but had a significant plasmatic expression in all patients. None of the topical formulations achieved measurable ciprofloxacin plasmatic levels. Among the topical formulations, the gel had the best mucosal results, despite the existence of polyposis.

Water protection after tympanostomy (Shepard) tubes does not decrease otorrhea incidence - retrospective cohort study.

INTRODUCTION: Myringotomy for tube insertion is the most common otologic surgery. Otorrhea is a frequent complication of this procedure and, to prevent it, most surgeons strongly recommend avoiding contact with water as this is thought to adversely impact on post-operative quality of life. OBJECTIVE: To understand the benefit of this recommendation. METHODS: Observational study - retrospective cohort study comparing the incidence of post-operative otorrhea and its impact on patients' quality of life, in two groups of patients comprising children under 10 years of age who underwent bilateral myringotomy and tube placement for chronic otitis media with effusion between May 2011 and May 2012. One group received water protection care after surgery, the other did not. Data was collected through telephonic interview, after one year of follow up (one year after the procedure). Water exposure without protection was considered the exposure event. Incidence of otorrhea and perceived impact on quality of life were the outcome measures. Results were compared after logistic regression. RESULTS: We included 143 children: 116 were not exposed to water without protection and 27 were exposed. In the not exposed group 36.2% had at least one episode of otorrhea, compared to 40.0% of the exposed group. Odds ratio for otorrhea on exposed was 1.21 (95% CI 0.51-2.85, p=0.6). Negative impact on quality of life was reported by parents of 48.2% on the not exposed children, compared to 40.7% on the exposed group. This difference was not significant (p=0.5). CONCLUSION: We found that recommending water protection did not have beneficial effect on the incidence of otorrhea after myringotomy with tubes on chronic otitis media with effusion. However, such measures did not appear to have a negative impact on quality of life. This is a populational observational study with few cases (143 cases); these final statements would be better stated by a very large populational study with another large control group.

[Stapedo-Vestibular Ankylosis: Retrospective Study of Five Cases in São Tomé e Príncipe]. / Anquilose Estapedo-Vestibular: Estudo Retrospetivo de Cinco Casos em São Tomé e Príncipe.

INTRODUCTION: Otosclerosis is a common form of conductive hearing loss characterized by abnormal bone remodeling exclusively in the otic capsule. The prevalence of otosclerosis varies in racial populations and is described as being rare in black African populations. In this paper we aim to report five cases of clinical, and surgically confirmed, otosclerosis in black individuals, in São Tomé and Príncipe. MATERIAL AND METHODS: Since February 2011, Ear, Nose and Throat consultations and surgeries specialty have been carried out at Dr. Ayres de Menezes Hospital in cooperation with the project 'Health for all'. A retrospective analysis was undertaken of the records of all patients subjected either to stapedectomy or partial stapedectomy until February 2014. Information regarding clinical presentation, audiometric data and surgery reports was recorded. RESULTS: Five adult patients underwent stapedectomy or partial stapedectomy. All of them presented with normal otoscopy, conductive or mixed hearing loss on audiogram and normal tympanometry with absent stapedial reflexes. None of the patients had signs of infection or history of head trauma. Three cases showed improvement in the air-bone gap after surgery. The other two were lost to follow-up. DISCUSSION: We documented and surgically confirmed five cases of clinical otosclerosis in this population. A thematic review was carried out and concluded that, despite being described as a rare event in this race, available literature on this topic is not enough to state that there is lower prevalence of otosclerosis amongst the African population. CONCLUSION: Even if not common, otosclerosis cannot be disregarded as a possible cause for conductive hearing loss among the population of São Tomé and Principe.

Introdução: A otosclerose é uma causa frequente de hipoacusia de condução caracterizada pela alteração da remodelação óssea localizada exclusivamente à cápsula ótica. Diferenças rácicas são evidentes na literatura e, ao contrário dos caucasianos, as descrições na população de origem africana são raras. Neste trabalho pretende-se reportar cinco casos observados, e cirurgicamente confirmados, de otosclerose em indivíduos de raça negra, em São Tomé e Príncipe. Material e Métodos: Desde fevereiro de 2011, efetuam-se consultas e cirurgias de Otorrinolaringologia no Hospital Ayres de Menezes, em São Tomé e Príncipe, inseridas no projeto 'Saúde para todos ­ Especialidades'. Neste trabalho realizou-se um estudo retrospetivo dos doentes submetidos a estapedotomia ou estapedectomia parcial durante estas missões até fevereiro de 2014. Recolheu-se informação relativa à apresentação clínica, resultados audiométricos e relatórios cirúrgicos. Resultados: Cinco doentes, adultos, foram submetidos a procedimento cirúrgico. Todos apresentavam otoscopia normal, ausência de história de traumatismo cranioencefálico ou quadro infecioso, audiograma com hipoacusia mista ou de condução e timpanograma tipo A, sem reflexos estapédicos. Em três doentes foi possível realizar audiograma pós-operatório, verificando-se melhoria do gap aero-ósseo. Discussão: Neste trabalho documentam-se cinco casos de otosclerose clínica, e cirurgicamente confirmada, na população negra de São Tomé e Príncipe. Efetuada uma revisão temática, constata-se que, apesar de a otosclerose ser considerada rara nesta raça, os dados disponíveis parecem insuficientes para determinar se, de facto, diferentes raças têm diferentes incidências da doença. Conclusão: Apesar de rara, a otosclerose não pode ser ignorada como uma possível causa de hipoacusia de condução em São Tomé e Príncipe.

Does calcemia influence the onset of myringosclerosis after myringotomy with the insertion of ventilation tubes? / ¿Influye la calcemia en la aparición de miringoesclerosis después de miringotomía con inserción de tubos de ventilación?

Introduction: Myringosclerosis is one of the most frequent late complications of the insertion of ventilation tubes, and its aetiopathogenesis remains unknown. The calcification that occurs in the formation of myringosclerosis plaque raises the hypothesis of the presence of a calcium metabolism disorder. The objective is to determine whether calcemia contributes to the development of myringoscelerosis after insertion of ventilation tubes. Material and methods: A longitudinal, prospective, analytical cohort study was conducted in patients undergoing myringotomy with the insertion of ventilation tubes due to otitis media with effusion. Calcemia was evaluated pre-operatively and in the follow-up the appearance of myringosclerosis and the percentage of the tympanum involved were evaluated. Results: The study included 156 patients (297 ears), with calcemia values ranging from 7.6 to 10.2 mg/dl. Myringosclerosis was identified in 35.4% of the operated ears. No relationship was found between the appearance of myringosclerosis and calcemia (p = .596). It was found, however, that the greater the percentage of the tympanum affected by myringosclerosis, the lower the calcemia values (p = .014). Conclusion: The population studied had calcemia values within the normal range, which allows us to infer that no changes in calcium metabolism are required for the development of myringosclerosis. Moreover, unlike in previous studies, higher calcium levels are not associated with more myringosclerosis. Calcemia did not influence the appearance of myringosclerosis after myringotomy with the insertion of ventilation tubes (AU)

Introducción: La miringoesclerosis es una de las complicaciones tardías más frecuentes de la inserción de tubos de ventilación pero su etiopatogenia sigue siendo desconocida. La calcificación que se produce en la formación de la placa miringoesclerótica plantea la hipótesis de la presencia de un trastorno en el metabolismo del calcio. El objetivo es determinar si la calcemia contribuye al desarrollo de miringoscelerosis después de la inserción de tubos de ventilación. Material y métodos: Se realizó un estudio longitudinal, prospectivo, de cohorte analítica en pacientes tratados con miringotomía con inserción de tubos de ventilación, debido a otitis media con efusión. Se evaluó la calcemia antes de la operación y en el seguimiento se evaluó la presencia de miringoesclerosis y el porcentaje de afectación del tímpano. Resultados: El estudio incluyó a 156 pacientes (297 oídos), con valores de calcemia comprendidos entre 7,6 y 10,2 mg/dl. Se identificó miringoesclerosis en el 35,4% de los oídos operados. No se encontró relación entre la aparición de miringoesclerosis y calcemia (p = 0,596). Se encontró, sin embargo, que cuanto mayor es el porcentaje de afectación del tímpano por miringoesclerosis, menores son los valores de calcemia (p = 0,014). Conclusión: La población estudiada tuvo valores de calcemia dentro del rango normal, lo que nos permite inferir que no se requieren cambios en el metabolismo del calcio para desarrollar miringoesclerosis. Por otra parte, al contrario que en estudios anteriores, los niveles de calcio superiores no se asociaron a un incremento de miringoesclerosis. La calcemia no influye en la aparición de miringoesclerosis después de miringotomía con inserción de tubos de ventilación (AU)

Biomarkers of Presbycusis and Tinnitus in a Portuguese Older Population.

Introduction: Presbycusis or age-related hearing loss (ARHL) is a ubiquitous health problem. It is estimated that it will affect up to 1.5 billion people by 2025. In addition, tinnitus occurs in a large majority of cases with presbycusis. Glutamate metabotropic receptor 7 (GRM7) and N-acetyltransferase 2 (NAT2) are some of the genetic markers for presbycusis. Objectives: To explore patterns of hearing loss and the role of GRM7 and NAT2 as possible markers of presbycusis and tinnitus in a Portuguese population sample. Materials and Methods: Tonal and speech audiometry, tinnitus assessment, clinical interview, and DNA samples were obtained from patients aged from 55 to 75 with or without tinnitus. GRM7 analysis was performed by qPCR. Genotyping of single nucleotide polymorphisms (SNPs) in NAT2 was performed by PCR amplification followed by Sanger sequencing or by qPCR. Results: We screened samples from 78 individuals (33 men and 45 women). T allele at GRM7 gene was the most observed (60.3% T/T and 33.3% A/T). Individuals with a T/T genotype have a higher risk for ARHL and 33% lower risk for tinnitus, compared to individuals with A/A and A/T genotype, respectively. Being a slow acetylator (53%) was the most common NAT2 phenotype, more common in men (55.8%). Intermediate acetylator was the second most common phenotype (35.9%) also more frequent in men (82.6%). Noise exposed individuals and individuals with 'high frequency' hearing loss seem to have a higher risk for tinnitus. Our data suggests that allele AT of GRM7 can have a statistically significant influence toward the severity of tinnitus. Conclusion: For each increasing year of age the chance of HL increases by 9%. The risk for ARHL was not significantly associated with GRM7 neither NAT2. However, we cannot conclude from our data whether the presence of T allele at GRM7 increases the odds for ARHL or whether the A allele has a protective effect. Genotype A/T at GRM7 could potentially be considered a biomarker of tinnitus severity. This is the first study evaluating the effect of GRM7 and NAT2 gene in tinnitus.