The endoscopic transcanal approach to the internal auditory canal: an anatomic study.

PURPOSE: The internal auditory canal (IAC) plays a key role in lateral skull base surgery. Although several approaches to the IAC have been proposed, endoscope-assisted transcanal corridors to the IAC have rarely been studied. We sought to provide a step-by-step description of the transcanal transpromontorial approach to the IAC and analyze anatomic relationships that might enhance predictability and safety of this approach. METHODS: Ten cadaveric specimens were dissected and the extended transcanal transpromontorial approach to the IAC was established. Various morphometric measurements and anatomic landmarks were reviewed and analyzed. RESULTS: The proposed technique proved feasible and safe in all specimens. There was no inadvertent injury to the jugular bulb or internal carotid artery. The chorda tympani, a key landmark for the mastoid segment of the facial nerve, was identified in all dissections. The spherical recess of the vestibule and middle turn of cochlea are important landmarks for identification of the labyrinthine segment of the facial nerve. Identification of all boundaries of the working area is also essential for safe access. Among various morphometric measurements, the modiolus-IAC angle (≈ 150°) proved particularly consistent; given its ease of use and low variability, we believe it could serve as a landmark for identification and subsequent dissection of the IAC. CONCLUSIONS: The extended transcanal transpromontorial approach to the IAC is feasible and safe. Relying on anatomic landmarks to ensure preservation of the involved neurovascular structures is essential for a successful approach. The modiolus-IAC angle is a consistent, reproducible landmark for IAC identification and dissection.

Hearing Performance in Cochlear Implant Users Who Have Facial Nerve Stimulation.

Introduction Facial nerve stimulation (FNS) is a complication in cochlear implant (CI) when the electrical current escapes from the cochlea to the nearby facial nerve. Different management to reduce its effects are available, although changes might result in a less-than-ideal fitting for the CI user, eventually reducing speech perception. Objective To verify the etiologies that cause FNS, to identify strategies in managing FNS, and to evaluate speech recognition in patients who present FNS. Methods Retrospective study approved by the Ethical Board of the Institution. From the files of a CI group, patients who were identified with FNS either during surgery or at any time postoperatively were selected. Data collection included: CI manufacturer, electrode array type, age at implantation, etiology of hearing loss, FNS identification date, number of electrodes that generated FNS, FNS management actions, and speech recognition in quiet and in noise. Results Data were collected from 7 children and 25 adults. Etiologies that cause FNS were cochlear malformation, head trauma, meningitis, and otosclerosis; the main actions included decrease in the stimulation levels followed by the deactivation of electrodes. Average speech recognition in quiet before FNS was 86% and 80% after in patients who were able to accomplish the test. However, there was great variability, ranging from 0% in quiet to 90% of speech recognition in noise. Conclusion Etiologies that cause FNS are related to cochlear morphology alterations. Facial nerve stimulation can be solved using speech processor programming parameters; however, it is not possible to predict outcomes, since results depend on other variables.

Hearing Performance in Cochlear Implant Users Who Have Facial Nerve Stimulation

Abstract Introduction Facial nerve stimulation (FNS) is a complication in cochlear implant (CI) when the electrical current escapes from the cochlea to the nearby facial nerve. Different management to reduce its effects are available, although changes might result in a less-than-ideal fitting for the CI user, eventually reducing speech perception. Objective To verify the etiologies that cause FNS, to identify strategies in managing FNS, and to evaluate speech recognition in patients who present FNS. Methods Retrospective study approved by the Ethical Board of the Institution. From the files of a CI group, patients who were identified with FNS either during surgery or at any time postoperatively were selected. Data collection included: CI manufacturer, electrode array type, age at implantation, etiology of hearing loss, FNS identification date, number of electrodes that generated FNS, FNS management actions, and speech recognition in quiet and in noise. Results Data were collected from 7 children and 25 adults. Etiologies that cause FNS were cochlear malformation, head trauma, meningitis, and otosclerosis; the main actions included decrease in the stimulation levels followed by the deactivation of electrodes. Average speech recognition in quiet before FNS was 86% and 80% after in patients who were able to accomplish the test. However, there was great variability, ranging from 0% in quiet to 90% of speech recognition in noise. Conclusion Etiologies that cause FNS are related to cochlear morphology alterations. Facial nerve stimulation can be solved using speech processor programming parameters; however, it is not possible to predict outcomes, since results depend on other variables.

Brazilian Society of Otology task force - Vestibular Schwannoma ‒ evaluation and treatment.

OBJECTIVE: To review the literature on the diagnosis and treatment of vestibular schwannoma. METHODS: Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on vestibular schwannoma were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions. RESULTS: The topics were divided into 2 parts: (1) Diagnosis - audiologic, electrophysiologic tests, and imaging; (2) Treatment - wait and scan protocols, surgery, radiosurgery/radiotherapy, and systemic therapy. CONCLUSIONS: Decision making in VS treatment has become more challenging. MRI can diagnose increasingly smaller tumors, which has disastrous consequences for the patients and their families. It is important to develop an individualized approach for each case, which highly depends on the experience of each surgical team.

Generation of four induced pluripotent stem cells lines from PBMC of the DFNA58 family members: Two hearing-impaired duplication carriers (USPi006-A e USPi007-A) and two normal-hearing noncarriers (USPi004-A and USPi005-A).

The DFNA58 locus contains a genomic duplication involving three protein-coding genes (CNRIP1, PLEK, and PPP3R1's exon 1) and other uncharacterized lncRNA genes (LOC101927723, LOC107985892 and LOC102724389). To clarify the role of these genes in hearing and precisely determine their role in hearing loss, four iPSC lines were generated from two carriers and two noncarriers of the duplication.

Pioneer Tree Bellucia imperialis (Melastomataceae) from Central Amazon with Seedlings Highly Dependent on Arbuscular Mycorrhizal Fungi.

Bellucia imperialis is one of the most abundant pioneer tree species in anthropized areas of the Central Amazon, and has ecological importance for the environmental resilience of phosphorus (P)-depleted areas. Thus, we investigated whether B. imperialis depends on symbiosis with arbuscular mycorrhizal fungi (AMF) to grow and establish under the edaphic stresses of low nutrient content and low surface moisture retention capacity of the substrate. We tried three AMF inoculation treatments: (1) CON-no mycorrhizae; (2) MIX-with AMF from pure collection cultures, and (3) NAT-with native AMF, combined with five doses of P via a nutrient solution. All CON treatment seedlings died without AMF, showing the high mycorrhizal dependence of B. imperialis. Increasing P doses significantly decreased the leaf area and shoot and root biomass growth for both the NAT and MIX treatments. Increasing P doses did not affect spore number or mycorrhizal colonization, but decreased the diversity of AMF communities. Some species of the AMF community showed plasticity, enabling them to withstand shortages of and excess P. B. imperialis was shown to be sensitive to excess P, promiscuous, dependent on AMF, and tolerant of scarce nutritional resources, highlighting the need to inoculate seedlings to reforest impacted areas.

A three-dimensionally printed otological model for cholesteatoma mastoidectomy training.

PURPOSE: To relate the creation and expert validation (face and content validity) of an affordable three-dimensional (3-D) printed model of temporal bones with chronic otitis media with cholesteatoma (COMC) as a simulator for mastoidectomy. METHODS: We performed computed tomography (CT) of the temporal bones of a patient with COMC followed at the University of São Paulo (USP) Hospital with 3-D Slicer to create a 3-D model of the affected bone using light-curing resin and silicone (cholesteatoma). The final 3-D printed images were scored by 10 otologists using a customized version of the Michigan Standard Simulation Scale Experience (MiSSES). Internal consistency and inter-rater reliability were assessed using Cronbach's α and intraclass correlations. RESULTS: Otologists consistently scored the model positively for fidelity, educational value, reactions, and the overall model quality. Nine otologists agreed that the model was a good educational device for surgical training of COMC. All experts deemed the model ready-or nearly ready-for use. The final cost of the model, including raw materials and manufacturing, was 120 USD. CONCLUSIONS: Using 3-D printing technology, we created the first anatomically accurate, low-cost, disease-reproducing 3-D model of temporal bones for mastoidectomy training for cholesteatoma.

Association between chemosensory impairment with neuropsychiatric morbidity in post-acute COVID-19 syndrome: results from a multidisciplinary cohort study.

Preliminary methodologically limited studies suggested that taste and smell known as chemosensory impairments and neuropsychiatric symptoms are associated in post-COVID-19. The objective of this study is to evaluate whether chemosensory dysfunction and neuropsychiatric impairments in a well-characterized post-COVID-19 sample. This is a cohort study assessing adult patients hospitalized due to moderate or severe forms of COVID-19 between March and August 2020. Baseline information includes several clinical and hospitalization data. Further evaluations were made using several different reliable instruments designed to assess taste and smell functions, parosmia, and neuropsychiatric disorders (using standardized psychiatric and cognitive measures). Out of 1800 eligible individuals, 701 volunteers were assessed on this study. After multivariate analysis, patients reporting parosmia had a worse perception of memory performance (p < 0.001). Moderate/severe hypogeusia was significantly associated with a worse performance on the word list memory task (p = 0.012); Concomitant moderate/severe olfactory and gustatory loss during the acute phase of COVID-19 was also significantly associated with episodic memory impairment (p = 0.006). We found a positive association between reported chemosensory (taste and olfaction) abnormalities and cognition dysfunction in post-COVID-19 patients. These findings may help us identify potential mechanisms linking these two neurobiological functions, and also support the speculation on a possible route through which SARS-CoV-2 may reach the central nervous system.

Brazilian Society of Otology task force - Vestibular Schwannoma - evaluation and treatment

Abstract Objective: To review the literature on the diagnosis and treatment of vestibular schwannoma. Methods: Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on vestibular schwannoma were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions. Results: The topics were divided into 2 parts: (1) Diagnosis - audiologic, electrophysiologic tests, and imaging; (2) Treatment - wait and scan protocols, surgery, radiosurgery/radiotherapy, and systemic therapy. Conclusions: Decision making in VS treatment has become more challenging. MRI can diagnose increasingly smaller tumors, which has disastrous consequences for the patients and their families. It is important to develop an individualized approach for each case, which highly depends on the experience of each surgical team.

Assessment Protocol for Candidates for Bone-Anchored Hearing Devices

Abstract Introduction The technology regarding bone-anchored hearing devices has been advancing. Nevertheless, complications are still often reported, which can impair treatment adherence and lead to discontinuation of use. There is a lack of studies conducted in tropical countries, where complications can be even greater, as well as standardized protocols for selection, indication and evaluation. Objective To characterize implanted patients from a Brazilian public institution and describe the medical and audiological assessment protocols to which they were submitted during the selection process and in the follow-up after surgery. Method An observational, cross-sectional study evaluating the medical records of patients with hearing loss and ear malformations and describing the care protocol through which they were treated. Results The medical records of 15 patients were reviewed: 6 received transcutaneous implants, and 9, percutaneous implants; 9 patients reported some type of skin lesion, 2 reported pain on the follow-up visit, and 3 had osseointegration failure. The time between surgery and activation ranged from 2 to 9 months. The median scores on the sentences, Sentences in Noise and Monosyllable tests were 100%, 60% and 80%, respectively. Conclusion It was possible to characterize the patients who received implants at the institution. The patients performed well in silence and had greater difficulty in noise. Even patients who had complications did not complain about the audibility and sound quality. It is essential to develop a model and to standardize the assessment and follow-up methods aimed at the benefit of users of bone-anchored hearing devices, as well as to enable the technico-scientific development in this field.

Assessment Protocol for Candidates for Bone-Anchored Hearing Devices.

Introduction The technology regarding bone-anchored hearing devices has been advancing. Nevertheless, complications are still often reported, which can impair treatment adherence and lead to discontinuation of use. There is a lack of studies conducted in tropical countries, where complications can be even greater, as well as standardized protocols for selection, indication and evaluation. Objective To characterize implanted patients from a Brazilian public institution and describe the medical and audiological assessment protocols to which they were submitted during the selection process and in the follow-up after surgery. Method An observational, cross-sectional study evaluating the medical records of patients with hearing loss and ear malformations and describing the care protocol through which they were treated. Results The medical records of 15 patients were reviewed: 6 received transcutaneous implants, and 9, percutaneous implants; 9 patients reported some type of skin lesion, 2 reported pain on the follow-up visit, and 3 had osseointegration failure. The time between surgery and activation ranged from 2 to 9 months. The median scores on the sentences, Sentences in Noise and Monosyllable tests were 100%, 60% and 80%, respectively. Conclusion It was possible to characterize the patients who received implants at the institution. The patients performed well in silence and had greater difficulty in noise. Even patients who had complications did not complain about the audibility and sound quality. It is essential to develop a model and to standardize the assessment and follow-up methods aimed at the benefit of users of bone-anchored hearing devices, as well as to enable the technico-scientific development in this field.

Outcomes of Early Versus Late Tracheostomy in Patients With COVID-19: A Multinational Cohort Study.

Timing of tracheostomy in patients with COVID-19 has attracted substantial attention. Initial guidelines recommended delaying or avoiding tracheostomy due to the potential for particle aerosolization and theoretical risk to providers. However, early tracheostomy could improve patient outcomes and alleviate resource shortages. This study compares outcomes in a diverse population of hospitalized COVID-19 patients who underwent tracheostomy either "early" (within 14 d of intubation) or "late" (more than 14 d after intubation). DESIGN: International multi-institute retrospective cohort study. SETTING: Thirteen hospitals in Bolivia, Brazil, Spain, and the United States. PATIENTS: Hospitalized patients with COVID-19 undergoing early or late tracheostomy between March 1, 2020, and March 31, 2021. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: A total of 549 patients from 13 hospitals in four countries were included in the final analysis. Multivariable regression analysis showed that early tracheostomy was associated with a 12-day decrease in time on mechanical ventilation (95% CI, -16 to -8; p < 0.001). Further, ICU and hospital lengths of stay in patients undergoing early tracheostomy were 15 days (95% CI, -23 to -9 d; p < 0.001) and 22 days (95% CI, -31 to -12 d) shorter, respectively. In contrast, early tracheostomy patients experienced lower risk-adjusted survival at 30-day post-admission (hazard ratio, 3.0; 95% CI, 1.8-5.2). Differences in 90-day post-admission survival were not identified. CONCLUSIONS: COVID-19 patients undergoing tracheostomy within 14 days of intubation have reduced ventilator dependence as well as reduced lengths of stay. However, early tracheostomy patients experienced lower 30-day survival. Future efforts should identify patients most likely to benefit from early tracheostomy while accounting for location-specific capacity.

Complications of Transcutaneous Protheses - A Systematic Review of Publications Over the Past 10 Years

Abstract Introduction Bone conduction implants, responsible for transmitting sound from an external processor to the inner ear, can be divided into active and passive, depending on the vibratory stimulus location. The use of transcutaneous device has increased, given its aesthetic appeal, the complications and limitations of percutaneous devices, and patient's treatment adherence, focusing mainly on efficacy. However, various complications are associated with the use of transcutaneous prosthesis, which can often be serious. Objective To approach the literature on complications involving transcutaneous bone-anchored prostheses through a systematic review of articles published in the past 10 years (2011-2021). Data Synthesis The MEDLINE, EMBASE, Scopus, and Cochrane Library databases were searched. All articles written in English reporting on currently available transcutaneous prosthesis implantation and its complications were selected. Studies on both children and adults were included. The data on complications were extracted, and complications were classified as minor or major and associated to each device used. Thirty-seven articles were included in the study, of which 14 were prospective cohort studies, 22 were retrospective case series, and 1 was a case report. Most studies (18) included both adults and children. Moreover, 901 implantations were performed, of which 552 implanted Baha Attract (Cochlear Ltd., Sydney, Australia), 244 implanted BoneBridge (MED-EL, Innsbruck, Austria), and 105 implanted Sophono (Sophono Inc., Boulder, CO, USA]). Furthermore, 192 adverse events were reported (total complication rate, 21.3%), with 161 minor complications (84.3%) and 31 major complications (16.1%). Conclusion Transcutaneous prosthesis is an audiological alternative with fewer complications than percutaneous prosthesis. However, its indication should be judicious because complications are common, and although most complications are minor, serious infections requiring explantation may develop.

Clinical, sociodemographic and environmental factors impact post-COVID-19 syndrome.

Background: Sociodemographic and environmental factors are associated with incidence, severity, and mortality of COVID-19. However, little is known about the role of such factors in persisting symptoms among recovering patients. We designed a cohort study of hospitalized COVID-19 survivors to describe persistent symptoms and identify factors associated with post-COVID-19 syndrome. Methods: We included patients hospitalized between March to August 2020 who were alive six months after hospitalization. We collected individual and clinical characteristics during hospitalization and at follow-up assessed ten symptoms with standardized scales, 19 yes/no symptoms, a functional status and a quality-of-life scale and performed four clinical tests. We examined individual exposure to greenspace and air pollution and considered neighbourhood´s population density and socioeconomic conditions as contextual factors in multilevel regression analysis. Results: We included 749 patients with a median follow-up of 200 (IQR = 185-235) days, and 618 (83%) had at least one of the ten symptoms measured with scales. Pain (41%), fatigue (38%) and posttraumatic stress disorder (35%) were the most frequent. COVID-19 severity, comorbidities, BMI, female sex, younger age, and low socioeconomic position were associated with different symptoms. Exposure to ambient air pollution was associated with higher dyspnoea and fatigue scores and lower functional status. Conclusions: We identified a high frequency of persistent symptoms among COVID-19 survivors that were associated with clinical, sociodemographic, and environmental variables. These findings indicate that most patients recovering from COVID-19 will need post-discharge care, and an additional burden to health care systems, especially in LMICs, should be expected.

Complications of Transcutaneous Protheses - A Systematic Review of Publications Over the Past 10 Years.

Introduction Bone conduction implants, responsible for transmitting sound from an external processor to the inner ear, can be divided into active and passive, depending on the vibratory stimulus location. The use of transcutaneous device has increased, given its aesthetic appeal, the complications and limitations of percutaneous devices, and patient's treatment adherence, focusing mainly on efficacy. However, various complications are associated with the use of transcutaneous prosthesis, which can often be serious. Objective To approach the literature on complications involving transcutaneous bone-anchored prostheses through a systematic review of articles published in the past 10 years (2011-2021). Data Synthesis The MEDLINE, EMBASE, Scopus, and Cochrane Library databases were searched. All articles written in English reporting on currently available transcutaneous prosthesis implantation and its complications were selected. Studies on both children and adults were included. The data on complications were extracted, and complications were classified as minor or major and associated to each device used. Thirty-seven articles were included in the study, of which 14 were prospective cohort studies, 22 were retrospective case series, and 1 was a case report. Most studies (18) included both adults and children. Moreover, 901 implantations were performed, of which 552 implanted Baha Attract (Cochlear Ltd., Sydney, Australia), 244 implanted BoneBridge (MED-EL, Innsbruck, Austria), and 105 implanted Sophono (Sophono Inc., Boulder, CO, USA]). Furthermore, 192 adverse events were reported (total complication rate, 21.3%), with 161 minor complications (84.3%) and 31 major complications (16.1%). Conclusion Transcutaneous prosthesis is an audiological alternative with fewer complications than percutaneous prosthesis. However, its indication should be judicious because complications are common, and although most complications are minor, serious infections requiring explantation may develop.

Post-acute sequelae of SARS-CoV-2 infection: relationship of central nervous system manifestations with physical disability and systemic inflammation.

BACKGROUND: Despite the multitude of clinical manifestations of post-acute sequelae of SARS-CoV-2 infection (PASC), studies applying statistical methods to directly investigate patterns of symptom co-occurrence and their biological correlates are scarce. METHODS: We assessed 30 symptoms pertaining to different organ systems in 749 adults (age = 55 ± 14 years; 47% female) during in-person visits conducted at 6-11 months after hospitalization due to coronavirus disease 2019 (COVID-19), including six psychiatric and cognitive manifestations. Symptom co-occurrence was initially investigated using exploratory factor analysis (EFA), and latent variable modeling was then conducted using Item Response Theory (IRT). We investigated associations of latent variable severity with objective indices of persistent physical disability, pulmonary and kidney dysfunction, and C-reactive protein and D-dimer blood levels, measured at the same follow-up assessment. RESULTS: The EFA extracted one factor, explaining 64.8% of variance; loadings were positive for all symptoms, and above 0.35 for 16 of them. The latent trait generated using IRT placed fatigue, psychiatric, and cognitive manifestations as the most discriminative symptoms (coefficients > 1.5, p < 0.001). Latent trait severity was associated with decreased body weight and poorer physical performance (coefficients > 0.240; p ⩽ 0.003), and elevated blood levels of C-reactive protein (coefficient = 0.378; 95% CI 0.215-0.541; p < 0.001) and D-dimer (coefficient = 0.412; 95% CI 0.123-0.702; p = 0.005). Results were similar after excluding subjects with pro-inflammatory comorbidities. CONCLUSIONS: Different symptoms that persist for several months after moderate or severe COVID-19 may unite within one latent trait of PASC. This trait is dominated by fatigue and psychiatric symptoms, and is associated with objective signs of physical disability and persistent systemic inflammation.

Tonsillotomy by a Fractional Carbon Dioxide Laser: A New Technique in the Treatment of Chronic Tonsillitis.

Introduction: Chronic tonsillitis has a global prevalence, ranging from 5% to 12%. Its clinical manifestations, like recurrent acute tonsillitis, tonsils hypertrophy, caseum and halitosis, can lead adult patients to be submitted to palatine tonsillectomy, surgery that has morbidity and the potential risk of complications, including severe bleeding. This article proposes a new therapy for chronic tonsillitis in adult patients using a fractional carbon dioxide (CO2) laser, which is a fast, minimally invasive procedure capable of removing the need for the traditional tonsillectomy in many patients. The present research aimed to verify the efficacy of tonsillotomy by fractional ablation using the CO2 laser by comparing the number of bacterial infections, tonsils hypertrophy, halitosis and caseum; it is also aimed at analyzing the benefits, risks and complications of the technique. Methods: In this clinical prospective study, 20 patients were subjected to one session of tonsillotomy by fractional ablation and were followed up for a year. The control group was formed by the same patients in the pre-procedure period (one year) without treatment. Statistical analysis: The Wilcoxon paired test, Friedman tests, and multiple non-parametric comparisons were utilized to analyze the data (significance level of 5%). Results: No complications occurred, and the procedure was fast (30 seconds), safe and tolerated well without general anesthesia. After 1 year, there was a total remission of recurrent acute tonsillitis in 95% of the patients, and after 6 months there was a statistically significant improvement in halitosis and caseum, and tonsils size reduction (P<0.05). The level of satisfaction average was 10 after 3 months and 8 after one year. Conclusion: tonsillotomy by fractional ablation using the CO2 laser is a safe, efficient procedure for chronic tonsillitis in adults, and it can be incorporated into daily clinical practice.