Position paper on olfactory dysfunction: 2023

BACKGROUND

Since publication of the original Position Paper on Olfactory Dysfunction in 2017 (PPOD-17), the personal and societal burden of olfactory disorders has come sharply into focus through the lens of the COVID-19 pandemic. Clinicians, scientists and the public are now more aware of the importance of olfaction, and the impact of its dysfunction on quality of life, nutrition, social relationships and mental health. Accordingly, new basic, translational and clinical research has resulted in significant progress since the PPOD-17. In this updated document, we present and discuss currently available evidence for the diagnosis and management of olfactory dysfunction. Major updates to the current version include, amongst others: new recommendations on olfactory related terminology; new imaging recommendations; new sections on qualitative OD and COVID-19 OD; updated management section. Recommendations were agreed by all co-authors using a modified Delphi process.

CONCLUSIONS

We have provided an overview of current evidence and expert-agreed recommendations for the definition, investigation, and management of OD. As for our original Position Paper, we hope that this updated document will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency, and generalisability of work in this field.

Mucormycosis in the Middle East and North Africa: Analysis of the FungiScope® registry and cases from the literature

BACKGROUND

Regional differences in the underlying causes, manifestations and treatment of mucormycosis have been noted in studies covering Europe, Asia and South America.

OBJECTIVES

To review cases of mucormycosis across the Middle East and North Africa (MENA) region in order to identify epidemiological, treatment and outcome trends in this region.

PATIENTS/METHODS

Cases of proven or probable invasive mucormycosis from the region were identified from the FungiScope^® database and the medical literature. For each case, information on underlying condition, site of infection, pathogenic species, therapeutic intervention, type of antifungal therapy and outcome were analysed.

RESULTS

We identified 310 cases of mucormycosis in the MENA region. The number of reported cases increased by decade from 23 before 1990 to 127 in the 2010s. In this region, the most common underlying conditions associated with mucormycosis were diabetes mellitus (49.7%) and conditions associated with immunosuppression (46.5%). The majority of patients received treatment with antifungals (93.5%), with a large proportion treated with both antifungals and surgery (70.6%). Overall mortality rates decreased from 47.8% before 1990 to 32.3% in the 2010s.

CONCLUSIONS

The number of reported cases of mucormycosis in the MENA region has risen over the past few decades, in line with increases in the number of patients with underlying conditions associated with this infection. Although the majority of patients received treatment with antifungal therapies and/or surgery, the associated mortality rate remains high and there is a clear need for more effective prevention and treatment strategies in the MENA region.

Relationship between odor intensity estimates and COVID-19 prevalence prediction in a Swedish population

In response to the COVID-19 pandemic, countries have implemented various strategies to reduce and slow the spread of the disease in the general population. For countries that have implemented restrictions on its population in a step-wise manner, monitoring of COVID-19 prevalence is of importance to guide decision on when to impose new, or when to abolish old, restrictions. We are here determining whether measures of odor intensity in a large sample can serve as one such measure. Online measures of how intense common household odors are perceived and symptoms of COVID-19 were collected from 2440 Swedes. Average odor intensity ratings were then compared to predicted COVID-19 population prevalence over time in the Swedish population and were found to closely track each other (r=-0.83). Moreover, we found that there was a large difference in rated intensity between individuals with and without COVID-19 symptoms and number of symptoms was related to odor intensity ratings. Finally, we found that individuals progressing from reporting no symptoms to subsequently reporting COVID-19 symptoms demonstrated a large drop in olfactory performance. These data suggest that measures of odor intensity, if obtained in a large and representative sample, can be used as an indicator of COVID-19 disease in the general population. Importantly, this simple measure could easily be implemented in countries without widespread access to COVID-19 testing or implemented as a fast early response before wide-spread testing can be facilitated.

Diabetes in the practice of otolaryngology

Diabetes mellitus is the most common endocrine disease, characterized by chronic hyperglycemia. The hyperglycemic milieu leads to endothelial injury in blood vessels of variant size, which results in microangiopathy and macroangiopathy (atherosclerosis). Consequential ischemia of nerves and hyperglycemia by itself lead to nerve degeneration and generalized neuropathy, affecting most often the sensory peripheral nerves and the autonomic nervous system. Auditory, vestibular and olfactory sensorium may be compromised by DM. People with DM have an increased susceptibility to infection, as a result of neutrophil dysfunction and impaired humoral immunity. Therefore DM predisposes to certain infectious diseases, such as fungal sinusitis or malignant otitis externa, which are rare in general population. Recovery from infections or from injuries may be compromised by coexisting DM. In this review we discuss complications of DM in the head and neck region. Otolaryngologists and general practitioners should be alert to specific conditions related to DM and be minded of the relevant complications and consequences.

Position paper on olfactory dysfunction

Background

Olfactory dysfunction is an increasingly recognised condition, associated with reduced quality of life and major health outcomes such as neurodegeneration and death. However, translational research in this field is limited by heterogeneity in methodological approach, including definitions of impairment, improvement and appropriate assessment techniques. Accordingly, effective treatments for smell loss are limited. In an effort to encourage high quality and comparable work in this field, among others, we propose the following ideas and recommendations. Whilst the full set of recommendations are outlined in the main document, points include the following: • Patients with suspected olfactory loss should undergo a full examination of the head and neck, including rigid nasal endoscopy with small diameter endoscopes. • Subjective olfactory assessment should not be undertaken in isolation, given its poor reliability. • Psychophysical assessment tools used in clinical and research settings should include reliable and validated tests of odour threshold, and/or one of odour identification or discrimination. • Comprehensive chemosensory assessment should include gustatory screening. • Smell training can be helpful in patients with olfactory loss of several aetiologies.

Conclusions

We hope the current manuscript will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency and generalisability of work in this field.

A Head and Tube Stabilizing Apparatus for Acoustic Rhinometry Measurements

A new apparatus consisting of a chin rest and forehead support system and an adjustable acoustic tube holder is described. This device provides patient comfort, technical convenience and precise positioning that contribute to reliable measurement. Moderate pressure between forehead and supporting bar incorporated into the apparatus did not induce significant alterations in results.

The Effects of an External Nasal Dilator on Labor

Background

The aim of this study was to assess the effect of an external nasal dilator on several variables characterizing labor in both mother and fetus.

Methods

One hundred and fifty primigravida women in active labor were randomized to wear, throughout labor, either a dilator spring-loaded nasal strip or a placebo device. Data were obtained during labor and compared between the groups. After delivery, the satisfaction rate was assessed.

Results

No differences were found between the study and the control group regarding rate of induction or augmentation of labor as well as Montevideo units reached, frequency of rupture of membranes, duration of the active phase and second stage of labor, usage of epidural analgesia, normal fetal heart pattern, meconium-stained amniotic fluid, and neonatal well being. Length of maternal and neonatal hospitalization also did not differ between the groups. Satisfaction rate was significantly higher in parturient women wearing nasal strips with a dilator spring than in parturient women wearing a placebo spring (P < 0.0001).

Conclusion

Nasal strips do not change the course but ameliorate the quality of labor by improving the ease of breathing. Nasal dilators sustain the respiratory effort associated with the long process of labor and may control the switch from nasal to oronasal breathing during delivery.

Position paper on olfactory dysfunction

BACKGROUND

Olfactory dysfunction is an increasingly recognised condition, associated with reduced quality of life and major health outcomes such as neurodegeneration and death. However, translational research in this field is limited by heterogeneity in methodological approach, including definitions of impairment, improvement and appropriate assessment techniques. Accordingly, effective treatments for smell loss are limited. In an effort to encourage high quality and comparable work in this field, among others, we propose the following ideas and recommendations. Whilst the full set of recommendations are outlined in the main document, points include the following: - Patients with suspected olfactory loss should undergo a full examination of the head and neck, including rigid nasal endoscopy with small diameter endoscopes. - Subjective olfactory assessment should not be undertaken in isolation, given its poor reliability. - Psychophysical assessment tools used in clinical and research settings should include reliable and validated tests of odour threshold, and/or one of odour identification or discrimination. - Comprehensive chemosensory assessment should include gustatory screening. - Smell training can be helpful in patients with olfactory loss of several aetiologies.

CONCLUSIONS

We hope the current manuscript will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency and generalisability of work in this field.

From Nose to Brain: Un-Sensed Electrical Currents Applied in the Nose Alter Activity in Deep Brain Structures

Rules linking patterns of olfactory receptor neuron activation in the nose to activity patterns in the brain and ensuing odor perception remain poorly understood. Artificially stimulating olfactory neurons with electrical currents and measuring ensuing perception may uncover these rules. We therefore inserted an electrode into the nose of 50 human volunteers and applied various currents for about an hour in each case. This induced assorted non-olfactory sensations but never once the perception of odor. To validate contact with the olfactory path, we used functional magnetic resonance imaging to measure resting-state brain activity in 18 subjects before and after un-sensed stimulation. We observed stimulation-induced neural decorrelation specifically in primary olfactory cortex, implying contact with the olfactory path. These results suggest that indiscriminate olfactory activation does not equate with odor perception. Moreover, this effort serendipitously uncovered a novel path for minimally invasive brain stimulation through the nose.

Collecting clinical data in primary ciliary dyskinesia- challenges and opportunities

Rationale: Primary ciliary dyskinesia (PCD) is under diagnosed and underestimated. Most clinical research has used some form of questionnaires to capture data but none has been critically evaluated particularly with respect to its end-user feasibility and utility.

Objective: To critically appraise a clinical data collection questionnaire for PCD used in a large national PCD consortium in order to apply conclusions in future PCD research.

Methods: We describe the development, validation and revision process of a clinical questionnaire for PCD and its evaluation during a national clinical PCD study with respect to data collection and analysis, initial completion rates and user feedback.

Results: 14 centers participating in the consortium successfully completed the revised version of the questionnaire for 173 patients with various completion rates for various items. While content and internal consistency analysis demonstrated validity, there were methodological deficiencies impacting completion rates and end-user utility. These deficiencies were addressed resulting in a more valid questionnaire.

Conclusions: Our experience may be useful for future clinical research in PCD. Based on the feedback collected on the questionnaire through analysis of completion rates, judgmental analysis of the content, and feedback from experts and end users, we suggest a practicable framework for development of similar tools for various future PCD research.

Orbital complications associated with paranasal sinus infections - A 10-year experience in Israel

OBJECTIVE

Orbital involvement is the most common complication of sinus infections. The epidemiology of the disease is continuously changing in the antibiotic era.

MATERIALS AND METHODS

Data on patients who were hospitalized due to acute sinusitis and orbital complications were retrospectively collected and analyzed from four medical centers in Israel during the years 2002-2012.

RESULTS

288 patients were included in the study, the average age was 14.4 years, 180 were males, and 220 were children. No significant annual increase in the number of patients was noted. The lowest number of patients was found during the summer 19.4%. A linear direct correlation was found between older age and prolonged hospital stay. Children were presented with a significantly higher Chandler score than adults. No patient had cavernous sinus thrombosis. 101 (35%) patients received antibiotics before hospital admission. Their average hospital stay was similar to those who were not treated prior to admission. 106 patients (39.8%) had fever. A direct correlation was found between older age and the presence of fever. 102 (35.4%) patients had leukocytosis. The difference in white blood cell count between patients younger than two years of age to the other groups was statistically significant. Forty four (15.3%) patients underwent surgical intervention. A direct correlation was found between leukocytosis and older age to surgery.

CONCLUSIONS

Periorbital cellulitis occurs mainly in children and males and is less frequent in the summer. Children tend to have worse orbital involvement with lower temperatures than adults. Older age and leukocytosis are associated with surgical intervention.

A Homozygous Nme7 Mutation Is Associated with Situs Inversus Totalis

We investigated the cause of situs inversus totalis (SIT) in two siblings from a consanguineous family. Genotyping and whole-exome analysis revealed a homozygous change in NME7, resulting in deletion of an exon causing an in-frame deletion of 34 amino acids located in the second NDK domain of the protein and segregated with the defective lateralization in the family. NME7 is an important developmental gene, and NME7 protein is a component of the γ-tubulin ring complex. This mutation is predicted to affect the interaction of NME7 protein with this complex as it deletes the amino acids crucial for the binding. SIT associated with homozygous deletion in our patients is in line with Nme7(-/-) mutant mice phenotypes consisting of congenital hydrocephalus and SIT, indicating a novel human laterality patterning role for NME7. Further cases are required to elaborate the full human phenotype associated with NME7 mutations.

Severity of pneumococcal versus non-pneumococcal acute otitis media in children

BACKGROUND

Pneumococcal acute otitis media (AOM) has been previously considered as a more severe disease than that caused by other otopathogens, based on clinical and/or otologic scores. We sought to test this hypothesis in the pneumococcal conjugated vaccine (PCV) era.

METHODS

Children <6 years who presented with 'severe' AOM episodes with middle ear fluid (MEF) cultures during 2008-2013 were retrospectively identified. 'Severe' AOM episodes were considered if tympanocentesis was required or if spontaneous otorrhea was present. Data were extracted for demographics, clinical and laboratory tests. Children were categorised according to their PCV status as 'unimmunised' or 'PCV7/PCV13 immunised' and according to their MEF culture results into the 'pneumococcal' or the 'non-pneumococcal' group. Leukocytosis was defined as white blood cells (WBC) count >15 000/μL, and elevated C-reactive protein (CRP) level was considered as >50 mg/L.

RESULTS

Of 295 eligible AOM episodes, 106 (36%) were culture positive. Children in the pneumococcal group (65, 61%) had a significantly higher WBC counts and higher CRP levels, were more often <2 years old and were more prone to complicate with acute mastoiditis (AM), compared to children in the non-pneumococcal group, P = 0.03, P = 0.02, P = 0.04 and P = 0.03, respectively. In the pneumococcal group, unimmunised children had higher WBC counts when compared with PCV13-immunised children (P = 0.04), but there were no appreciable differences in CRP levels between unimmunised and PCV7/PCV13-immunised children.

CONCLUSION

Pneumococcal AOM is associated with higher leukocytosis and CRP levels than non-pneumococcal AOM. Circulating Streptococcus pneumoniae strains causing 'severe' AOM in PCV13-immunised children yielded lower inflammatory responses when compared with unimmunised children.

H-coil repetitive transcranial magnetic stimulation for treatment of temporal lobe epilepsy: A case report

Low frequency repetitive TMS (rTMS) of a cortical seizure focus is emerging as an antiepileptic treatment. While conventional rTMS stimulators activate only superficial cortical areas, reaching deep epileptic foci, for example in temporal lobe epilepsy (TLE), is possible using specially designed H-coils. We report the results of rTMS in a young adult with pharmacoresistant bilateral TLE who underwent three courses (of 10, 15, and 30 daily sessions) of unilateral rTMS over the hemisphere from which seizures originated most often. Seizure frequency was assessed before and after each block of rTMS sessions, as was the tolerability of the procedure. Seizure frequency declined significantly, by 50 to 70% following each rTMS course. All sessions were well-tolerated.

Endoscopic Occlusion of Tracheoesophageal Fistula in Ventilated Patients Using an Amplatzer Septal Occluder

Acquired tracheoesophageal fistula (TEF) is a challenging, life threatening condition. It most commonly appears in critically ill patients requiring prolonged mechanical ventilation, who cannot withstand open neck or chest surgery. An endoscopic technique could be better tolerated by these patients. We present our experience using a cardiac Amplatzer ASD septal occluder for an endoscopic TEF repair in ventilation-dependent patients. Two high risk patients underwent the procedure under general anesthesia and close respiratory monitoring. In one patient the device was inserted through the trachea and in the other through the esophagus. In both cases fistula closure was achieved for different periods of time allowing the patients a temporary relief of symptoms. The procedure was well tolerated by the patients, and no significant adverse effect documented. The technique was successful as a temporary solution for unstable patients with TEFs and should be considered as a treatment modality for similar patients.

A reach-out system for video microscopy analysis of ciliary motions aiding PCD diagnosis

BACKGROUNDS

High-speed Video-Microscopy Analysis (HVMA) is now being used to aid diagnosis of Primary Ciliary Dyskinesia (PCD). Only a few centers however, are equipped with the available resources and equipment to perform these tests. We describe our experience in HVMA reaching-out to many more peripheral and relatively remote areas. A portable computer with HVMA software, video camera and a microscope were used. Fourteen disperse pediatric centers were reached and a total of 203 subjects were tested within a relatively short time (Clinical Trial Registration: NCT 01070914 (registered February 6, 2010).

RESULTS

With an average time of 20 minutes per patient, the system enabled us to test approximately 10-15 subjects per day. A valid HVMA result was made in 148 subjects and helped in the diagnosis of PCD in many of the patients who were subsequently confirmed to have PCD by electron microscopy and/or immunofluoresence and/or genetics and/or nasal Nitric Oxide testing. The sensitivity of abnormal HVMA to accurately predict PCD was 90.2%.

DISCUSSION AND CONCLUSION

This is the first report of an out-reach system to record HVMA for improved diagnosis of PCD in remote regions that are not within reach of PCD centers and experts. It provides immediate preliminary results and instantaneous feedback to the physician, patient and his/her family members in these areas. Future studies to compare this system to conventional desk top systems are warranted.

TRIAL REGISTRATION

NCT 01070914 (registered February 6, 2010).

A Russian adaptation of the tinnitus handicap inventory

OBJECTIVE

To establish a Russian version of the English THI.

DESIGN

The English THI (THI-E) was translated into Russian by two bilingual investigators, independently. The final Russian THI version (THI-R) was constructed by a third investigator, from the two translations. This version was administered to fifty consecutive patients at a tinnitus clinic. Participants also assessed the loudness of their tinnitus, and completed the Russian versions of the Beck's depression inventory and the state anxiety Inventory.

STUDY SAMPLE

The participants were fifty consecutive patients (older than 18 years of age with a tinnitus lasting over three months) who were treated at a tinnitus clinic.

RESULTS

A very good internal consistency was found (α = 0.94), with significant correlation between the THI-R score and the Beck depression inventory score. Factor analysis confirmed a uni-dimensional structure of the inventory.

CONCLUSIONS

A valid and reliable THI-R questionnaire was constructed.

Disinhibition of olfaction: human olfactory performance improves following low levels of alcohol

We hypothesize that true human olfactory abilities are obscured by cortical inhibition. Alcohol reduces inhibition. We therefore tested the hypothesis that olfactory abilities will improve following alcohol consumption. We measured olfaction in 85 subjects, 45 in a between-subjects design, and 40 in a repeated-measures within-subjects design before and after consumption of alcoholic or non-alcoholic beverages. Subjects were also assessed using neurocognitive measures of inhibition. Following alcohol consumption, blood alcohol levels ranged from 0.005% to 0.11%. Across subjects, before any consumption of alcohol, we found that individuals who were less inhibited had lower (better) olfactory detection thresholds (r=0.68, p<0.005). Moreover, after alcohol consumption, subjects with low alcohol levels could make olfactory discriminations that subjects with 0% alcohol could not make (chance=33%, alcohol=51.3±22.7%, control=34.7±31.6%, t(43)=2.03, p<0.05). Within subjects, we found correlations between levels of alcohol and olfactory detection (r=0.63, p<0.005) and discrimination (r=-0.50, p<0.05), such that performance was improved at low levels of alcohol (significantly better than baseline for detection) and deteriorated at higher levels of alcohol. Finally, levels of alcohol-induced improved olfactory discrimination were correlated with levels of alcohol-induced cognitive disinhibition (r=0.48, p<0.05). Although we cannot rule out alternative non-inhibitory alcohol-induced routes of influence, we conclude that improved olfaction at low levels of alcohol supports the notion of an inhibitory mechanism obscuring true olfactory abilities.

Acute Mastoiditis in the Pneumococcal Conjugate Vaccines Era

Objectives:

(1) Describe the changing trends in mastoiditis incidence and bacteriology in the pneumococcal conjugate vaccine (PCV) era.

Methods:

PCV-7 and PCV-13 have been gradually implemented in the Israeli national immunization program in 2009 and 2010, respectively. We retrospectively identified children aged 0-6 years who had middle ear cultures obtained from “severe” acute otitis media (AOM) episodes, defined as AOM requiring tympanocentesis or presenting with spontaneous otorrhea, during the years 2008-2013. Of those, we identified children with acute mastoiditis. Data were extracted for demographic, clinical and microbial information.

Results:

Data from 295 eligible AOM episodes reported in 279 children were collected. Of those, 56 children with 57 episodes of acute mastoiditis were identified. Of these 36 were boys (64%) and 37 (66%) were <2 years old. During the pre-PCV and the PCV introduction period (January 2008-November 2010), mastoiditis incidence rate was significantly higher than the post-PCV introduction era (December 2010-December 2013) incidence, 0.23 versus 0.16/“severe” AOM episode, respectively ( P = .04). Mastoiditis developed despite adequate systemic antibiotic therapy for AOM in 28 (49%) patients. Of the 21 (37%) positive cultures, Streptococcus pneumoniae was the most common bacteria, which was solely isolated in 17 (81%) episodes and in combination of Haemophilus influenzae in 1 (5%) episode. Notably, there were no isolates of S pneumoniae from mastoiditis patients following the first year after PCV-13 introduction.

Conclusions:

Mastoiditis incidence complicating “severe” AOM decreased after the introduction of PCVs, which can be directly attributed to their effectiveness in reducing pneumococcal-related AOM burden and complications.

Characteristics of Supraglottitis in Adults

Objectives:

Describe the demographics, clinical presentation, interventions, and outcomes of adult patients diagnosed with acute supraglottitis.

Methods:

We retrospectively identified adult patients with acute supraglottitis during the years 1990 through 2013 by using relevant International Classification of Disease codes. Data were extracted for demographic and clinical information.

Results:

A total of 288 eligible patients were enrolled. Diagnosis was made by either indirect or fiber-optic laryngoscopy (or both modalities). The incidence rate of acute supraglottis was 4.3 out of 100,000 patients/year, with a steep rise during the years 1999 through 2013. A slight male predominance was observed (n = 160, 56%). The mean age was 50 ± 16 years, and 77% were 30 to 70 years old. Sore throat (94%) and dysphagia (88%) were the most common presenting symptoms, which had begun 2 days prior to hospitalization. Comorbidities were reported in 62% of the patients. Swabs were obtained in 17% of patients, of those 23% were positive. Patients were hospitalized either in the otolaryngology department (n = 255, 89%) or in the intensive care unit (ICU) (n = 33, 11%). Of the ICU patients, 19 (58%) had an airway securing intervention procedure (84% upon admission, 16% during initial 24 hours surveillance). Amoxicillin-clavulanate was administered in 61% of patients. Intravenous and inhalational corticosteroids were administered in 190 (66%) patients. The mortality rate was 0.003%.

Conclusions:

The signs and symptoms of supraglottitis in adults are different from those in the pediatric population. Patients presenting with sore throat, dysphagia, or odynophagia should be cautiously suspected for supraglottitis until proven otherwise. Treatment includes intravenous antibiotics and steroids and outcomes are excellent.

New Algorithm for Supraglottitis Staging in Adults

Objectives:

(1) Critically review the current staging systems of supraglottitis in adults. (2) Suggest a new algorithm for infections involving the supraglottis based on clinical staging considering anatomical subsites and outcome correlation.

Methods:

We retrospectively identified adult patients with acute supraglottitis during the years of 1990 through 2013 by using International Classification of Disease codes. Patients were graded by using 2 systems: the Scope grading system for epiglottitis, and our new suggested grading system, which relies on the edema in 3 subsites: the epiglottis, the aryepiglottic folds and arytenoids, and the larynx. Those subsites were given the following grades: 0 = no edema, 1 = mild edema, 2 = moderate edema, and 3 = severe edema. Summation of the 3 subsites scores was performed in order to assess the need for airway intervention.

Results:

A total of 288 eligible patients were enrolled. Diagnosis was made by either indirect or fiberoptic laryngoscopy (or by both modalities). One hundred seventy-eight patients (62%) had Scope grades of 0 or 1, and 110 patients (38%) had Scope grades of 2 or 3. Of these, 24% required an airway intervention. According to our classification, 236 patients (82%) who had a score of ≤4 were less likely to undergo a securing airway intervention, when compared with the 52 patients (18%) who had a score of ≥5, 4% vs 33%, respectively ( P = .03). All patients graded with ≥8 score required airway intervention.

Conclusions:

Our new suggested flow chart of decisions is based on an easy grading system, which allows dynamic description of patient progression during sequential examinations, easy information transmission, and decision making.

Cardiovascular risk factors as causes for hearing impairment

The purpose of this paper is to provide a contemporary review of the correlation between cardiovascular risk factors (CVRFs) and hearing impairment (HI) . We conducted a comprehensive review of the literature in order to assess the effects of the different CVRFs on HI. We focused on the pathological findings in the inner ear and their correlation with cochlear function in population-based studies. We found that CVRFs adversely affect hearing acuity. HI diagnosis should be accompanied by detecting and treating CVRFs, according to the presented outline, which may augment hearing rehabilitation and improve the general health and the well-being of the patient. © 2014 S. Karger AG, Basel.

Water Pipe Smoking: Effects, Attitudes and Directions

Water pipe (WP) smoking is prevalent in several countries and is emerging as a major international public health issue. This article reviews the literature on WP smoking practices and its health effects. Water pipe smoking in the Middle East is more common in women compared to cigarette smoking. WP smoking has harmful effects similar to cigarette smoking, and the nicotine and tar content of WP smoke is higher than that of cigarettes. Still, many users believe that WP is less harmful than cigarettes and are unaware of the damage that WP can cause to their health. There is limited literature on WP smoking, highlighting the need for research in several areas including: epidemiology of WP smoking, sociological dimensions and tobacco control. The unique social and traditional role of WP smoking renders forgiving, culture-sensitive and patient approach.

Neural activity at the human olfactory epithelium reflects olfactory perception

Organization of receptive surfaces reflects primary axes of perception. In vision, retinal coordinates reflect spatial coordinates. In audition, cochlear coordinates reflect tonal coordinates. However, the rules underlying the organization of the olfactory receptive surface are unknown. To test the hypothesis that organization of the olfactory epithelium reflects olfactory perception, we inserted an electrode into the human olfactory epithelium to directly measure odorant-induced evoked responses. We found that pairwise differences in odorant pleasantness predicted pairwise differences in response magnitude; that is, a location that responded maximally to a pleasant odorant was likely to respond strongly to other pleasant odorants, and a location that responded maximally to an unpleasant odorant was likely to respond strongly to other unpleasant odorants. Moreover, the extent of an individual's perceptual span predicted their span in evoked response. This suggests that, similarly to receptor surfaces for vision and audition, organization of the olfactory receptor surface reflects key axes of perception.

Head and neck manifestations of 22q11.2 deletion syndromes

The allelic loss of 22q11.2 results in various developmental failures of pharyngeal pouch derivatives ("22q11.2 deletion syndromes", 22q.11DS), consequently affecting the anatomy and physiology of head and neck (H&N) organs. The objective of this paper was to describe those manifestations. Two 22q11.2DS patients with H&N manifestations were studied along with a comprehensive review of the English literature, from 1975 to 2010 regarding the associated H&N malformations among 22q11.2DS. A 24-year-old mentally disabled 22q11.2DS male presented with right hemithyroid enlargement, causing significant compressive signs. Sonography revealed a homogeneous 8 × 3 cm lesion, replacing almost the entire thyroid lobe. Fine needle aspiration revealed colloid material and abundant eosinophils. The hemithyroidectomy specimen confirmed follicular adenoma. A 19-year-old mentally disabled 22q11.2DS female underwent CT-angiography due to an upper GI bleeding. The study revealed a vascular malformation in the infratemporal fossa. Reviewing the reported data regarding 22q11.2DS-associated H&N malformations revealed abnormalities and malfunctions of the thyroid gland, parathyroid glands, thymus agenesis, cleft palate, carotid artery aberrations, malformations of the larynx and trachea and esophageal dysmotility. 22q11.DS patients may present with H&N anatomical abnormalities, along with hormonal dysfunctions, which require special awareness once treatment is offered, especially when concerning anesthetic and surgical aspects. In addition, hSNF5/INI1, a tumor suppressor gene, detected at location 22q11.2 was described to be "knocked out" in some patients. This may be associated with H&N tumors reported in these patients.

Battery ingestion in children

INTRODUCTION

Ingestion of batteries by children became more frequent in recent years, due to the increasing accessibility of electronic toys and devices to children. Due to their electrochemical composition, impacted batteries in the esophagus may cause an extensive damage. Following the removal of a battery, the post-esophagoscopy management is still controversial.

CASE PRESENTATION

An otherwise healthy 8 year-old boy presented to the pediatric emergency room 3h after the unintentional swallowing of a lithium battery. On examination, the patient was diaphoretic and tachypneic. Plain PA chest film revealed a 2.5 cm diameter radiopaque round object in the upper esophagus. The patient was scheduled for an urgent rigid esophagoscopy which was performed 2h after admission. Esophagoscopy findings included an impacted lithium battery in an advanced emptying process at a level of 17 cm from the incisor teeth, with a 3rd degree ulcerative esophagitis. It was not possible to visualize either the distal esophagus or the stomach. A nasogastric tube was not inserted because of a significant risk for esophageal perforation if bluntly passed. Post-operative medical therapy included fasting, administration of intravenous antibiotic therapy, antacids, and steroids. Flexible esophagoscopy superior to the level of the mucosal injury performed one day later, revealed erosive esophagitis, without evidence of perforation. Upper digestive tract gastrografin swallow test performed 2 days after esophagoscopy did not demonstrate a leak from the esophagus, and oral feeding was carefully re-initiated. Treatment was discontinued the following day. Follow up on days 10 and 14 revealed a healthy child with normal swallowing.

DISCUSSION

Battery ingestion-related injury results from direct pressure necrosis, local electrical currents and alkali leakage. Signs and symptoms of ingested battery are related to impaction duration, size of battery, battery content and peristaltic waves of the esophagus. Appropriate imaging studies should be performed to maximize identification of the foreign body before esophagoscopy. Esophageal stenting and adjuvant medical therapy (steroid therapy, antibiotic therapy and anti-reflux therapy) have a low evidence level of clinical benefit following caustic injuries from impacted batteries and spillage of their content to the esophagus. A judicious management should be tailored in each patient. Increased public and health personnel awareness is necessary to diminish the incidence of battery ingestion.

Changing trends of peritonsillar abscess

OBJECTIVE

This retrospective, cohort study aims to assess the changing characteristics of peritonsillar abscess (PTA).

METHOD

Data were obtained from PTA patient records admitted to a secondary hospital over a 10-year period.

RESULTS

A total of 427 patients, aged 31.6 +/- 15.2 years (range, 3-91), were treated for PTA, reflecting an incidence of 0.9/10 000/y. Forty-seven (11%) patients had more than one episode. There was no sex, seasonal, or side predominance. Thirteen (3%) patients developed complications. One hundred four (24.4%) patients were 40 years or older, had a longer hospital stay, and were prone to complications. One hundred two (23.8%) patients did not have an anteceding pharyngotonsillitis. Smoking was more common among patients with PTA as compared with the general population and was associated with more complications. A total of 283 (66.2%) patients developed PTA in spite of prior antibiotic therapy; 51.1% of smokers that received prior antibiotics had a higher incidence of Streptococcus viridans isolates.

CONCLUSION

Peritonsillar abscess may have changed its characteristics: affecting more older patients having a worse and longer course and PTA evolvement without anteceding tonsillitis or in spite of a prior adequate antibiotic therapy. Smoking may be a predisposing factor.

Predicting odor pleasantness with an electronic nose

A primary goal for artificial nose (eNose) technology is to report perceptual qualities of novel odors. Currently, however, eNoses primarily detect and discriminate between odorants they previously “learned”. We tuned an eNose to human odor pleasantness estimates. We then used the eNose to predict the pleasantness of novel odorants, and tested these predictions in naïve subjects who had not participated in the tuning procedure. We found that our apparatus generated odorant pleasantness ratings with above 80% similarity to average human ratings, and with above 90% accuracy at discriminating between categorically pleasant or unpleasant odorants. Similar results were obtained in two cultures, native Israeli and native Ethiopian, without retuning of the apparatus. These findings suggest that unlike in vision and audition, in olfaction there is a systematic predictable link between stimulus structure and stimulus pleasantness. This goes in contrast to the popular notion that odorant pleasantness is completely subjective, and may provide a new method for odor screening and environmental monitoring, as well as a critical building block for digital transmission of smell.

Electronic noses (eNoses) are devices aimed at mimicking animal noses. Typically, these devices contain a set of sensors that generate a pattern representing an odor. Application of eNoses entails first “training” the eNose to a particular odor, and once the eNose has “learned”, it can then be used to detect and identify this odor. Using this approach, eNoses have been tested in applications ranging from disease diagnosis to space-ship interior environmental monitoring. However, in contrast to animal noses, eNoses have not been used to generate information on novel odors they hadn't learned. Here, rather than train an eNose on particular odorants, we trained an eNose to the perceptual axis of odorant pleasantness. We found that this eNose was then able to generalize and rate the pleasantness of novel odors it never smelled before, and that these ratings were about 80% similar to those of naïve human raters who had not participated in the eNose training phase. Furthermore, the results replicated across cultures without retraining of the device. This result contrasts the popular notion that odorant pleasantness is completely subjective, and may allow for numerous applications, such as an environmental monitor that would warn of malodor regardless of its source.

Laryngeal cancer in acquired immunodeficiency syndrome

With improved survival, more AIDS patients, especially heavy smokers and alcohol abusers, may be confronted with laryngeal squamous cell carcinoma. Since curative treatment may require aggressive combined therapy, these patients, often suffering from immunosupression and poor general condition, present unique therapeutic challenges. The objective of the study was to describe treatment dilemmas. This case report presents a detailed description of an AIDS patient with carcinoma of the larynx. A patient with T3N0M0 laryngeal carcinoma and AIDS underwent tracheotomy and biopsy, followed by severe neck and pulmonary infection. After convalescence, radiotherapy was administered, with no evidence of a disease during a 3.5-year follow-up. During his remaining life, the patient developed severe psychoaffective disorder, his immune state deteriorated until he demised from sepsis. In conclusion, patients with HIV infection, especially having a history of tobacco or alcohol abuse, should be carefully examined for head and neck carcinoma that is likely to be more aggressive. Following surgery, AIDS patients may have worse wound healing and a greater tendency to contract infections. Radiotherapy and especially chemotherapy may cause life-threatening complications. Although early detection may increase survival, curative treatment should involve many disciplines and extra caution.

Odorant concentration dependence in electroolfactograms recorded from the human olfactory epithelium

Electroolfactograms (EOGs) are the summated generator potentials of olfactory receptor neurons measured directly from the olfactory epithelium. To validate the sensory origin of the human EOG, we set out to ask whether EOGs measured in humans were odorant concentration dependent. Each of 22 subjects (12 women, mean age = 23.3 yr) was tested with two odorants, either valeric acid and linalool (n = 12) or isovaleric acid and l-carvone (n = 10), each delivered at four concentrations diluted with warm (37 degrees C) and humidified (80%) odorless air. In behavior, increased odorant concentration was associated with increased perceived intensity (all F > 5, all P < 0.001). In EOG, increased odorant concentration was associated with increased area under the EOG curve (all F > 8, all P < 0.001). These findings substantiate EOG as a tool for probing olfactory coding directly at the level of olfactory receptor neurons in humans.

Nasopharyngeal cysts

INTRODUCTION

Nasopharyngeal cysts are uncommon, and are mostly asymptomatic. However, these lesions are infrequently found during routine endoscopies and imaging studies. In even more rare cases, they may be the source for unexplained sinonasal symptoms, such as CSF rhinorrhea, visual disturbances and nasal obstruction.

PURPOSE OF REVIEW

This presentation systematically reviews the different nasopharyngeal cysts encountered in children, emphasizing the current knowledge on pathophysiology, recent advances in molecular biology and prenatal diagnosis, clinical presentation, imaging and treatment options.

SUMMARY

With the advent of flexible and rigid fiber-optic technology and modern imaging techniques, and in particularly prenatal diagnostic techniques, nasopharyngeal cysts recognition is more common than previous times and requires an appropriate consideration. Familiarity with these lesions is essential for the pediatric otolaryngologist.