An Overview of the Effect of Age at Time of Cochlear Implantation on Language Outcomes in Jordan: A Retrospective Cohort Study.

INTRODUCTION: Cochlear Implantation (CI) surgery has long been used as an effective treatment for children with bilateral profound sensorineural hearing loss who failed to benefit from the use of hearing aids. Among other factors, the age at which implantation is done is thought to have an effect on the speech progression outcome of patients postoperatively. OBJECTIVES: The Jordanian CI Program has limited resources, and Jordan has an underdeveloped early screening and intervention program for deafness. In this study, we aimed to explore the effect of age at time of implantation on receptive and expressive language outcomes in Jordan, to guide funding and focus efforts on patient groups who would benefit most, thus reducing unnecessary longterm morbidity and disability, and improving cost efficiency. METHODS: Data was gathered from all major sectors in Jordan on patients who underwent CI from 2006 to 2018 (a total of 1815 patients). We compared the language outcome 2 to 4 years after implantation for patients aged below 3 years, 3 to under 6, 6 to under 9 years, and 9 and older at the time of implantation. RESULTS AND CONCLUSION: We found a statistically significant difference in language outcomes between patients aged below 6 years vs those 6 and older, with better receptive and expressive language outcomes in the younger age groups.

Efficacy of pillar implants to reduce snoring and daytime sleepiness.

OBJECTIVE: To measure the efficacy of pillar implants in reducing snoring. MATERIALS AND METHODS: A total of 30 adult patients who underwent pillar implants were assessed preoperatively and at 1, 3, 6 and 12 months after the implantation. Improvement was measured using snoring frequency, visual analog scale for snoring loudness, and Epworth sleepiness scale for daytime sleepiness. RESULTS: The mean snoring frequency, loudness and Epworth score were reduced from 6.9, 9.2 and 7.4 at the baseline to 5, 5.9 and 5.6, respectively, at 12 months postoperatively (all p < 0.03). The partial implant extrusion rate was 6.7%. CONCLUSION: We suggest that a pillar implant procedure should be considered before proceeding to more morbid surgeries in patients with snoring and daytime sleepiness.

The feasibility of vagal nerve stimulation revision surgery and surgical techniques: a retrospective review.

BACKGROUND: With the large number of VNS implants performed worldwide, the need for removal or replacement of the device in selected cases is emerging, this removal or replacement of VNS can be challenging. AIMS/OBJECTIVE: To describe the feasibility and safety of revising vagal nerve stimulation surgery in terms of the indications, surgical techniques, and outcomes. MATERIALS AND METHODS: A retrospective study, a series of eight cases with VNS implants that needed revision surgery have been reviewed, four devices were completely removed and four were only revised. The revision surgery was performed after a range of 7 months to 6 years, due to different reasons. Initial surgeries and revisions were performed at the otolaryngology department in a major tertiary center. CONCLUSIONS AND SIGNIFICANCE: We concluded that the previously implanted vagal nerve stimulation electrodes can be completely removed without any significant sequelae on the nerve. It may also be re-implanted safely at the previously used segment of the vagus nerve with a similar outcome in seizure control as the initial implantation.

Congenital Hairy Polyp Causing Severe Upper Airway Obstruction in a Newborn: A Case Report.

BACKGROUND Hairy polyps are rare tumors mainly comprising fatty tissues covered by skin and hair follicles, with varied localizations and sizes. Early excision of the polyps by surgery is an effective treatment resulting in a permanent cure. We present a case of successful management of severe obstruction of the oropharynx in a newborn who presented with a large mass of congenital hairy polyp. CASE REPORT A vaginally delivered infant, weighing 3 kg, presented immediately after birth with cyanosis symptoms, failure of the first cry, and respiratory distress signs. The newborn was born to a mother with an uneventful pregnancy. Screening tests during the pregnancy reported no congenital anomalies. The newborn's hematological and biochemical test results were normal. After presenting these symptoms, the newborn was immediately intubated and put on a nasogastric feeding tube, which revealed a small portion of a polyp-like mass. A computed tomography (CT) scan further confirmed a large pedunculated mass, measuring 3×2 cm, arising from the soft palate, and obstructing the oropharynx. Histopathological examination confirmed the presence of a hairy polyp. The polyp was wholly removed transorally using the Covidien LigaSure device without the need for endoscopy. This procedure allowed safe extubation, and the baby was discharged home without symptoms 4 days after birth. CONCLUSIONS This case sheds light on the importance of considering hairy polyp in the differential diagnosis of pharyngeal mass with respiratory distress in pediatric patients. This report also describes our experience using the LigaSure surgical device without needing endoscopic visualization to successfully resect the hairy polyp without complications.

The impact of COVID-19 outbreak on otolaryngology practice, jordanian experience: A qualitative study.

BACKGROUND: In response to the rapid spread of coronavirus disease 2019 (COVID-19) caused by "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2), many countries including Jordan have implemented strict lockdowns. These lockdowns were associated with temporary suspension of all outpatient clinics and all elective (Non emergent, non-oncologic) surgical procedures. OBJECTIVE: We aimed to report the impact of COVID-19 outbreak on otolaryngology practice in Jordan. METHODS: Retrospectively we reviewed all admissions to the otolaryngology wards of King Abdullah University Hospital during the lockdown and for the same dates for the year 2019, results were compared.Additionally, an online questionnaire was sent to a sample of Jordanian otolaryngologists in June 2020. The questionnaire was comprised of a series of multiple choice questions regarding each physician's participation in the treatment or screening of COVID-19 patients, the number of consultations during the lockdown, the numbers of elective and emergency surgical procedures performed during the lockdown and the effects the lockdown had on their practices, their patients conditions and teaching and training processes.The study was done in line with the criteria set by the Standards for Reporting Qualitative Research (O'Brien et al., September 2014) [12]. STRENGTHS AND WEAKNESSES: In our study, we aimed to include the experience of all otolaryngology practitioners in Jordan, providing a comprehensive view of the lockdown effects on practice in the region. The data found is likely representative of lockdown effects on all departments, not just otolaryngological practice, and may be beneficial in providing a pathway to minimize any negative impact on patient care.However, our data may be limited due to its dependence on responses through a Whatsapp questionnaire, with no guarantee that the answers provided are fully accurate. It also may have a certain degree of sampling bias, as while the questionnaire was sent to all ENT practitioners in Jordan, answering it was totally optional, and so people who did not respond to the survey were not accounted for. RESULTS: During the lockdown period in Jordan all outpatient clinics were closed, and all elective surgical procedures (non-emergency and non-oncologic procedures) were suspended. During the lockdown it was observed that there was a reduction in the number of admissions related to post-operative complications, head and neck abscesses & infections and foreign bodies related admission when compared to the same period of 2019.A total of 144 otolaryngologists have participated in the questionnaire part of the study. More than half of the participants (n = 80, 55.6%) reported providing 10 or less consultations during the lockdown, more than half of the them have not performed any emergency surgical procedures during the lockdown, and a total of 110 (76.4%) of the 144 participants reported having at least 1 patient whose condition worsened during the lockdown due to lack or delay in medical care. CONCLUSION: The COVID-19 pandemic, and the resultant lockdown period in Jordan has caused a significant shift in otolaryngological practice throughout the country, with a complete cessation of all outpatient clinics and elective surgical procedures and admissions, with activity being limited to oncological and emergency procedures only. These changes have already impacted the dynamics of patient care and might lead to a risk of diagnostic delays which will have severe impacts on patient's health.

Neonatal Screening for Congenital Hearing Loss in the North of Jordan; Findings and Implications.

BACKGROUND: Congenital hearing loss is one of the important illnesses that affect newborns. Early diagnosis and treatment are a challenge for medical authorities in developing countries to improve children's functional, intellectual, emotional, and social abilities. We aimed to study the prevalence of congenital hearing loss in northern Jordan community and identify factors that could affect hearing screening protocol. METHODS: Prospective cross-sectional study of 1595 infants born in our hospital underwent hearing screening tests. Totally, 104 were tested in NICU and the rest examined in the nursery room using Otoacoustic emission (OAE) test as a primary testing tool. The patients were followed in the three hearing screening phases. Factors affecting screening results were studied and analyzed. RESULTS: The total number of newborns who didn't pass the first OAE test in one or both ears were 90 (5.6%); 69 from the nursery group and 21 from the NICU group. In the 2nd screening phase 21 (23.3%) didn't attend the appointment. Sixty-four passed the second screening OAE test. Five newborns (5.6%) had a second refer result in one or both ears and referred for a diagnostic ABR test. Three infants passed the test and two found to have bilateral hearing loss. CONCLUSIONS: Hearing screening test is conducted via a 3-phases-protocol. OAE is used in the first two phases and ABR in the third phase. Hearing results is significantly affected for infants admitted to NICU. The following factors increase OAE fail response: mechanical ventilation for more than 5 days, Hyperbilirubinemia, associated congenital anomalies. Mode of delivery doesn't have statistical significance on hearing screening results.

Assessing effects of modification of middle meatal silastic splint after endoscopic sinus surgery for nasal polyps: A randomized controlled study.

PURPOSE: To investigate the efficacy of middle meatal silastic splint in preventing adhesions after bilateral endoscopic sinus surgery (ESS) for chronic rhinosinusitis with nasal polyps (CRSwNP), and to assess nasal symptoms and endoscopic findings in splinted and non-splinted sides. METHODS: After completion of ESS, silicon silastic splints were randomly inserted in the middle meatus of one nasal side, while no stent in the other side (control). The surgeon was blinded to the side selection, and splint insertion until removal after 1 week. Patients were followed -up after 1 week, 1 and 6 months. Each side of the nasal cavity was assessed for adhesions, crusting, pus, pain, nasal obstruction, and nasal discharge by endoscopic examination and visual analogue scale. RESULTS: Forty-nine patients (98 nasal sides) were included. At the 1st week visit, there was no significant difference between the splinted and non-splinted sides for all investigated parameters.After 1- month, adhesions were seen in 10% of the splinted sides, while it was in 26% of the non-splinted sides (P = 0.037).At the 6 -month follow-up visit, the adhesions rate remained 10% in the splinted sides, however the rate increased to 32% in the non-splinted sides (P = 0.007). All other examined parameters remained statistically insignificant between both sides throughout the follow -up visits. CONCLUSIONS: Middle meatal silastic splint is significantly reducing middle meatal adhesions with low complication rate in CRSwNP patients undergoing ESS. Our results support its usage when the middle turbinate is unstable or traumatized during surgery.

Chronic rhinosinusitis due to cyano-acrylic glue after endoscopic transsphenoidal pituitary surgery.

BACKGROUND: To reduce the risk of cerebrospinal fluid leak, clinicians utilize a filling material placed in the sella followed by floor reconstruction with various materials, including glue sealing. Cyano-acrylic glue Glubran®2 glue is commercially available and is generally used as embolizing agent and for the prevention of cerebrospinal fluid leakage. CASE DESCRIPTION: A 25-year-old woman underwent endoscopic endonasal transsphenoidal surgery for pituitary adenoma. After tumor resection, sellar floor reconstruction was performed by mucosal graft and Glubran®2 glue. The early post-operative period was uneventful. However, 2 months after surgery, the patient complained of headache, facial pain and greenish foul-smelling nasal discharge with solid particles dripping from the nose. Medical treatment was unsuccessful. Brain MRI showed inflammation and thickening of the sphenoidal and para-sphenoidal mucosa. The patient underwent endoscopic endonasal surgery and a solid glass-like mass surrounded by inflamed infected mucosa was seen in the inferior and lateral aspects of the sphenoid sinus. Efforts were made to erupt and de-crust the solid mass until total resection was achieved. Early post-operative period was uneventful, and a course of antibiotics was continued until total disappearance of the discharge. CONCLUSION: To the best of our knowledge, this is the first case reporting of acrylic glue (Glubran®2)-related sinusitis. Surgeon should be aware about similar side effects for the glue material that would complicate the surgery.

Prevalence of Frontal Sinus Aplasia in Jordanian Individuals.

Our paper aims to investigate the prevalence of frontal sinus aplasia among Jordanian individuals and compare it with values from different populations. Retrospectively, the study was done for 167 of the paranasal sinuses coronal tomography (CT) for patients who attended the clinic from January 2019 to August 2019 in King Abdullah University Hospital Irbid, Jordan. The authors analyzed the multiplanar CT scans to perform our work. The authors excluded the following images from our study: patients younger than 18 years old, patients with history of skull base trauma that impaired visualization of the frontal sinus, and images with fibro-osseous lesions that impaired the visualization of the frontal sinus. The prevalence of bilateral frontal sinus aplasia is 4.2% among Jordanian individuals and 6.6% is the prevalence of unilateral frontal sinus aplasia. Both values are consistent with average values among different populations. Moreover, we noticed the higher prevalence in both the bilateral and unilateral frontal sinus aplasia in males compared to females. The prevalence of frontal sinus aplasia among Jordanian individuals is almost within the same values among different populations. These numbers regarding the bilateral and unilateral frontal sinus aplasia is crucial to push the surgeon to evaluate CT of the paranasal sinuses preoperatively and focus on the presence of frontal sinuses on CT images to prevent unwanted complications during sinus surgeries.

Overview of Upper Airway Management During COVID-19 Outbreak: Head and Neck Surgeon's Perspective.

At the end of December, 2019, a new virus was named severe acute respiratory syndrome coronavirus 2 appeared in Wuhan, China, and the disease caused is called as coronavirus disease 2019 (COVID-19) by World Health Organization, which to date having infected more than 3,588,773 people worldwide, as well as causing 247,503 deaths. A human to human transmission is thought to be predominantly by droplet spread, and direct contact with the patient or contaminated surfaces. This study aims to provide a comprehensive overview as well as to highlight essential evidence-based guidelines for how head and neck surgeon and healthcare providers need to take into consideration during their management of the upper airway during the COVID-19 pandemic safely and effectively to avoid the spread of the virus to the health provider.

Effect of Depth of Total Intravenous General Anesthesia on Intraoperative Electrically Evoked Compound Action Potentials in Cochlear Implantation Surgery.

PURPOSE: This study aims to compare the effect of the depth of total intravenous anesthesia (TIVA) on intraoperative electrically evoked compound action potential (e-ECAP) thresholds in cochlear implant operations. METHODS: Prospectively, a total of 39 patients aged between 1 and 48 years who were scheduled to undergo cochlear implantation surgeries were enrolled in this study. Every patient received both light and deep TIVA during the cochlear implant surgery. The e-ECAP thresholds were obtained during the light and deep TIVA. RESULTS: After comparing the e-ECAP means for each electrode (lead) between the light and deep anesthesia, no significant differences were detected between the light and deep anesthesia. CONCLUSION: The depth of TIVA may have no significant influence on the e-ECAP thresholds as there was no statistical difference between the light and deep anesthesia.

Acoustic characteristics of Arabic pharyngealized obstruents in children with cochlear implants.

Speech production of children with cochlear implants (CIs) is generally characterized by low intelligibility and reduced phoneme accuracy. However, limited research investigated their speech production using acoustic measures. The current study examined voice onset time (VOT) for pharyngealized plosives [t,d], and spectral moments and noise duration for pharyngealized fricatives [s,ð] produced by Arabic speaking children with CIs. Productions from children with CIs were compared with both chronological age-matched and hearing experience-matched normal hearing children. Results showed that children with CIs exhibited difficulty producing distinct VOTs between plosives and produced different spectral patterns of both fricatives relative to both comparison groups; however, they were able to produce an acoustic distinction between both fricatives. Children with CIs produced the fricatives with lower spectral mean and higher skewness and kurtosis. The sources for inter-group differences in the acoustic measures appeared to be due in part to limitations in the quality of auditory input provided by CIs as well as reduced motor experience in speech production. Results suggest that VOT and spectral moments are sensitive to changes in perceived sound quality. Spectral moments analysis appears to give details on subtle aspects of fricative production at the phonetic level beyond that available using perceptual judgments.

Accuracy of intraoperative electrophysiological testing in confirming correct cochlear implant electrode positions.

Objective: To investigate the accuracy of intraoperative electrophysiological studies in detecting incorrectly positioned electrodes in cochlear implant surgery. Study design: A retrospective chart review. Setting: Tertiary referral centre. Patients: In total, 104 consecutive patients with a mean age of 5 years underwent cochlear implant surgery at our centre between January 2012 and December 2013. All patients were implanted with Cochlear Nucleus Freedom implants. Method: A retrospective study to compare intraoperative neural response telemetry (NRT), impedance and electrode position using Stenver's transorbital plain X-ray view. Results: Intraoperative electrophysiological tests for patients with Cochlear Nucleus Freedom implants showed 97% sensitivity and 100% specificity compared with postoperative X-ray imaging. Conclusion: NRT results for the position of cochlear implants were very accurate when checked by X-ray imaging showing that this technique is sufficient in most cases. Stenver's plain X-ray view is needed in complicated cases with abnormal NRT testing or difficult electrode insertion.

The vagal nerve stimulation outcome, and laryngeal effect: Otolaryngologists roles and perspective.

INTRODUCTION: Epilepsy is one of the most common neurologic disorders. Vagus nerve stimulation (VNS), first investigated in 1938 and subsequently studied as a potential therapy for epilepsy. The FDA approved the use of VNS in 1997 as an adjunctive non-pharmacologic symptomatic treatment option for refractory epilepsy for adults and adolescents over 12years. VNS can cause laryngeal and voice side effects that can be managed by otolaryngologists safely and effectively. OBJECTIVES: This study is to review the outcomes of vagal nerve stimulator (VNS) implantation in terms of the surgical procedures, complications, seizure frequency, and the clinical effect on larynx and vocal folds motion. METHODS: Series of thirty consecutive patients who had VNS implantation between 2007 and 2014 were recruited. Seizure-frequency outcome, surgical complications and device adverse effects of VNS were retrospectively reviewed. Additional evaluation included use of the Voice Handicap Index and Maximum Phonation Time (MPT) were conducted before and after the implantation. Videolaryngoscopy was used to evaluate the vocal fold mobility before and after the VNS implantation. RESULTS: Seizure frequency reduction over a minimum of 2years of follow up demonstrated: 100% in seizure frequency reduction in 1 patient, drastic reduction in seizure frequency (70-90%) in 9 patients, a good reduction in terms of seizure frequency (50%) in 8 patients, a 30% reduction in 5 patients, no response in 6 patients, and 1 patient had increased frequency. The most commonly reported adverse effects after VNS activation were coughing and voice changes with pitch breaks, as well as mild intermittent shortness of breath in 33% of patients. For those patients secondary supraglottic muscle tension and hyper function with reduced left vocal fold mobility were noticed on videolaryngoscopy, though none had aspiration problems. Surgical complications included a wound dehiscence in one patient (3%) which was surgically managed, minor intra-operative bleeding 3%; a superficial wound infection in one patient (3%) which was treated conservatively, none of the complications necessitated VNS removal. CONCLUSIONS: VNS appears to be an effective non-pharmacologic adjuvant therapy in patients with medically refractory seizures. With the favorable adverse-effect profile previously described, VNS is generally well tolerated and of a great benefit to such patients. Laryngeal side effects, of which hoarseness being of the greatest repetition, are the most common after the VNS implantation. VNS can affect the voice and reduced vocal cord motion on the implantation side with secondary supraglottic muscle tension. Otolaryngologists are not only capable of performing VNS implantation, but can also manage surgical complications, assess laryngeal side effects and treat them as needed.

Effect of total intravenous vs volatile anesthetics on intraoperatively acquired electrically evoked compound action potential in children undergoing cochlear implant surgery: A randomized prospective study.

OBJECTIVE: The purpose of the present study was to compare the effects of inhalational anesthesia to those of total intravenous anesthesia on intraoperative electrically evoked compound action potential (e-ECAP) thresholds in children undergoing cochlear implantation. STUDY DESIGN: Randomized prospective study. SETTING: Tertiary referral teaching hospital. PATIENTS: Forty children aged 6 months to 17years with bilateral severe-to-profound sensorineural hearing loss and undergoing cochlear implantation were enrolled in the study. INTERVENTION: Patients were randomly assigned (1:1 ratio) into 2 groups to receive inhalational or total intravenous anesthesia. MEASUREMENTS: The e-ECAP measurements were obtained with neural response telemetry software. MAIN RESULTS: All electrodes showed lower e-ECAP thresholds under propofol, and results were statistically significant for the apical electrodes (P<.05). There was no statistical difference in the impedances between the 2 groups. Propofol minimally affected the e-ECAP. In contrast, the impedance was not affected by anesthesia. CONCLUSION: Volatile anesthetics result in higher e-ECAP thresholds in children, suggesting that e-ECAP thresholds acquired during inhalational anesthesia overestimate auditory nerve stimulation levels, which may cause discomfort postoperatively and adversely affect the child's adaptation to the implant. We recommend the use of total intravenous anesthesia for the measurement of the e-ECAP thresholds during cochlear implant surgery.

The effect of topical 5-flurouracil application post endoscopic inferior turbinoplasty.

RATIONALE AND OBJECTIVES: Adhesions are the most common complication after nasal surgery and revision. 5-Fluorouracil (5-FU) reduces various adhesions and epithelial growth related complications. The aim of this study was to evaluate the effects of 5-flurouracil application in the nasal cavity after a multi-procedure nasal surgery in term of complications frequency. MATERIALS AND METHODOLOGY: Institutional ethical approval was granted and a double-blinded prospective clinical trial was conducted to study the effect of 5-fu on post-operative complications. At the end of a combined endoscopic inferior turbinoplasty with one or more other nasal surgeries, 5-flurouracil-soaked cottonoid with 1mL of 5-flurouracil (5mg/mL) was applied in one side of nasal cavity and saline-soaked cottonoid was applied contralaterally and left for 5min. Patients were assessed over 2months postoperatively by a blinded observer in terms of adhesions, crustation, discharge, pain, discharge, loss of smell and other complications and nasal symptoms. RESULTS: On the 1st follow up week postoperatively, adhesions were observed in (24 patients) 35%, bilateral in (6 patients) 9% and unilateral in (18 patients) 26%. Unilateral Adhesions were statistically significantly higher in control sides than those in 5-FU sides (22% vs 4% respectively) (p=0.025). Crustation, continued to statistically significantly diminish over time (p=0.035). On the 8th follow up week, adhesions reduction was still statistical significant at the 5-FU treated side (p=0.01). CONCLUSION: 5-FU is safe and effective in preventing adhesions formation when applied during combined endoscopic inferior turbinoplasty procedure with other nasal procedure surgery.

A case report of unusual pneumomediastinum after endoscopic sinus surgery.

INTRODUCTION: Endoscopic sinus surgery is a minimally invasive procedure used to restore normal sinus ventilation and mucociliary function. It is a routine otolaryngology procedure with a success rate of about 90% for symptomatic improvement in patients with refractory chronic rhinosinusitis. Because of the proximity of the paranasal sinuses to the brain and the orbit, it cannot be performed without a potential risk of complications. In our case, without early clinical suspicion, proper diagnosis and management, this unusual occurrence of pneumomediastinum after endoscopic sinus surgery may have led to major complications or even death. PRESENTATION OF CASE: We report a case of unusual mediastinal emphysema in a 53-year-old man after removal of the nasal pack on the day after endoscopic sinus surgery. DISCUSSION: To the best of our knowledge, there are only two reported cases of mediastinal emphysema after endoscopic sinus surgery. What made our case unique was the absence of smoking history, pulmonary disease or infection and normal preoperative chest CT scan. We investigated further with postoperative chest CT scan, bronchoscopy and esophagoscopy to rule out anesthesia related laryngotracheal injury. In our case, the pneumomediastinum was successfully treated conservatively; however, it could have proceeded to mediastinitis, septicemia and death if it had not been diagnosed and treated early. CONCLUSION: Damage to the lamina papyracea can occur during endoscopic sinus surgery and presents as periorbital emphysema. Extension of the emphysema down to the mediastinum cannot be ignored as a possible etiology of the pneumomediastinum. Early diagnosis and proper management are important to avoid mortality.

Relationship of psychological and oral health statuses with self-perceived halitosis in a Jordanian population: a cross-sectional study.

BACKGROUND: Self-perceived halitosis could be a symptom of a psychosomatic or psychogenic disorder. The aim of this cross-sectional study was to clarify the relationship of self-perceived halitosis with psychological and oral health statuses. METHODS: One hundred participants with a history of halitosis were enrolled from a teaching hospital. They were divided into the self-perceived and suggested groups if they sensed and did not sense the malodor, respectively. Demographic and socioeconomic information, smoking status, and oral hygiene practices were noted. Complete nasal, oral, and periodontal examinations with organoleptic tests (OLTs) and N-benzoyl-DL-arginine-2-naphthylamide (BANA) tests were conducted. The participants also completed the validated Arabic version of the 90-item revised symptom checklist (SCL-90R). Data were compared by analysis of variance, chi-square test, Student's t-test, and multivariate logistic regression. RESULTS: The self-perceived group had higher OLT scores (p = 0.005) and were significantly younger (p = 0.001) than the suggested group. A significantly higher number of its participants were smokers (p = 0.004). No significant differences were observed in socioeconomic information, oral hygiene practices, oral conditions, and BANA test results. Further, no significant association was noted between self-perceived halitosis and the nine psychological dimensions of SCL-90R. CONCLUSIONS: Halitosis is a multifactorial symptom that requires multidisciplinary management. Self-reporting of the condition is unique entity and trust worthy symptom. It tends to be related to nonoral pathologies and extrinsic causes such as smoking.

Improved Construction of Auricular Prosthesis by Digital Technologies.

Implant-retained auricular prostheses are a successful prosthetic treatment option for patients who are missing their ear(s) due to trauma, oncology, or birth defects. The prosthetic ear is aesthetically pleasing, composed of natural looking anatomical contours, shape, and texture along with good color that blends with surrounding existing skin. These outcomes can be optimized by the integration of digital technologies in the construction process. This report describes a sequential process of reconstructing a missing left ear by digital technologies. Two implants were planned for placement in the left mastoid region utilizing specialist biomedical software (Materialise, Belgium). The implant positions were determined underneath the thickest portion (of anti-helix area) left ear that is virtually simulated by means of mirror imaging of the right ear. A surgical stent recording the implant positions was constructed and used in implant fixtures placement. Implants were left for eight weeks, after which they were loaded with abutments and an irreversible silicone impression was taken to record their positions. The right existing ear was virtually segmented using the patient CT scan and then mirror imaged to produce a left ear, which was then printed using 3D printer (Z Corp, USA). The left ear was then duplicated in wax which was fitted over the defect side. Then, it was conventionally flasked. Skin color was digitalized using spectromatch skin color system (London, UK). The resultant silicone color was mixed as prescribed and then packed into the mold. The silicone was cured conventionally. Ear was trimmed and fitted and there was no need for any extrinsic coloring. The prosthetic ear was an exact match to the existing right ear in shape, skin color, and orientation due to the great advantages of technologies employed. Additionally, these technologies saved time and provided a base for reproducible results regardless of operator.