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Abstract Objective To review key evidence-based recommendations for the diagnosis and treatment of peripheral facial palsy in children and adults. 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 peripheral facial palsy 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 main parts: (1) Evaluation and diagnosis of facial palsy: electrophysiologic tests, idiopathic facial palsy, Ramsay Hunt syndrome, traumatic peripheral facial palsy, recurrent peripheral facial palsy, facial nerve tumors, and peripheral facial palsy in children; and (2) Rehabilitation procedures: surgical decompression of the facial nerve, facial nerve grafting, surgical treatment of long-term peripheral facial palsy, and non-surgical rehabilitation of the facial nerve. Conclusions Peripheral facial palsy is a condition of diverse etiology. Treatment should be individualized according to the cause of facial nerve dysfunction, but the literature presents better evidence-based recommendations for systemic corticosteroid therapy.

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Abstract Objective Compare thermal variation in the region of the External Acoustic Canal (EAC) and the Round Window (RW) using different rigid endoscopes and light sources in human temporal bones. Method This is an analytical experimental study using human temporal bones. Thermal variation was assessed during ten minutes, using a thermometer in the region of the EAC and the RW of two temporal bones, right and left. We used three different endoscopes (0° 4-mm, 0° 3-mm and 30° 4-mm) and five intensity/type light source (Halogen 100%, LED 50%, LED 100%, Xenon 50% and Xenon 100% with the same endoscope light fiber. Results We found temperature elevations in the EAC and RW in all measurements. Larger caliber endoscopes (4-mm) and light sources at 100% intensity generated higher temperatures, slightly higher in halogen and xenon. The 30° endoscopes tended to put more heat on structures, with little difference in most measurements. We identified greater temperature variations in the EAC of the right and left temporal bones compared to the RW overall. The highest temperature acquired in the present study was in the EAC of the temporal bone with a 4-mm and 30° endoscope, using xenon light source (intensity of 100%), with an increase of 4.51 °C. Conclusion The type of endoscope and light source can influence the thermal variation and the risk of tissue injury during endoscopic ear surgery. Larger endoscopes with xenon and halogen light sources at maximum intensity generate more heat. Level of evidence: 5.

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Abstract Objective To determine the prevalence, epidemiological profile, and clinical characteristics of Oral or Oropharyngeal Mucosal Lesions (OOPML) in patients attended at the Otorhinolaryngology Service of the Evandro Chagas National Institute of Infectious Diseases (INI-FIOCRUZ) from 2005 to 2017. Methods Statistical analysis of descriptive data from medical records (gender, age, education level, skin color, origin, smoking, alcoholism, HIV co-infection, time of disease evolution, first symptom, and OOPML location) was performed. Results Of 7551 patients attended at the service, 620 (8.2%) were included in the study. OOPML were classified into developmental anomalies (n = 3), infectious diseases (non-granulomatous n = 220; granulomatous n = 155), autoimmune diseases (n = 24), neoplasms (benign n = 13; malignant, n = 103), and unclassified epithelial/soft tissue diseases (n = 102). OOPML of infectious diseases (60.5%) and neoplasms (18.7%) were the most frequent. The predominant demographics of patients with OOPML were: males (63.5%), white (53.5%), and those in the fifth to sixth decades of life (43.3%). Local pain (18.1%) and odynophagia (15%) were the most reported first symptoms, and the most frequent OOPML sites were the palatine tonsil (28.5%), hard palate (22.7%), and tongue (20.3%). The median evolution time was three months. Conclusions Infectious OOPML were the most frequent, as expected in a reference center for infectious diseases, and thus, they are likely to be less frequent in general care and/or dental services. Underreporting of OOPML is possible, as oral/oropharyngeal examination is often not included in the routine medical examination. Oral cavity/oropharynx examination should be performed by specialists, such as dentists and otorhinolaryngologists, who have the expertise in identifying OOPML, even in incipient/asymptomatic cases. Given the numerous diseases in which OOPML can present, diagnosis could be facilitated by multidisciplinary teams, potentially enabling the early treatment of diseases, and thus, reduce morbidity and improve prognosis. The use of standardized medical records for oral/oropharyngeal systematic examination could provide relevant tools for differential diagnoses and information for new clinical-epidemiological studies. Level of evidence: Level 3.

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Abstract Objectives This study aimed to evaluate quality-of-life and satisfaction outcomes in patients undergoing the MES using the Portuguese version of the Nasal Obstruction Symptom Evaluation (NOSE-p) and Rhinoplasty Outcome Evaluation (ROE), and also to evaluate the frequency of possible complications of this technique. Methods We conducted a single-center prospective study with patients who had the indication for MES, from May 2016 to September 2020 at the Facial Plastic Surgery Clinic of Otolaryngology Department of the Hospital de Clinicas de Porto Alegre. The primary outcome was the relative postoperative change in NOSE-p. Secondary outcome was the variation in ROE, a validated quality-of-life questionnaire for rhinoplasty patients. Results Of the 31 patients submitted to extracorporeal septorhinoplasty who were evaluated, twenty-seven patients were included. Preoperative and postoperative NOSE-p scale scores were 65.2 ± 29.9 and 23.5 ± 26.7, respectively (mean differences of 42.04; [95% CI 27.35-56.73]; p< 0.0001). Pre and postoperative ROE scores were 38.3 ± 24.3 vs. 67.29 ± 29.7, respectively (mean differences of −29.02; [95% CI −40.5 to −17.5]; p= 0.0001). Residual septal deviation was verified in 2 patients (7.4%). Conclusion Most of the patients submitted to modified extracorporeal septoplasty had a significant improvement in quality of life scores of nasal obstruction, with good aesthetical outcomes and low indices of postoperative complications. Level of evidence: Level 3.

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Abstract Objectives Montelukast is a well-known leukotriene receptor antagonist commonly used in treating allergic rhinitis and asthma. Omega-3 fatty acid is also known as an antiallergic and immunomodulator molecule. This study aimed to elucidate the efficacy of systemic montelukast and omega-3 fatty acid treatment in allergic rhinitis models in Wistar Hannover rats. Methods This research was conducted on 28 healthy Wistar Hannover rats weighing 250-350 g. After establishing the allergic rhinitis model, nasal symptoms were observed and scored, and the nasal mucosa of all rats was investigated histologically. Light microscopy was utilized to evaluate the degree of ciliary loss, goblet cell hyperplasia, vascular congestion, vascular proliferation, inflammatory cell infiltration, eosinophil infiltration, and hypertrophy in chondrocytes. Results As a result of the analysis of the data obtained from the study, it was determined that typical allergic rhinitis symptoms such as nasal scratching and sneezing were significantly reduced in the rats in the montelukast and omega-3 treated group, and these symptoms did not increase after repeated intranasal OVA-protease applications. Histological examinations after fish oil treatment did not reveal typical inflammatory changes in allergic rhinitis. None of the rats in the montelukast and omega-3 groups had any increase in goblet cells, whereas 14.3% of the rats in the control group and 28.6% of the rats in the allergic rhinitis group had mild increase. Last but not least, 71.4% of rats in the allergic rhinitis group had a moderate increase. The difference between the groups was statistically significant (p< 0.001). Conclusion Regarding the outcomes of this research, it was observed that w-3 fatty acids had antiallergic effects, both histopathological and clinical, in the allergic rhinitis model. We believe that further randomized controlled trials incorporating larger cohorts are warranted to verify the use of omega-3 fatty acids in treating allergic rhinitis. The level of evidence of this article is Level 2.

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Abstract Objectives To make recommendations on the diagnosis and treatment of post-extubation laryngitis (PEL) in children with or without other comorbidities. Methods A three-iterative modified Delphi method was applied. Specialists were recruited representing pediatric otolaryngologists, pediatric and neonatal intensivists. Questions and statements approached topics encompassing definition, diagnosis, endoscopic airway evaluation, risk factors, comorbidities, management, and follow-up. A consensus was defined as a supermajority >70%. Results Stridor was considered the most frequent symptom and airway endoscopy was recommended for definitive diagnosis. Gastroesophageal reflux and previous history of intubation were considered risk factors. Specific length of intubation did not achieve a consensus as a risk factor. Systemic corticosteroids should be part of the medical treatment and dexamethasone was the drug of choice. No consensus was achieved regarding dosage of corticosteroids, although endoscopic findings help defining dosage and length of treatment. Non-invasive ventilation, laryngeal rest, and use of comfort sedation scales were recommended. Indications for microlaryngoscopy and bronchoscopy under anesthesia were symptoms progression or failure to improve after the first 72-h of medical treatment post-extubation, after two failed extubations, and/or suspicion of severe lesions on flexible fiberoptic laryngoscopy. Conclusions Management of post-extubation laryngitis is challenging and can be facilitated by a multidisciplinary approach. Airway endoscopy is mandatory and impacts decision-making, although there is no consensus regarding dosage and length of treatment.

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Abstract Objectives To report two new variants of ALMS1 gene and to discuss the audiological evolution and clinical phenotype in two pairs of siblings with Alström syndrome. Report This paper is a multi-disciplinary diagnostic evaluation, with genetic and audiological analysis that aims to report two new variants of the ALMS1 gene and to discuss the audiological evolution and clinical phenotype in a case series of patients with familial Alström syndrome. Therefore, we describe 4 cases presenting a complete audiometric profile of two pairs of unrelated siblings, to provide a better understanding of this very rare disease. Additionally, the present study identified two heterozygous mutations in the ALMS1 gene. Conclusion This Clinical Capsule Report highlights the importance of audiological monitoring throughout the development of patients with Alström syndrome. The two variants found were not previously reported in the literature, which expands the spectrum of ALMS1 variants in Alström syndrome.

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Abstract Objectives This study aimed to compare the efficacy of labetalol and lidocaine in tympanoplasty surgery, specifically evaluating their impact on hemodynamic changes and perioperative outcomes. Methods A randomized controlled trial was conducted with 64 patients scheduled for tympanoplasty. Patients were randomly assigned to receive either 0.5-2 mg/min labetalol or 1.5 mg/kg/h lidocaine 1% to achieve controlled hypotension during surgery. The efficacy of the drugs was assessed by comparing the Mean Arterial Pressure (MAP), surgeon's satisfaction, time to target MAP, bleeding volume, postoperative pain scores, the need for analgesic medication in recovery, sedation, and other additional parameters. Results The hemodynamic parameters showed a similar trend over time in both the labetalol and lidocaine groups. The median bleeding volume in the labetalol group (10 cc) was lower than that in the lidocaine group (30 cc), although this difference was not statistically significant (p= 0.11). Similarly, surgeon's satisfaction level, pain intensity, and sedation level in the recovery room did not show statistically significant differences between the two groups (p> 0.05). The duration of surgery, recovery stay, and extubation time also did not significantly differ between the groups. Both medications took approximately the same time (20 min) to reach the target MAP and exhibited comparable hemodynamic responses (p> 0.05). Conclusion Both labetalol and lidocaine effectively achieved controlled hypotension during tympanoplasty surgery, thereby improving surgical conditions. The choice of medication should be based on individual patient characteristics and the anesthesiologist's judgment. Level of evidence: II.

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Abstract Objective Kawasaki Disease (KD) may mimic Parapharyngeal (PPI) and Retropharyngeal Infections (RPI), leading to misdiagnosis as Deep Neck Infections (DNIs). The treatment plans for the two diseases are different, and delayed treatment can lead to serious complications. Therefore, prompt diagnosis and management are necessary. This study was performed to evaluate the clinical features of KD mimicking DNIs and explore the treatment options. Methods Children with cellulitis or abscess in parapharyngeal or retropharyngeal space in neck CT were included in this study. The medical records of enrolled children were retrospectively reviewed. Results In total, 56 children were diagnosed with PPI or/and RPI. Twenty-two (39.3%) participants were eventually diagnosed with KD, and 34 (60.7%) were diagnosed with DNIs. Compared with the DNIs group, the KD group had a higher body temperature (p = 0.007), and higher levels of AST (p = 0.040), ALT (p = 0.027), and ESR (p = 0.030). Deep cervical cellulitis (p = 0.005) were more common in the KD group. However, deep neck abscess often occurred in the DNIs group (p = 0.002), with parapharyngeal abscess being the most common type of abscess (p = 0.004). The KD mimicking DNIs cases did not respond to antibiotic treatment, but symptoms significantly improved after the use of Immunoglobulin (IVIG) and aspirin. Conclusion Children with KD may exhibit retropharyngeal or parapharyngeal inflammation in the early stages. KD should be considered a differential diagnosis for children with DNIs, high fever, and no response to antibiotic therapy. Surgery in KD mimicking deep neck abscess requires caution. Level of Evidence I.

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Abstract Objective Our aim in this study is to identify the core genes of chronic rhinosinusitis with nasal polyps and analyze the correlations between it and inflammation-related genes. Methods GSE72713 dataset containing gene expression data of ECRSwNP, nonECRSwNP and healthy samples was obtained from Gene Expression Omnibus (GEO) and filtered by limma to identify DEGs among three groups, then the functions and correlated pathways of DEGs were analyzed using GO and KEGG. The core DEGs were selected by the intersection of DEGs and the PPI network was constructed via STRING. The correlations between the expression levels of CRSwNP core gene and inflammation-related genes were analyzed via the Mann-Whitney U test. Results The DEGs among ECRSwNP, nonECRSwNP, and CTRL were filtered respectively, and enrichment analysis showed they were associated with olfaction and/or immune responses. The PPI network was constructed by 7 core DEGs obtained via the intersection among three groups, and ALOX15 was confirmed as the core gene in the network. Subsequently, the correlations between the expression levels of ALOX15 and inflammation-related genes were illustrated. Conclusion In this study, the core gene ALOX15 was selected from the DEGs among ECRSwNP, nonECRSwNP, and CTRL. IL5, IL1RL1, and IL1RAP were found to exhibit a significant positive correlation with ALOX15. Level of Evidence Level 3.

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Abstract Objective To analyze variability in the distance between the Anterior Ethmoidal Artery (AEA) and the anterior Skull Base (SB), as well as the frequency of lateral asymmetry in a Latin American population using computed tomography. Methods A total of 250 computed tomography scans of paranasal sinuses in coronal reconstruction (500 AEAs) were analyzed. After determining the image with the best anatomical view of the artery, the distance between its midpoint and the ethmoidal roof was measured, and the images were independently interpreted by 2 physicians. Results Of the 500 AEAs, 279 (55.8%) adhered to or passed through the SB at a distance of 0 mm. A total of 221 AEAs (44.2%) were at some distance from the SB, of which 107 (48.4%) were on the right side, ranging from 1.18 to 6.75 mm, and 114 (51.5%) were on the left side, ranging from 1.15 to 6.04 mm. The overall mean distance between the AEA and SB was 1.22 (SD = 1.57) mm, increasing to 2.77 (SD = 1.14) when the arteries adhered to the SB were excluded. Seventy-six individuals (30.4%) had a lateral distance variation > 1 mm. Conclusion Our study includes the largest sample of AEA analyzed with computed tomography scans of paranasal sinuses. There was some distance between the AEA and SB in almost half the patients, and we found a high rate of lateral variability >1 mm. Level of evidence: Level 3.

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Abstract Objectives The internal acoustic meatus is an osseous canal that connects the inner ear to the posterior cranial fossa. It is located in the petrous portion of the temporal bone. A thin cribriform osseous plate known as the fundus is situated at the lateral end of the canal. This study assesses the structural and numerical variations of the fundus formations. Methods Fifty-four temporal bones of unknown gender and age were examined with the surgical microscope. Results The temporal bones analyzed were 46.2% right-sided and 53.7% left-sided. Only one temporal bone had two parallel transverse crests, while three had a single anterior crest that split into two branches posteriorly. The number of foramina at the transverse crest varied, with 29.6% having none, 48.1% having a single foramen, and 22.2% having several foramina. An anterior crest structure was seen in 53.7% of the temporal bones, with 5% having a slightly constricted entry to the facial canal. In cases with a single nerve foramen, 48.1% had one, while 51.8% had more than one, including examples with three or four foramina. A crest was found between the foramina of the single nerve in 7% of patients. Furthermore, a crest between the saccular nerve foramen and the high fiber foramina was seen in 25.9% of cases, and 5% had two saccular nerve foramina. Conclusion We think that revealing the anatomical, structural and numerical variations in the fundus will be useful in explaining the disease-symptom relationship. Level of evidence: Level 4.

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Abstract Objective To investigate whether additional Cognitive Behavior Therapy (CBT) combined with conventional therapy improves outcomes for patients with Persistent Postural-Perceptual Dizziness (PPPD) compared with conventional therapy alone. Methods Two reviewers independently searched PubMed, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov for relevant Randomized Controlled Trials (RCTs) examining CBT for PPPD which were conducted and published in English from January 2002 to November 2022. RCTs reporting any indicators for assessing corresponding symptoms of PPPD were included, such as Dizziness Handicap Inventory (DHI), Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), Hospital Anxiety and Depression Scale (HADS), and Patient Health Questionnaire-9 (PHQ-9). Two independent reviewers conducted extraction of relevant information and evaluation of risk of bias. The Cochrane Collaboration risk of bias tool version 1.0 was used to evaluate risks and assess the quality of the included studies, and Cochrane Review Manager 5.3 software (RevMan 5.3) was used to perform meta-analyses. Results The results of six RCTs indicated that combining additional CBT with conventional therapy significantly improved outcomes for PPPD patients compared with conventional therapy alone, especially in DHI-Total scores (Mean Difference [MD = −8.17], 95% Confidence Interval [95% CI: −10.26, −6.09], p< 0.00001), HAMA scores (MD = −2.76, 95% CI: [−3.57, −1.94], p< 0.00001), GAD-7 scores (MD = −2.50, 95% CI [−3.29, −1.70], p< 0.00001), and PHQ-9 scores (MD = −2.29, 95% CI [−3.04, −1.55], p< 0.00001). Subgroup analysis revealed a significant benefit of additional CBT compared with conventional therapies alone, including Vestibular Rehabilitation Therapy (VRT) (MD = −8.70, 95% CI: [−12.17, −5.22], p< 0.00001), Selective Serotonin Reuptake Inhibitor (SSRI) (with controlled SSRI: MD = −10.70, 95% CI: [−14.97, −6.43], p< 0.00001), and VRT combined with SSRI (MD = −6.08, 95% CI [−9.49, −2.67], p= 0.0005) in DHI-Total scores. Conclusion Additional CBT combined with conventional therapy may provide additional improvement for patients with PPPD compared with conventional therapy alone. However, more RCTs are needed to support and guide the application of CBT in treating PPPD. Level of evidence: I; Systematic review of RCTs.

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Abstract Introduction Biologics targeting type 2 inflammation have revolutionized the way we treat patients with Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). Particularly in severe and difficult-to-control cases, these drugs have provided a new reality for these patients, allowing for the effective and safe treatment of extensive diseases that were not completely managed with the typical strategy of surgery and topical medications. Objectives The experience achieved with the approval of these medications by ANVISA for use in CRSwNP and the knowledge obtained regarding outcomes, adverse effects, and the ideal patient profile prompted the update of the previously published guideline, with a detailed review of the most recent scientific literature, the personal experiences of experts, and the adaptation to the reality of the Brazilian healthcare system, both public and private. Results We proposed a new eligibility criterion for biologics in patients with CRSwNP based on four pillars of indication: the impact of the disease on the patient’s life, whether in the presence of specific symptoms or in overall quality of life; the extent of sinonasal disease; the presence of type 2 comorbidities, considering other associated diseases that may also benefit from anti-T2 biologics, and the presence of biomarkers to define type 2 inflammation, especially those associated with worse disease prognoses. Conclusions This innovative and pioneering method has two major advantages. First, it ensures a comprehensive evaluation of patients; second, it is flexible, as advancements in our understanding of the disease and changes in cost-effectiveness can be addressed by simply adjusting the required score for indication, without the need to modify the entire evaluation scheme.

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Abstract Objective To compare the oncological results and the functional outcomes of patients undergoing Total Laryngectomy (TL) with the non-surgical treatment (organ preservation protocol) in the treatment of advanced laryngeal carcinomas through systematic review and meta-analysis. Methods A literature survey strategy was employed in order to perform a systematic review of the available evidence. Success rate and functional outomes after oncological treatment of patients with advanced laryngeal carcinomas was evaluated through systematic review and metanalysis, comparing TL and organ preservation protocol. Results The surgical treatment was associated with better survival outcomes. When stratifying by T stage, while patients with T4 staging have less risk of mortality with TL, there is no difference between the different treatments for patients with T3 tumors. Surgery is related to a lower chance of recurrence, late dysphagia and feeding tube dependence. Conclusion Patients with T4 tumors should undergo TL as their treatment of choice. For patients with T3 tumors, there is no differences on the risk of mortality according to the therapeutic option, however, there is a greater chance of recurrence and dysphagia when surgery is not performed.