João Paço

Pathophysiology, Diagnosis and Treatment of Somatosensory Tinnitus: A Scoping Review

Somatosensory tinnitus is a generally agreed subtype of tinnitus that is associated with activation of the somatosensory, somatomotor, and visual-motor systems. A key characteristic of somatosensory tinnitus is that is modulated by physical contact or movement. Although it seems common, its pathophysiology, assessment and treatment are not well defined. We present a scoping review on the pathophysiology, diagnosis, and treatment of somatosensory tinnitus, and identify priority directions for further research. Methods: Literature searches were conducted in Google Scholar, PubMed, and EMBASE databases. Additional broad hand searches were conducted with the additional terms etiology, diagnose, treatment. Results: Most evidence on the pathophysiology of somatosensory tinnitus suggests that somatic modulations are the result of altered or cross-modal synaptic activity within the dorsal cochlear nucleus or between the auditory nervous system and other sensory subsystems of central nervous system (e.g., visual or tactile). Presentations of somatosensory tinnitus are varied and evidence for the various approaches to treatment promising but limited. Discussion and Conclusions: Despite the apparent prevalence of somatosensory tinnitus its underlying neural processes are still not well understood. Necessary involvement of multidisciplinary teams in its diagnosis and treatment has led to a large heterogeneity of approaches whereby tinnitus improvement is often only a secondary effect. Hence there are no evidence-based clinical guidelines, and patient care is empirical rather than research-evidence-based. Somatic testing should receive further attention considering the breath of evidence on the ability of patients to modulate their tinnitus through manouvers. Specific questions for further research and review are indicated.

Including auditory tube function on models is relevant to assess water exposure after tympanostomy tubes–Multiphase computerized fluid dynamics model

INTRODUCTION Myringotomy with tympanostomy tube is the most common otologic surgery and some patients are still advised to avoid water. However, there is no evidence supporting this, with published papers questioning the need for this advice. METHODS A Multiphase Computational Fluid Dynamics (CFD) model was created using computerized tomography images of a childs healthy ear. It was then used to study the flow of fluids through the external ear, tympanic cavity, and auditory tube, with and without submersion. RESULTS The model accurately described the behavior of the air retained in the patients nasopharynx and tympanic cavity. A simulated elevation of pressure in the external auditory canal without submersion, without increase of pressure in the nasopharynx, demonstrated that fluids promptly crossed the tympanostomy tube into the middle ear. However, simulated elevation of pressure in the external auditory canal with concurrent elevation of air pressure in the nasopharynx during submersion did not lead to passive tube opening nor to any detectable flow through the tympanostomy tube. CONCLUSIONS In the model, submersion increases pressure in the nasopharynx which offsets the pressure in the external auditory canal. So, in the absence of a pressure gradient, no passive tubal opening took place, and no air or fluid flow was detected through the transtympanic tube. This model now includes the exhaust function of the auditory tube in the model and shows its relevance.

Biomarkers of presbycusis and tinnitus in a Portuguese older population

Introduction: Presbycusis or age-related hearing loss (ARHL) is a ubiquitous health problem. It is estimated that it will affect up to 1.5 billion people by 2025. In addition, tinnitus occurs in a large majority of cases with presbycusis. Glutamate metabotropic receptor 7 (GRM7) and N-acetyltransferase 2 (NAT2) are some of the genetic markers for presbycusis. Objectives: To explore patterns of hearing loss and the role of GRM7 and NAT2 as possible markers of presbycusis and tinnitus in a Portuguese population sample. Materials and Methods: Tonal and speech audiometry, tinnitus assessment, clinical interview, and DNA samples were obtained from patients aged from 55 to 75 with or without tinnitus. GRM7 analysis was performed by qPCR. Genotyping of single nucleotide polymorphisms (SNPs) in NAT2 was performed by PCR amplification followed by Sanger sequencing or by qPCR. Results: We screened samples from 78 individuals (33 men and 45 women). T allele at GRM7 gene was the most observed (60.3% T/T and 33.3% A/T). Individuals with a T/T genotype have a higher risk for ARHL and 33% lower risk for tinnitus, compared to individuals with A/A and A/T genotype, respectively. Being a slow acetylator (53%) was the most common NAT2 phenotype, more common in men (55.8%). Intermediate acetylator was the second most common phenotype (35.9%) also more frequent in men (82.6%). Noise exposed individuals and individuals with ‘high frequency’ hearing loss seem to have a higher risk for tinnitus. Our data suggests that allele AT of GRM7 can have a statistically significant influence toward the severity of tinnitus. Conclusion: For each increasing year of age the chance of HL increases by 9%. The risk for ARHL was not significantly associated with GRM7 neither NAT2. However, we cannot conclude from our data whether the presence of T allele at GRM7 increases the odds for ARHL or whether the A allele has a protective effect. Genotype A/T at GRM7 could potentially be considered a biomarker of tinnitus severity. This is the first study evaluating the effect of GRM7 and NAT2 gene in tinnitus.

Sickle Cell Trait, Malaria and Sensorineural Hearing Loss–A Case-Control Study from São Tomé and Príncipe

Background: Hearing loss is a problem with higher incidence in South Asia, Asia Pacific and sub-Saharan Africa. In these countries there is also associated history of anemia and malaria. Objective: This study aims to identify a putative role of Beta globin mutation - sickle cell trait and HL in Sao Tome and Principe population. Methods: A retrospective case-control study of a convenience sample was collected during Otolaryngologist Humanitarian Missions in Sao Tome and Principe. Control group includes individuals with normal hearing in both ears, and the case group has participants presenting bilateral or unilateral HL. It was evaluated the potential risk factors and sickle cell trait with HL, as well self-report of malaria infection, consanguinity, familial history of HL. The HbS gene point mutation (Glu6Val) was determined by PCR-RFLP. Results: Our results showed a statistical significance between HL - oral language and self-report of HL. Taken altogether, our data did not reveal association between sickle cell trait and HL. However, a statistical association between HL and self-report of malaria was found. Conclusion: No association between sickle cell trait and the high prevalence of HL was found. Self-report of Malaria was found as a risk factor for the development of HL in Sao Tome and Principe population. The multifactorial profile of HL shall not exclude the relevance of other etiologic factors than Malaria to justify the high prevalence of HL in Sao Tome and Principe and further investigation must be applied.

Five Years of Humanitarian Missions in São Tomé and Príncipe

INTRODUCTION: Since February 2011, a group of otolaryngologists from CUF Infante Santo Hospital, a private healthcare unit in Portugal, invited by a non-governmental organization to provide equipment and properly skilled professionals to help and treat otolaryngology diseases in Sao Tome and Principe. These missions included surgical procedures, consultation and hearing evaluation. METHODS: This work is a retrospective chart review of all otolaryngology cases performed during these missions since 2011 to 2016, and what we done during mission. RESULTS: During these missions, we have found some common pathologies. Deafness is the most prevalent after which follows the lymphoid tissue of oropharynx pathology. On these 18 missions a total of 1057 otolaryngology assessments were conducted. The main surgery was oral cavity with adenoidectomy and tonsillectomy. The results of all audiological tests performed during these 18 missions, reveal an increase of sensorineural deafness. DISCUSSION: These missions’ purpose is to allow healthcare access to all, to identify people with hearing and language problems and to adapt prosthetics, if possible, mainly for children and young adults.We have witnessed a considerable improvement on the children to whom we have adapted prosthetics. Some of them return to school, have friends and became more social. As the result of this work, we conclude that all Humanitarian Missions must be adapted to each country’s needs as we have done over the past five years.

P136: The True Story of Menière’s Disease

tion. Included are case presentations of use of MDCT in superior canal dehiscence syndrome, cochlear implantation, ossicular erosion, and fixation. RESULTS: MDCT was first introduced in 1992 with a dual channel detector. However, 64-row scanners are now available as of 2003. First designed to increase scanning times and decrease slice thickness, latest generations have made great advancements in isometric imaging allowing for on-demand multiplanar reconstruction as well as increased fidelity in three dimensional reconstruction. While not well described in the literature, properties of MDCT augment our abilities to accurately diagnose otologic disease. For example, the ability to align CT images directly in the plane of the superior semicircular canal aids in finding bony dehiscences in superior canal syndrome. In addition, high-definition CT images aid in characterization of electrode array placement in cochlear implantation. Ossicular pathologies can also present a challenge to conventional imaging whereas MDCT improves diagnostic accuracy. CONCLUSIONS: Multidetector row computed tomography has increased the ability to accurately diagnose certain otologic diseases. Improvements in MDCT are changing our clinical practice.

P140: The Unknown Malleus Anterior Ligament

posterior tympanotomy for insertion of the cochlear implant electrodes. Some 36 patients submitted to this technique from July 2002 to August 2005; its feasibility and the occurrence of intraand postoperative complications were considered. RESULTS: Fourteen patients were female (39%). Age ranged from 4 to 61 years (mean 18 years; mode 5 years). Twenty-two patients were between 4 and 12 years of age. The Combined Approach technique was feasible and cochlear implantation was successful in all cases. No complications were observed intraand postoperatively. The mean and median follow-up was 15 months (range: 1 to 37 months). The transcanal route has the advantage of providing a wider surgical field for the operation. Moreover, it allows the drill to be positioned at a favorable angle that facilitates the procedure. The round window is easily visualized, which results in accurate identification of the cochleostomy site. The work at difficult areas such the anterior segment of cochlea basal turn is also favorable. Another important aspect is that the Combined Approach technique facilitates preservation of facial nerve integrity. A very small posterior tympanotomy is performed, and maneuvers are performed away from the facial nerve. CONCLUSIONS: In the group studied, the Combined Approach technique was a simple and safe alternative to the classic cochlear implantation technique.

P112: Intratemporal Facial Nerve Tumors: Management Controversies

male and 32 female) were recruited from a tinnitus clinic and underwent a detailed neuro-otological examination including otoscopy, stapedius reflexes, middle ear pressure measurements, pure tone audiometry, tinnitus pitch and loudness matches. Tinnitus severity was assessed by the Tinnitus Questionnnaire (TQ) and subjects were genotyped for two biallelic BDNF markers, an intronic A T substitution (refSNP# rs2049046), plus a functional missense variant (Val66Met, rs6265). RESULTS: When genotypes were grouped at both loci assuming dominance of the lesser alleles, no effects were observed for the intronic BDNF variant. However, carriers of the BDNF missense variant differed significantly from other subjects with regard to the prevalence of comorbid hearing impairment (p .01). In addition, tinnitus symptomatology was found to be milder in male subjects carrying the missense variant (p .05). CONCLUSIONS: This is the first study to address the participation of BDNF variants in the genetic susceptibility to chronic tinnitus. Pending replication in larger samples, a genotype-wise association with comorbid hearing impairment and, to a lesser extent, with tinnitus severity, argues in favour of a modifying role in defined tinnitus phenotypes.

P138: Treatment of Imbalance Post-Gentamicin

history, scientific discoveries and chronology of Menière’s disease and the importance of Charles Skinner Hallpike and Hugh Cairns. METHODS: The authors reviewed medical literature and medical history of Prosper Menière’s, Charles Skinner Hallpike, and Hugh Cairns. Special emphasis is given on the investigations of Hallpike on temporal bones of patient with Menière’s disease: clinical history, removal and methods of preparation of the temporal bones, and interpretation of the microscope readings. RESULTS: The observations of Hallpike on the temporal bones of patients with Menière’s disease when compared with others from normal individuals were published on 1938 and tried to explain the disease: obliteration of the endolymphatic duct, failure of re-absortion of endolymph and ionic changes, pressure increase leading to ischemia of macula and producing an attack, explanation of hearing loss and tinnitus by compression of the Corti unit. CONCLUSIONS: Through a review of medical literature the authors point out some aspects of Menière’s disease, with special interest in the thorough works of Charles Skinner Hallpike on temporal bones of patients with Menière’s disease and his explanation of Menière’s disease and attacks.

Variations in osteo-meatal drainage and its clinical implications

Objectives: The authors suggest a systematization of osteo-meatal drainage based on nonselected consecutive observations of sinus CT scans. The maxillary drainage is classically described as a mucociliar activity converged to the maxillary ostium (natural ostium), nevertheless there might be accessory ostiuns. Methods: The authors observed 50 consecutive sinus CT scans (high spatial resolution 2.5 mm coronal plans). We also used virtual endoscopy and compared the findings with microscopic and endoscopic observation of anatomic human specimen in cadavers. Results: The maxillary drainage area is usually observed in 3 continuous plans: Segment 1, anterior or ethmoidomaxillary channel (consists of a long channel that communicates maxillary sinus with the anterior ethmoidal complex). Segment 2: Medium or labial (consists of the horizontal portion of uncinate process that acts like a vertical wall separating infundibular lumen from middle meatus). Segment 3: Posterior or direct meatal (corresponds to the most posterior and horizontal portion of uncinate process, communicating directly to the middle meatus). This is the most inconstant of the 3 segments. The results are equally comparable to those achieved in anatomic human specimen in cadavers. Conclusion: Based on facts achieved by virtual endoscopy we conclude that maxillary drainage is done through a cleft or multiple, continuous ostiuns. This clinical systematization has implications in a clinical and surgical perspective, permits to explain why in cases of massive ethmoidal inflammatory disease, maxillary sinus remains intact since one of the drainage segments is not blocked. Otherwise, if those segments are blocked there is maxillary disease.