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Lailach S, Zahnert T. Results and Quality of Life after Implantation of Active Middle Ear Implants. Laryngorhinootologie 2022; 101:S3-S35. [PMID: 35605611 DOI: 10.1055/a-1647-8616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The provision of implantable hearing aids represents an area with high development and innovation potential. On the one hand, this review article provides an overview of current indication criteria for the treatment with active middle ear implants. On the other hand, outcome parameters as well as functional results after implantation of active middle ear implants are demonstrated and discussed. The focus is mainly placed on audiological results as well as the subjective health status. "Patient Reported Outcome Measures" (PROMs) have become an integral part of the evaluation of hearing implant treatment. Due to low evidence level criteria, the study situation regarding audiological as well as subjective outcome parameters is not satisfactory. The lack of an international consensus on accepted outcome parameters makes a meta-analytical analysis of results immensely difficult. In the studies published to date, patients with sensorineural hearing loss and patients with conductive or mixed hearing loss offered better speech recognition after implantation of an active middle ear implant compared to conventional hearing aids. Current analyses show a significant improvement in general as well as hearing-specific quality of life after implantation of an active middle ear implant. To date, no validated, hearing-specific quality-of-life measurement instruments exist for assessing the success of fitting in children. Especially in children with complex malformations of the outer ear and the middle ear, excellent audiological results were shown. However, these results need to be substantiated by quality-of-life measurements in future.
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Affiliation(s)
- Susen Lailach
- Universitätsklinikum Dresden Klinik und Poliklinik für Hals-, Nasen-, Ohrenheilkunde, Kopf- und Halschirurgie (Klinikdirektor: Prof. Dr.med. Dr. h.c. Thomas Zahnert) Dresden
| | - Thomas Zahnert
- Universitätsklinikum Dresden Klinik und Poliklinik für Hals-, Nasen-, Ohrenheilkunde, Kopf- und Halschirurgie (Klinikdirektor: Prof. Dr.med. Dr. h.c. Thomas Zahnert) Dresden
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Buhl C, Schindler V, Pfiffner F, Veraguth D, Huber A, Röösli C. Subjective Sound Quality Detection (HISQUI) over Time after Vibrant Soundbridge Implantation. J Clin Med 2022; 11:jcm11071811. [PMID: 35407420 PMCID: PMC9000017 DOI: 10.3390/jcm11071811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 02/01/2023] Open
Abstract
Background: To evaluate the long-term audiological outcomes combined with the Hearing Implant Sound Quality Index (HISQUI) after Vibrant Soundbridge (VSB) implantation. Methods: Prospective recall cohort study of patients who received a VSB in a tertiary academic medical center between 1996 and 2017. Air conduction (AC) and bone conduction (BC), sound field thresholds in aided and unaided conditions, and speech discrimination in noise (Oldenburger sentence test) were measured. Postoperative results were compared with preoperative audiograms. Furthermore, the HISQUI was evaluated. Results: Ten patients (eleven implants) were included, the mean follow up period was nine years. The mean AC threshold preoperatively was between 63 and 70 dB, and the BC was between 38 and 49 dB from 500 to 4000 Hz. In the free-field audiogram, the mean threshold was between 61 and 77 dB unaided vs. between 28 and 52 dB in the aided condition. The average signal to noise ratio (SNR) in the Oldenburger sentence test in the unaided condition was 10 dB ± 6.7 dB vs. 2 dB ± 5.4 dB in the aided condition. Three patients reported a good to very good hearing result, four patients a moderate, and three patients a poor hearing result. There was a significant association between the years of implantation and the HISQUI (p = 0.013), as well as a significant decrease by 14 HISQUI points per 10 dB SPL decline (SE 5.2, p = 0.023). There was a significant difference between the change of BC over the years and the HISQUI, as well as the number of years after implantation and the HISQUI. On average, per dB decrease in BC, the HISQUI decreases by 1.4 points, and every year after implantation the HISQUI decreases by 2.7 points. Conclusions: The aided threshold in free field and speech understanding in noise improved significantly with VSB. An increase over time of BC thresholds was observed as well as a decrease in HISQUI score. This decrease in BC thresholds over time may be due to presbycusis. Therefore, monitoring of these patients over time should be considered to discuss alternative hearing rehabilitation measures in a timely manner.
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Affiliation(s)
- Christof Buhl
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland; (C.B.); (F.P.); (D.V.); (A.H.)
| | - Valeria Schindler
- Department of Gastroenterology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland;
| | - Flurin Pfiffner
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland; (C.B.); (F.P.); (D.V.); (A.H.)
| | - Dorothe Veraguth
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland; (C.B.); (F.P.); (D.V.); (A.H.)
| | - Alexander Huber
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland; (C.B.); (F.P.); (D.V.); (A.H.)
| | - Christof Röösli
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland; (C.B.); (F.P.); (D.V.); (A.H.)
- Correspondence: ; Tel.: +41-44-255-1111
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Xie F, Zhen X, Zhu H, Kou Y, Li C, Guo L, Shi L, Han J, Zhou X. Development and Validation of a Prognostic Model to Predict Hearing Recovery for Patients With Chronic Otitis Media. EAR, NOSE & THROAT JOURNAL 2021:1455613211065519. [PMID: 34907786 DOI: 10.1177/01455613211065519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To explore the factors affecting postoperative hearing recovery in chronic otitis media (COM) patients, establish a clinical prediction model for hearing recovery, and verify the accuracy of the model. METHODS Data of patients with COM who were admitted to our hospital between January 1, 2012 and September 30, 2020 were retrospectively analyzed. We collected data on relevant clinicopathological characteristics of patients. The patients were randomly divided into the development cohort and validation cohorts. A postoperative air-bone gap (ABG) ≤20 dB was defined as successful hearing recovery. Univariate and multivariable logistic regression analyses were used to investigate the association of several prognostic factors with hearing recovery. These factors were then used to establish a nomogram. The model was subjected to bootstrap internal validation and performance evaluation in terms of discrimination, calibration, and clinical validity. RESULTS This study included 2146 patients with COM: the development cohort comprised 1610 patients (mean [standard deviation; SD] age, 44.1 [14.7] years; 733 men [45.5%]) and the validation cohort included 536 patients (mean [SD] age, 42.9 [14.4] years; 234 men [43.7%]). Multivariable logistic regression analysis showed that age, duration of onset, styles of surgery (tympanoplasty, canal wall up-CWU, or canal wall down-CWD), ossicular prosthesis, granulation or calcified blocks around the ossicular chain, ossicular chain integrity, duration of drilling, eustachian tube dysfunction, mixed hearing loss, semicircular canal fistula, and second surgery were associated with hearing recovery. A nomogram based on these variables was constructed. The area under the curve was 0.797 (95% confidence interval [CI], 0.778-0.812) in the development cohort and 0.798 (95% CI, 0.7605-0.8355) in the validation cohort. CONCLUSIONS This study demonstrated the various clinical factors correlated with hearing recovery in patients with COM. The nomogram developed with these data could provide personalized risk estimates of hearing recovery to enhance preoperative counseling and help to set realistic expectations in patients.
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Affiliation(s)
- Fengyang Xie
- Department of Otorhinolaryngology Head and Neck Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, 34708Shandong University, Jinan, China
| | - Xiaoyue Zhen
- Minimally Invasive Urology Center, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Haiyuan Zhu
- Department of Otorhinolaryngology Head and Neck Surgery, 34708Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yan Kou
- Neonatal Department, 518873The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Changle Li
- Department of Otorhinolaryngology Head and Neck Surgery, 34708Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Ling Guo
- Department of Otorhinolaryngology Head and Neck Surgery, 34708Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Li Shi
- Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Cheeloo College of Medicine, 12589Shandong University, Jinan, China
| | - Jie Han
- Department of Otorhinolaryngology Head and Neck Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, 34708Shandong University, Jinan, China
| | - Xuanchen Zhou
- Department of Otorhinolaryngology Head and Neck Surgery, 34708Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Totally implantable active middle-ear implants: a large, single-surgeon cohort. The Journal of Laryngology & Otology 2021; 135:304-309. [PMID: 33745469 DOI: 10.1017/s0022215121000335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES This study aimed to evaluate hearing outcomes and device safety in a large, single-surgeon experience with the totally implantable active middle-ear implants. METHODS This was a retrospective case series review of 116 patients with moderate-to-severe sensorineural hearing loss undergoing implantation of active middle-ear implants. RESULTS Mean baseline unaided pure tone average improved from 57.6 dB before surgery to 34.1 dB post-operatively, signifying a mean gain in pure tone average of 23.5 dB (p = 0.0002). Phonetically balanced maximum word recognition score improved slightly from 70.5 per cent to 75.8 per cent (p = 0.416), and word recognition score at a hearing level of 50 dB values increased substantially from 14.4 per cent to 70.4 per cent (p < 0.0001). Both revision and explant rates were low and dropped with increasing surgeon experience over time. CONCLUSION This study showed excellent post-operative hearing results with active middle-ear implants with regard to pure tone average and word recognition score at a hearing level of 50 db. Complication rates in this case series were significantly lower with increasing experience of the surgeon. Active middle-ear implants should be considered in appropriate patients with moderate-to-severe sensorineural hearing loss who have struggled with conventional amplification and are good surgical candidates.
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Warnholtz B, Schär M, Cuny P, Sonntag K, Beutner D, Dobrev I, Röösli C, Sim JH. A New Stapes-Head Coupler for the Vibrant Soundbridge System. Audiol Neurootol 2021; 26:287-294. [PMID: 33647905 DOI: 10.1159/000512600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 10/12/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The Vibrant Soundbridge (MED-EL Medical Electronics, Austria) is an active middle ear implant with a floating mass transducer (FMT) for patients with conductive, sensorineural, or mixed hearing loss. While the FMT is vertically aligned above the stapes head (SH) with the current Vibroplasty Clip coupler (MED-EL Medical Electronics), the new SH coupler was developed to mount the FMT on the inferior side of the stapes and to fit in the reduced middle ear space after canal-wall-down mastoidectomy. METHODS Using 11 human cadaveric temporal bones (TBs), placements of the new SH couplers on the stapes were examined, and effective stimuli to the cochlea were evaluated by measuring piston-like motion of the stapes footplate with a current of 1 mA on the FMT. The results were assessed in comparison with the Vibroplasty Clip coupler. RESULTS The new SH coupler showed perfect coupling on the stapes in 9 out of 11 TBs. A small gap between the SH and the plate of the connection link part was unavoidable in 2 TBs but had negligible effect on vibrational motion of the stapes. Vibrational motion of the stapes with the new SH coupler was reduced at frequencies above 3 kHz compared to the corresponding motion with the current Vibroplasty Clip coupler, but the relative attenuation over all 11 cadaveric temporal bones was <10 dB. CONCLUSIONS The new SH coupler provides an alternative with more stable fixation when placement of the current Vibroplasty Clip coupler is limited due to insufficient space after canal-wall-down mastoidectomy, while still delivering effective stimuli to the cochlea.
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Affiliation(s)
- Birthe Warnholtz
- Department of Otolaryngology, Head and Neck Surgery, University Hospital Zürich, Zürich, Switzerland.,Department of Otolaryngology, Head and Neck Surgery, University of Zürich, Zürich, Switzerland
| | - Merlin Schär
- Department of Otolaryngology, Head and Neck Surgery, University Hospital Zürich, Zürich, Switzerland.,Department of Otolaryngology, Head and Neck Surgery, University of Zürich, Zürich, Switzerland
| | - Pascale Cuny
- Department of Otolaryngology, Head and Neck Surgery, University Hospital Zürich, Zürich, Switzerland.,Department of Otolaryngology, Head and Neck Surgery, University of Zürich, Zürich, Switzerland
| | | | - Dirk Beutner
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Göttingen, Göttingen, Germany
| | - Ivo Dobrev
- Department of Otolaryngology, Head and Neck Surgery, University Hospital Zürich, Zürich, Switzerland.,Department of Otolaryngology, Head and Neck Surgery, University of Zürich, Zürich, Switzerland
| | - Christof Röösli
- Department of Otolaryngology, Head and Neck Surgery, University Hospital Zürich, Zürich, Switzerland.,Department of Otolaryngology, Head and Neck Surgery, University of Zürich, Zürich, Switzerland
| | - Jae Hoon Sim
- Department of Otolaryngology, Head and Neck Surgery, University Hospital Zürich, Zürich, Switzerland, .,Department of Otolaryngology, Head and Neck Surgery, University of Zürich, Zürich, Switzerland,
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Dalgic A, Atsal G, Olgun L, Kirazli T. Long term results and evaluation of device satisfaction in patients used the vibrant sound bridge (VSB). Acta Otolaryngol 2021; 141:256-260. [PMID: 33528309 DOI: 10.1080/00016489.2020.1843708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients' satisfaction with the device is as important as the audiological gains in patients using these devices. OBJECTIVE In this study, we aimed to evaluate the hearing aid satisfaction of individuals using The Vibrant Sound Bridge (VSB) (Vibrant Med-El, Innsbruck, Austria) and to compare this result with audiologic results with and without devices. MATERIAL AND METHODS Patients who were using VSB were included in the study. Preoperative and postoperative pure tone averages and demographic datas of the patients to be included in the study were recorded. A shortened version of Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire, was used to evaluate patients' device satisfaction. RESULTS Fifteen patients with VSB were included in the study. The mean follow-up was 9.13 years. The preoperative air conduction threshold and the air-bone gap in all frequencies were significantly higher than postoperative values (p < .05). The functional gain was found as 28 dB. In the APHAB questionnaire, there was a significant difference between total score results and EC, BN, RV subscales in the patients using the device (p < .01). CONCLUSION AND SIGNIFICANCE Patients with VSB give satisfactory results in auditory gains. In particular, good indication and long-term use of the device increases the suitability and satisfaction of the patients.
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Affiliation(s)
- Abdullah Dalgic
- Department of Otolaryngology, University of Health Sciences Izmir Bozyaka Education and Research Hospital, Izmir, Turkey
| | - Gorkem Atsal
- Department of Otolaryngology, University of Health Sciences Izmir Bozyaka Education and Research Hospital, Izmir, Turkey
| | - Levent Olgun
- Department of Otorhinolaryngology, Izmir Baskent Zubeyde Hanım Training and Research Hospital, Izmir, Turkey
| | - Tayfun Kirazli
- Department of Otolaryngology, Ege University School of Medicine, Izmir, Turkey
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Long-Term Stability and Functional Outcome of an Active Middle Ear Implant Regarding Different Coupling Sites. Otol Neurotol 2019; 41:60-67. [PMID: 31746816 DOI: 10.1097/mao.0000000000002418] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Indication and implantation of active middle ear implants (AMEI) are well established. Choice of the coupling site depends from the individual anatomical situation. Long-term stability of different coupling sites in terms of functional outcome and complications are rare and were investigated in this study. DESIGN Retrospective analysis of 41 consecutive patients (45 ears) with coupling of the AMEI at the incus, stapes, and round window. Analysis of preoperative, postoperative, and long-term results of pure-tone average, speech discrimination in quiet at 65 dB (German language Freiburg Monosyllabic Test) and noise (German language Oldenburger Sentence Test), rate of revision surgeries as well as explantations and the novel parameter patient years (py). RESULTS Mean of follow-up was 3.0 ± 1.7 years resulting in a total of 135.6 py. Bone conduction was stable in all patients pre- to postoperatively as well as preoperatively to the long-term. Round window patients had the broadest air-bone gap (31.4 ± 19.4 dB HL) benefitting the most from the AMEI (functional gain = 39.0 ± 12.8 dB HL). Regarding speech discrimination, incus patients performed the best both in quiet (77.7 ± 22.8%) and noise (3.4 ± 2.9 dB SNR). In terms of revision surgery and explantations, round window patients exhibited the highest rates (20%). CONCLUSIONS Regarding all coupling sites, satisfying long-term stability results and comparable complication rates were reported with best performance of coupling to the incus. Implementation of patient years might be a novel parameter for the comparison of revisions and explantations.
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Is the use of a bone conduction hearing device on a softband a useful tool in the pre-operative assessment of suitability for other hearing implants? The Journal of Laryngology & Otology 2018; 132:505-508. [PMID: 30019669 DOI: 10.1017/s0022215118000816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess whether pre-operative assessment with a bone conduction hearing device on a softband is an accurate predictor of performance with one of two transcutaneous hearing implants.Study designCohort study comparing pre-and post-operative speech audiometry using correlation analysis. METHODS Pre-operative pure tone audiometry and aided half optimum speech recognition thresholds were compared with post-operative aided results for each ear that had undergone implantation. Data were collected prospectively. RESULTS Full data were available in 24 ears. In 19 out of 24 ears (79 per cent), the difference between pre- and post-operative speech scores was less than 10 dB, demonstrating a good clinical correlation. The Pearson correlation coefficient was calculated at 0.66 (95 per cent confidence interval = 0.357-0.842), indicating a strong statistical correlation. CONCLUSION Pre-operative softband testing shows good clinical correlation and strong statistical correlation with hearing implant performance. The findings suggest there is value in using the test to predict performance and guide patients' expectations.
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Jung J, Kim JW, Moon IS, Kim SH, Choi JY. Vibrant Soundbridge can improve the most comfortable listening level in sensorineural hearing loss: Our experience with 61 patients. Clin Otolaryngol 2017; 43:369-373. [PMID: 28834277 DOI: 10.1111/coa.12958] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2017] [Indexed: 11/30/2022]
Affiliation(s)
- J Jung
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - J W Kim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - I S Moon
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - S H Kim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - J Y Choi
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
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Weiss BG, Bertlich M, Scheele R, Canis M, Jakob M, Sohns JM, Ihler F. Systematic radiographic evaluation of three potential implantation sites for a semi-implantable bone conduction device in 52 patients after previous mastoid surgery. Eur Arch Otorhinolaryngol 2017; 274:3001-3009. [DOI: 10.1007/s00405-017-4609-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 05/10/2017] [Indexed: 11/25/2022]
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Monini S, Bianchi A, Talamonti R, Atturo F, Filippi C, Barbara M. Patient satisfaction after auditory implant surgery: ten-year experience from a single implanting unit center. Acta Otolaryngol 2017; 137:389-397. [PMID: 27918233 DOI: 10.1080/00016489.2016.1258733] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONCLUSIONS The satisfaction rate of the subjects with an auditory implant appears strictly related to the resulting auditory improvement, and the surgical variables would play a prevailing role in respect to the esthetic factors. OBJECTIVES To assess the rate of satisfaction in subjects who underwent the surgical application of an auditory device at a single Implanting Center Unit. METHOD A series of validated questionnaires has been administered to subjects who underwent the surgical application of different auditory devices. The Glasgow Benefit Inventory (GBI), the Visual Analog Scale (VAS), and the Abbreviated Profile of Hearing Aid Benefit (APHAB) have been used to compare the implanted situation with the hearing-aided one; a percutaneous bone conductive implant (pBCI) with an active middle ear implant (AMEI) on the round window in mixed hearing loss; and an invisible, fully-implantable device with a frankly and bulky semi-implantable device. RESULTS The mean GBI scores were higher in Vibrant Soundbridge (VSB)® and Bonebridge® subjects, without significant differences among the various devices. The mean VAS score increased for all the devices in comparison with the conventional hearing aid. The mean APHAB score was similarly better in the implanted condition as total and partial scores.
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Affiliation(s)
- Simonetta Monini
- NESMOS Department, ENT Clinic, Medicine and Psychology, Sapienza University, Rome, Italy
| | - Alessandra Bianchi
- NESMOS Department, ENT Clinic, Medicine and Psychology, Sapienza University, Rome, Italy
| | - Rita Talamonti
- NESMOS Department, ENT Clinic, Medicine and Psychology, Sapienza University, Rome, Italy
| | - Francesca Atturo
- NESMOS Department, ENT Clinic, Medicine and Psychology, Sapienza University, Rome, Italy
| | - Chiara Filippi
- NESMOS Department, ENT Clinic, Medicine and Psychology, Sapienza University, Rome, Italy
| | - Maurizio Barbara
- NESMOS Department, ENT Clinic, Medicine and Psychology, Sapienza University, Rome, Italy
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