Acta Oto Laryngologica 2021-07-28

"Intratympanic gentamicin injection for refractory ménières disease (MD) has potential effect in preventing contralateral MD occurrence"

Yongzhen Wu,Yujuan Zhou,Jing Yu,Zijun Song,Chunfu Dai,Jing Wang

Publication date 06-05-2021

Ménière's disease (MD), characterized by episodic vertigo attacks and fluctuating progressive hearing loss, is treated by low-dose intratympanic gentamicin (ITG) injections. Whether ITG causes hearing loss is controversial, and knowledge about its effects on the contralateral hearing and vestibular function is lacking. We aimed to evaluate the effect of ITG on bilateral auditory and otolith organ function in patients with unilateral refractory MD. The data of 30 patients was collected, including history, and pure tone audiometry and vestibular-evoked myogenic potentials (VEMPs) results before and one month after ITG treatment. Changes in vertigo were assessed at a two-year follow-up. One month after ITG injection, auditory thresholds between 125 Hz and 8 k Hz on the injection side remained unchanged but have improved on the contralateral side at 125 Hz, 250 Hz, 1 k Hz. The cervical and ocular VEMP solicitation rates on the injection side were lower than before the injection. Two years after treatment, vertigo was improved in 88.5% and complete controlled in 76.7% patients respectively. The intractable vertigo of MD can be effectively controlled by ITG injection. This can improve the low and medium frequency hearing level in the contralateral ear, suggesting that it might help prevent contralateral MD occurrence.

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Delayed postoperative complications in 624 consecutive cochlear implantation cases

Lusen Shi,Guangjie Zhu,Dengbin Ma,Chengwen Zhu,Jie Chen,Xiaoyun Qian,Xia Gao

Publication date 07-07-2021

Sensorineural hearing loss can be cured by cochlear implantation (CI), but complications can occur. Based on when the complications develop, they are categorized as intraoperative complications, early postoperative complications, or delayed postoperative complications (>3 months after the surgery).

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Magnetic resonance imaging of endolymphatic hydrops in patients with unilateral Meniere’s disease: a comparison between with and without herniation into the posterior and lateral semi-circular canals

Hiroshi Inui,Tsuyoshi Sakamoto,Taeko Ito,Tadashi Kitahara

Publication date 02-06-2021

The presence of endolymphatic hydrops (ELH) in patients with Meniere's disease (MD) is considered a pathological hallmark. We aimed to conduct a quantitative volumetric measurement of inner ear ELH in patients with unilateral MD (uMD). The values of uMD with and without herniation into the posterior semi-circular canal (h-PSC) and the lateral semi-circular canal (h-LSC) were compared using 3 D magnetic resonance imaging. This study included 130 individuals (47 controls and 83 patients with uMD). We measured the total fluid space (TFS) and endolymphatic space (ELS) volumes. We also evaluated the ELS/TFS volume ratios (%). The ELS/TFS volume ratios in the inner ear, cochlea, and vestibule were significantly different between the affected and contralateral sides in patients with h-PSC. Moreover, the ELS/TFS volume ratios of the inner ear, vestibule, and semi-circular canals in the affected ear were significantly higher in patients with h-PSC than in those without h-PSC. The vestibular ELS/TFS volume ratio in the affected ear was significantly higher in patients with h-LSC than in those without h-LSC. H-LSC is present in extended vestibular ELH. However, this is a result of ELH progression in the inner ear.

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Endoscopic intracanalicular vestibular schwannoma excision via middle ear corridors a surgical options

Tengku Mohamed Izam Tengku Kamalden,Khairunnisak Misron,Puvan Arul Arumugam

Publication date 29-04-2021

With more intracanalicular vestibular schwannoma (ICVS) diagnosed, treatment options are limited either to wait-and-see or surgery. The transpromontorial and infrapromontorial approaches allow direct route to the fundus of internal auditory canal with certain advantages in preserving facial nerve and even cochlear nerve. To describe the middle ear corridor approach for ICVS excision. All transpromontorial and infrapromontorial approaches for ICVS excision were recruited. The surgeries were performed at an otologic center by a single experienced otologist. Three cases of ICVS Koos Type I were included in this review. Two cases were operated with exclusive endoscopic transcanal transpromontorial approach excision of tumor. One case underwent concurrent transcanal excision of ICVS through infrapromontorial approach with cochlear implantation. Two of them developed facial nerve paresis. The last patient recovered fully with viable cochlear nerve enabling hearing restoration with cochlear implant. The potential of surgery in ICVS

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Comparison of inner ear deficits in Meniere’s variants and their significance

Yu-Jr Jeng,Yi-Ho Young

Publication date 23-06-2021

The declining order of abnormality rates in inner ear test battery of patients with Meniere's disease (MD) is consistent with the decreasing sequence of prevalence of hydrops formation in temporal bone donors of MD. This study investigated inner ear deficits in MD patients with falls, without falls, and after sac operation to compare their inner ear deficits. Twenty MD patients with falls (Group A), 20 MD patients without falls (Group B), and 20 MD patients after sac operation (Group C) were enrolled. All patients underwent an inner ear test battery. Group A (with falls) revealed a declining sequence of abnormality rates running from audiometry (92%), cervical vestibular-evoked myogenic potential (cVEMP) test (71%), caloric test (42%) to ocular VEMP (oVEMP) test (38%). In contrast, Group B (without falls) displayed a different declining sequence of abnormality rates running from audiometry, cVEMP test, and oVEMP test to caloric test. Similarly, Group C also displayed the same declining sequence of inner ear deficits to Group A, indicating that Groups A and C may share a similar mechanism. Comparing the declining sequence of inner ear deficits in two inner ear disorders may help determine whether both disorders share a similar mechanism.

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Adults with unilateral congenital ear canal atresia – sound localization ability and recognition of speech in competing speech in unaided condition

Malin Siegbahn,Cecilia Engmér Berglin,Malou Hultcrantz,Filip Asp

Publication date 01-06-2021

Individuals with unilateral hearing loss show poor spatial hearing, but individual variability is high. To investigate if the degree of hearing loss in unilateral ear canal atresia affects horizontal sound localization and speech recognition. Twelve subjects with unilateral ear canal atresia without childhood hearing intervention. Previously published data from eight normal-hearing subjects in normal binaural as well as experimentally induced unilateral hearing loss served as a reference. Horizontal sound localization and recognition of speech in spatially separate competing speech were assessed. Linear regression analysis demonstrated a relationship between sound localization accuracy (SLA) and the air conduction pure tone average of the atretic ear ( Individuals with congenital unilateral ear canal atresia show impaired horizontal SLA and recognition of speech in competing speech.

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Usefulness of stress-related hormones as predictors and prognostic factors for idiopathic sudden sensorineural hearing loss

Heesung Chae,Hyun Su Lee,Joo Hyung Lee,Minheon Kim,Sang Yoo Park,Young Joon Seo

Publication date 01-07-2021

The pathogenesis of Idiopathic sudden sensorineural hearing loss (ISSNHL) is ambiguous. Stress is commonly defined as a cause of the disease. Serum levels of stress-related hormone (cortisol, growth hormone, aldosterone, ADH, ACTH) may be elevated in patients with ISSNHL patients. We aimed to determine whether psychological factors and stress hormones in patients are associated with the severity of hearing loss and therapeutic outcomes. We hypothesized that the stress hormone level in the disease sequence is a strong prognostic factor of ISSNHL. Additionally, we investigated whether the subjective degree of psychological stress is likely to contribute to the therapeutic prognosis of ISSNHL, as determined using questionnaires. We conducted a prospective study of patients aged between 19 and 65 years admitted for the treatment of ISSNHL at our hospital. All patients underwent pure tone audiometry (PTA) on day 0, day 5 and 2 weeks after discharge. As an objective indicator of stress, we measured the level of HPA axis-related hormones. So, we measured serum cortisol, adrenocorticotropic hormone (ACTH), aldosterone and dehydroepiandrosterone sulfate (DHEAS) levels in the venous blood sample of patients on day 1 and day 5 after admission. In addition, for subjective stress measurements, depression and anxiety levels were assessed using self-reported questionnaires, Beck Depression Inventory (BDI), and Perceived Stress Scale (PSS) in the revised to Korean versions. Eighteen patients diagnosed with ISSNHL at the Department of Otorhino-laryngology were enrolled. Serum DHEAS level measured on day 1 showed a statistically significant correlation with the hearing threshold in the hearing test performed at the time of diagnosis ( We demonstrated the possible role of stress-related hormones in the pathogenesis of ISSNHL and suggest that depressive stress response can be a strong predictor of treatment response in patients with ISSNHL. However, the impact of response to stress on the inner ear and endolymph homeostasis remains unknown. Since this is a cross-sectional study, we can only comment on the relationship between stress and ISSNHL, not a causal relationship. Further investigation is necessary to identify the mechanism of interaction between stress and hearing ability in the inner ear.

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Audiologic outcomes and complications of active middle ear implantation in older adults

Sung Hwan Lim,Moon Seung Baeg,Beom Mo Koo,Seok Jung Hong,Pona Park,Hyun-Sang Cho,Seung Woo Kim,Choon Dong Kim,Hye Mi Park,Ga Eul Choi,Jihye Rhee

Publication date 15-06-2021

A few studies have reported the use of middle ear implants (MEIs) in older adults. To evaluate the audiologic outcomes and postoperative complications of MEIs in older adults. This retrospective study reviewed audiologic data and medical records from a single referral centre. We identified 34 patients aged ≥65 years who underwent middle ear implantation using the Vibrant Soundbridge Follow-up duration ranged from <1 to 5.3 years. The functional gain with MEIs significantly improved relative to the preoperative air conduction thresholds at 0.5, 1, 2, and 4 k Hz. Eight patients underwent explantation and 7 lost their external audio processor devices. Those who removed their implants because of the poor hearing (group 1) showed significantly worse hearing thresholds at 1 k Hz and speech discrimination scores than the others (group 2). MEIs for auditory rehabilitation can provide improved speech recognition and significant functional gains in older adults. Patients must be given appropriate preoperative explanations regarding the expected outcomes.

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Long-term survival outcomes after primary transoral robotic surgery (TORS) with concurrent neck dissection for early-stage oropharyngeal squamous cell carcinoma

Joakim Grant Frederiksen,Hani Ibrahim Channir,Mikkel Hjordt Holm Larsen,Anders Christensen,Jeppe Friborg,Birgitte Wittenborg Charabi,Niclas Rubek,Christian von Buchwald

Publication date 01-07-2021

In 2013, transoral robotic surgery (TORS) was implemented as a protocolled treatment alternative to the traditional radiotherapy (RT) in Denmark for oropharyngeal squamous cell carcinoma (OPSCC). In 2017, we published our first prospective feasibility study, showing that TORS with concurrent neck dissection successfully achieved negative margins in 29 out of 30 patients (97%) with early-stage OPSCC. This follow-up study aims to evaluate the five-year overall survival (OS), disease-specific survival (DSS) and recurrence-free survival (RFS). Retrospective follow-up study including 30 patients treated with TORS for early-stage OPSCC (T1-T2, N0-N1, M0, UICC 7th edition) from September 2014 to January 2016 at a single head and neck cancer centre in Denmark. The five-year OS, DSS and RFS, including a detailed analysis of the recurrences, were addressed. The five-year OS, DSS and RFS was 90%, 93% and 87%, respectively. Median follow-up was 54.5 months. Four patients developed a recurrence, with one regional, one distant metastatic (M) and two locoregional recurrences. The median time to recurrence was 24 months (range 3-42 months). This follow-up study demonstrates good five-year OS, DSS and RFS in a prospective cohort of patients undergoing TORS and neck dissection for early-stage OPSCC.

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

Ahmad I. Al Omari,Amjad Nuseir,Yazan Kanaan,Ra’ed Al-Ashqar,Firas Alzoubi

Publication date 19-05-2021

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. To describe the feasibility and safety of revising vagal nerve stimulation surgery in terms of the indications, surgical techniques, and outcomes. 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. 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.

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The impact of HPV genotypes on survival in HPV-positive oropharyngeal squamous cell carcinomas: a systematic review

Anne Skovvang,Jakob Schmidt Jensen,Martin Garset-Zamani,Amanda Carlander,Christian Grønhøj,Christian von Buchwald

Publication date 09-06-2021

Patients with HPV-positive (HPV+) oropharyngeal squamous cell carcinomas (OPSCCs) are known to have a better prognosis compared to patients with HPV-negative OPSCCs. To investigate the impact of specific HPV genotypes on survival in HPV + OPSCC. A systematic search of Pub Med and Embase for studies addressing the association between specific HPV genotypes and survival among patients with OPSCC was performed. Six studies ( Our findings indicate a favorable prognosis among patients with HPV16 OPSCC compared with HR non-HPV16 OPSCC. These results may be important when designing future trials and in the planning of follow-up regimes.

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Effects on cervical vestibular-evoked myogenic potentials of four clinically used head and neck measurement positions in healthy subjects

Kanako Masuda,Masatsugu Masuda,Yoshiharu Yamanobe,Kohei Mizuno,Tatsuo Matsunaga,Koichiro Wasano

Publication date 28-07-2021

The most reliable head and neck position for cervical vestibular-evoked myogenic potentials (cVEMPs) measurements yet to be determined. To assess how four body positions used during clinical recordings of cVEMPs affect cVEMP parameters. cVEMPs of 10 healthy subjects (26-50 years old) were recorded in four body positions: Mean background sternocleidomastoid muscle (SCM) electrical activity was significantly higher in positions C and D than in positions A and B. The latencies of p13 and n23 differed significantly among the four positions. Raw p13-n23 complex amplitude was significantly greater in positions C and D than in A and B. These differences were reduced when amplitudes were corrected by SCM activity. For positions A and B, one and two subjects, respectively, had an abnormal raw asymmetry ratio (AR). After correction, all subjects had normal ARs in all positions. Body positions in which the head is elevated produce a quicker and larger cVEMP response compared to positions in which the head is not elevated. The difference in ARs among positions can be ignored as long as the correction is made.

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The role of frozen section biopsy for submandibular gland tumors

Masahiro Suzuki,Yuta Nakaegawa,Tomotaka Kawase,Masakazu Ikeda,Shigeyuki Murono

Publication date 28-07-2021

Although there have been several reports of the diagnostic accuracy of frozen section biopsy (FSB) for parotid gland tumors, few studies have focused on its diagnostic accuracy for submandibular gland tumors. This study aimed to investigate the necessity of FSB with regard to its diagnostic accuracy for submandibular gland tumors (SGTs). About 42 SGT patients underwent both fine-needle aspiration cytology (FNAC) and FSB between 2005 and 2020. The results of FNAC and FSB were analyzed and compared with the final histological diagnoses. The respective sensitivity and specificity in detecting malignant tumors in 38 cases, excluding the four indeterminate FNAC cases, they were 0 and 97% for FNAC, and 100 and 97% for FSB. Considering the four indeterminate FNAC cases to be malignant, the respective sensitivity and specificity in detecting malignant tumors in the 42 cases were 50 and 92% for FNAC, and 100 and 95% for FSB. FSB may be useful for malignancy detection as a final histological diagnosis in cases that are diagnosed as benign or indeterminate by FNAC in SGTs.

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Laryngoscopic characteristics related to the risk of cancerization of vocal cord leukoplakia

Li-Juan Li,Zhan Yu,Ji-Qing Zhu,Mei-Ling Wang,Zhi-Xiang Li,Cong Yang,Xiao-Guang Ni

Publication date 28-07-2021

The diagnosis of vocal cord leukoplakia mainly relies on laryngoscopy. The morphology of vocal cord leukoplakia under laryngoscope is closely related to the pathological nature of leukoplakia. The specific manifestations associated with high-risk vocal cord leukoplakia remain to be explored. To investigate the characteristics of low-risk and high-risk vocal cord leukoplakia under conventional white light imaging (WLI) laryngoscopy and its correlations with narrow band imaging (NBI) laryngoscopy. One hundred and seventy-five cases of vocal cord leukoplakia were divided into low-risk and high-risk groups. The characteristics of low-risk and high-risk vocal cord leukoplakia under WLI laryngoscopy and its correlations with NBI laryngoscopy were analyzed. Logistic regression analysis showed that thickness and hyperemia were independent factors ( The sign of hyperemia under WLI laryngoscopy is significantly correlated with the visualized spots under NBI laryngoscopy. Hyperemia is an important feature for predicting malignant potential of vocal cord leukoplakia.

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Narrow-band imaging combined with salivary pepsin to diagnose patients with laryngopharyngeal reflux

Li Guo,Yuehong Liu

Publication date 24-07-2021

Laryngopharyngeal reflux (LPR) is a prevalent disease in the ENT outpatient department. Methods of LPR diagnosis differ much. Narrow-band imaging (NBI) and Salivary pepsin-level measurements have been considered as totally new ways for the diagnosis of LPR in recent years. We aimed to identify the specific manifestation of LPR and assess the correlation between NBI views and pepsin levels in LPR diagnosing. 130 Patients enrolled in our study were divided into LPR group and non-LPR group according to the scores of RSI and RFS. All individuals received endoscopic NBI tests and salivary pepsin measurements. NBI views of the larynx were divided into four grades based on the existing descriptive guidelines and our clinical observations, and the correlation between NBI grading and salivary pepsin levels was calculated. NBI grading and pepsin levels are significantly correlated with RFS/RSI scores. The diagnostic concentration of salivary pepsin was 33 ng/ml. There was a significant correlation between NBI grading and salivary levels. NBI grading system was proved to provide a better diagnostic value in the diagnosis of LPR. There was a possibility that a combination of these two methods might increase the diagnostic accuracy of this disease.

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Changes in olfactory bulbus volume and olfactory sulcus depth in the chronic period after COVID-19 infection

Bünyamin Güney,Ferda Bacaksızlar Sarı,Murat Yunus Özdemir,Neşat Çullu,Emrah Doğan,Turhan Togan

Publication date 22-07-2021

Although there are a limited number of studies investigating the changes in olfactory bulb volume (OBV) and olfactory sulcus depth (OSD) values in the acute and subacute periods after COVID-19 infection, there are no studies conducted in the chronic period. The aim of this study is to reveal the changes in OBV and OSD after COVID-19 in the chronic period. A total of 83 people were included in our study, including 42 normal healthy individuals (control group) and 41 patients with COVID-19 infection (10-12 months after infection). The COVID-19 group included 41 patients with the mean age 40.27 ± 14.5 years and the control group included 42 individuals with the mean age 40.27 ± 14.4. The mean OBV was 67.97 ± 14.27 mm Our findings show that COVID-19 infection causes a significant decrease in the OBV and OSD measurements in the chronic period.

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Characteristic manifestation of ocular and cervical vestibular evoked myogenic potentials findings in severe obstructive sleep apnea patients

Hui-Ping Luo,Jing Yu,Xin-Da Xu,Jing Wang,Qing Zhang,Hai-Tao Wu,Fang-Lu Chi

Publication date 22-07-2021

Studies of saccular and utricular function in patients with obstructive sleep apnea (OSA) are rare. We noticed that some OSA patients also had positive results in vestibular function tests, and this inspired our interest in exploring the vestibular function patterns of OSA patients. To investigate otolithic organ function in severe OSA patients who lack vestibular symptoms and systemic disease. 32 patients (64 ears) with severe OSA and 22 healthy controls (44 ears) were enrolled. The ocular and cervical vestibular-evoked myogenic potentials (oVEMP and cVEMP) and the caloric test were recorded and analyzed. The response rates of oVEMP (73.4%) and cVEMP (82.8%) in patients with severe OSA were significantly lower than those in controls. In oVEMP, elevated thresholds ( Disappearance or impairment of VEMPs could be observed in patients with severe OSA, and reflects different degrees of impairment in the utricle and saccule.

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Temporal processing, spectral processing, and speech perception in noise abilities among individuals with chronic kidney disease undergoing hemodialysis

Kaushlendra Kumar,Livingston Sengolraj,Mohan Kumar Kalaiah

Publication date 22-07-2021

In the literature, the effect of chronic kidney disease on the peripheral auditory system has been well documented. But studies investigating the effect of chronic kidney disease on speech perception and auditory processing abilities are limited. The present study investigated the effect of chronic kidney disease on different auditory processing tasks and speech perception in noise among adults. A total of 28 adults participated in the study. Group 1 included 14 individuals with chronic kidney disease undergoing hemodialysis, and Group 2 included 14 individuals with no known kidney complications. Amplitude modulation detection threshold, gap detection threshold, spectral ripple discrimination threshold, and speech recognition threshold in noise were measured. Independent samples Results showed poorer gap detection threshold, amplitude modulation detection threshold, spectral ripple discrimination threshold, and speech recognition threshold in noise among individuals with chronic kidney disease compared to individuals with no known kidney complications. The present study showed poorer auditory processing and speech perception abilities in individuals with chronic kidney disease.

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Clinicopathologic characteristics of Burkitt lymphoma of the head and neck in a non-endemic region—a Danish nationwide study

Cecilie Dupont Harwood,Patrick René Gerhard Eriksen,Erik Clasen-Linde,Jakob Schmidt Jensen,Peter Asdahl,Malin Rasmussen,Lisa Lyngsie Hjalgrim,Steffen Heegaard,Christian von Buchwald

Publication date 20-07-2021

Burkitt lymphoma rarely presents in head and neck (H&N) in Western countries. We aimed to characterise clinicopathological features of H&N Burkitt lymphoma in Denmark representing a non-endemic region. Clinical records were reviewed for a nationwide cohort of patients diagnosed with H&N Burkitt lymphoma in Denmark between 1980 and 2018. The diagnosis was histologically validated. Thirty-four patients with H&N Burkitt lymphoma (highest incidence in age group 0-9 years, male-to-female ratio 4.7:1) were included. Thirty-three lymphomas (97%) were extranodal. The tumour was visible at the clinical examination in 81% ( Due to the rarity of Burkitt lymphoma of the H&N, there is a high risk of clinical misdiagnosis. Our findings suggest which symptoms and clinical presentations to be aware of in the diagnostics work up that could lead to the diagnosis of Burkitt lymphoma.

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Practical aspects of sentinel node biopsy in oral cavity cancer: all nodes that emit a signal are important

Elina Panula,Jussi Hirvonen,Tero Vahlberg,Aleksi Schrey,Heikki Irjala

Publication date 20-07-2021

Sentinel node biopsy (SNB) is a safe and effective way to examine an N0 neck in early-stage oral cavity cancer (OCC). In this study, we evaluated the variables of SNB detection, surgery, and outcome. Ninety-two patients with N0 OCC examined with SNB were included. Number and brightness of nodes detected on preoperative imaging and during surgery were analyzed and compared with histological findings. Patients with recurrent disease were evaluated separately and the effect of smoking and alcohol consumption was analyzed. Eighteen patients had at least malignant cells in the sentinel lymph node (SLN); 18 patients had recurrent disease and nine patients died from the cancer. The negative predictive value of SNB was 95%. Six patients did not have metastases in the node with the strongest signal, but metastases were found in an SLN with a weaker signal. Smoking and alcohol consumption did not affect disease-specific or overall survival. SNB has been confirmed to be safe and effective in early stage N0 OCC. However, it is important to carefully harvest up to four hottest SLNs that emit a signal. Treatment of patients with only isolated tumor cells (ITC) in the SLN appears to be necessary.

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Possible pathomechanisms accounting for both sound/pressure-induced eye movements and video head impulse test data in superior canal dehiscence

Andrea Castellucci,Salvatore Martellucci,Pasquale Malara,Cecilia Botti,Valeria Del Vecchio,Cristina Brandolini,Gian Gaetano Ferri,Angelo Ghidini,Enrico Armato

Publication date 09-07-2021

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Feasibility of conducting type III home sleep apnoea test in children

Tina Kissow Lildal,Jannik Buus Bertelsen,Therese Ovesen

Publication date 30-06-2021

To test the feasibility of conducting unattended paediatric type III HSAT and to identify issues for improvements to optimize signal quality. Parents were instructed in setting up the unattended HSAT and reported their experiences. Signal quality and causes of signal failure of recordings were assessed. Forty children were included. Mean age was 5.2 years. Predefined success criteria were met in 53% of recordings. Main causes of signal failure were nasal cannula, pulse-oximetry and battery failure. Sensor fixation techniques were developed and implemented during the study and hence signal quality improved. Seventeen (94%) parents reported HSAT to be either easy or medium hard to use.

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