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Evaluation of quality of life of patients with benign paroxysmal positional vertigo associated with Meniere’s disease pre and post vestibular rehabilitation

Epidemiological profile of 277 patients with facial fractures treated at the emergency room at the ENT Department of Hospital do Trabalhador in Curitiba / PR, in 2010

Rhinoplasty and facial asymmetry: Analysis of subjective and anthropometric factors in the Caucasian nose

Profile of cochlear implant users of the city of Manaus

Quality of life and deglutition after total laryngectomy

Vestibular schwannoma: 825 cases from a 25-year experience

Cochlear implants: our experience and literature review

Limits on quality of life in communication after total laryngectomy

Respiratory muscle strength in asthmatic children

Electronic data collection for analysis of surgical maneuvers on patients submetted to rhinoplasty

Pharyngeal swallowing phase and chronic cough

Prevalence of noise-induced hearing loss in drivers

Evoked otoacoustic emissions in workers exposed to noise: A review

Laryngeal Leishmaniasis

Severe complication of posterior nasal packing: Case report

Recurrence of atypical fibroxanthoma. Diagnosis and treatment


Int. Arch. Otorhinolaryngol. 2012;16(4):424. DOI: 10.7162/S1809-97772012000400001

Editorial International Archives of Otorhinolaryngoloy Editorial - Technological Revolution in Otolaryngology 16th Volume (4) – Oct/Nov/Dec - 2012 Dear Reader,

New technologies have been implemented annually in daily ENT. Over the past 40 years, the technological revolution in our area, here to stay. At the end of the 60s and beginning of the 70s of last century, fiber optics rigid and flexible for use in ENT area, had its beginning, and quickly were incorporated into our diagnostic and therapeutic armamentarium, as well as its improvement in thereafter, with respect to size and thickness. These devices helped greatly in the development of Rhinology and Laryngology. After these came the stroboscopy and kymography, in order to make a detailed evaluation of the mucosal wave and the movements of the vocal folds. They were also very well accepted by the scientific community, being the most used stroboscopy in daily clinical practice. In the field of otology, parallel development was the knowledge of other areas of our specialty, with availability in the market of hearing aids (hearing aids individual - AASI) high technology with ever smaller sizes, adapting to each individual through computer inclusive. Cochlear implants and brain stem implants brought new perspectives on improving the quality of life of patients with major changes to certain groups of hearing impaired. More recently, it launched the Surgical robot named Da Vinci, produced in Intuitive Surgical Inc., Sunnyvale, California, USA, with the possibility of carrying out surgery through the oral cavity (Transoral Robotic Surgery - TORS), mainly for resection tumors located in the oropharynx, where the technical difficulty viewing by traditional methods means that we have to do an external opening of the cervical region, often with bone section, increasing the morbidity and mortality of patients. We are happy to receive a visit from you at our site: http://www.internationalarchivesent.org We hope to revisit them in future publications.

A big hug, Geraldo Pereira Jotz Editor-in-Chief International Archives of Otorhinolaryngoloy

I n d e x in L I L A C S and L I L A C S - E x p r e s s – L a t i n d e x – D O A J – F U N P E C - R P – S c i E L O Int. Arch. Otorhinolaryngol., São Paulo - Brazil, v.16, n.4, Oct/Nov/December - 2012.

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Int. Arch. Otorhinolaryngol. 2012;16(4):430-436. DOI: 10.7162/S1809-97772012000400002

Original Article

Evaluation of quality of life pre- and post-vestibular rehabilitation in patients with benign paroxysmal positional vertigo associated with Meniere’s disease Dayra Dill Socher1, Jan Alessandro Socher2, Viviane Jacintha Bolfe Azzi3. 1) Physiotherapist. Physiotherapist, Blumenau/SC. 2) PhD from the University of São Paulo. Professor of Otorhinolaryngology in Regional University of Blumenau Foundation. 3) Master of Physiotherapy, Methodist University of Piracicaba. Professor of Kinesiology, Course of Physiotherapy in Regional University of Blumenau Foundation. Institution:

FURB - Fundação Universidade Regional de Blumenau. Blumenau / SC – Brazil. Mailing address: Dayra Dill Socher - Alameda Duque de Caxias, 145 - room 306 - Center – Blumenau / SC – Brazil - Zip code 89015-010 – Telephone: (+55 47) 3035-4640 - E-mail: ftdayra@yahoo.com.br Article received in October 30, 2011. Article approved in July 22, 2012.

SUMMARY Introduction: Vertigo is a symptom that impacts the patients’ quality of life and may force them to cease performing activities of daily living. Here, we discuss benign paroxysmal positional vertigo (BPPV) and Meniere’s disease (MD), which show exacerbated symptoms when they appear in association. Vestibular rehabilitation (VR) is an effective treatment in reducing vertigo, especially in conjunction with other therapies. Aim: To evaluate the quality of life of patients with BPPV and MD before and after VR. Method: We conducted a descriptive observational qualitative and quantitative case study with 12 patients aged 35 to 86 years. All patients diagnosed with BPPV and MD received treatment in the ENT clinic. The Brazilian DHI questionnaire, which assesses the quality of life with a focus on physical, emotional, and functional aspects, was used for data collection, and was completed by patients before the first session and after the fifth session of VR. Data were tested using the Shapiro-Wilk normality test, followed by Wilcoxon, Friedman, and Spearman correlation tests (p < 0.05). Results: There were significant improvements in scores for all aspects, with median changes ranging from 12 to 0 in the physical, 6 to 1 in the emotional, and 11 to 1 in the functional aspect. There were no correlations between the scores and sample characteristics. Conclusion: VR was an effective method for the treatment of patients with BPPV and MD; it improves quality of life and shows the maximal influence on physical aspect scores, regardless of age or gender. Keywords: quality of life; vertigo; meniere disease; rehabilitation.

INTRODUCTION Dizziness has a high incidence worldwide, and the impact of vestibular disease on quality of life has been increasingly investigated. Many patients with dizziness restrict their daily activities and leisure in order to reduce the risk of onset of unpleasant and frightening symptoms, as well as to avoid the social embarrassment and stigma that these symptoms may cause (1). Benign paroxysmal positional vertigo (BPPV) is a disease with a high incidence worldwide, and can be regarded as the most frequent vestibular disease (2). There are few studies correlating BPPV and Meniere’s disease (MD) and their combined influence on the quality of life of patients (3, 4). Simultaneous diagnosis of BPPV and MD may worsen symptoms of dizziness

and thus worsen the quality of life, because the discomfort caused by these symptoms can significantly change the ability of patients to perform their usual tasks (4). Among existing evaluation instruments, the Dizziness Handicap Inventory (DHI) is an internationally validated instrument. This questionnaire assesses patients’ perception of the effects of the disabling vertigo on their quality of life, including the physical, emotional, and functional aspects. It is important to assess the individual’s condition at the beginning of treatment and to monitor the evolution of the disease course (1) (Chart 1). Treatment options for vertigo patients include medications, vestibular rehabilitation (VR) and, more rarely, surgical procedures (5). VR has been used as a strategy for the treatment of vestibular disorders because its goals are

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to provide security to the patient and integrate them into their social environment. VR aims to promote visual stabilization, improve static and dynamic balance, decrease sensitivity during head movement, and improve the overall function of the patient via proprioceptive and vestibular visual stimulation maneuvers (6). The objective of this study was to evaluate the preand post-VR quality of life of patients with MD-associated BPPV by using the Brazilian version of the DHI as an evaluation tool.

METHOD The study was approved by the Ethics in Research on Humans Foundation Regional University of Blumenau (FURB), under protocol 180/09. The sample consisted of 12 patients of both genders with a diagnosis of Meniere’s disease associated with benign paroxysmal positional vertigo

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(BPPV) of the posterior canal, who were seen at the ENT clinic during the period from October to December 2009. Inclusion criteria were as follows: clinical diagnosis of Meniere’s disease with complementary electrocochleographic findings, presence of nystagmus triggered by Dix Hill Pike maneuvers and lateral placement test identified under the guidance of videonystagmography, no treatment initiation or maintenance during the period between surveys, agreement to undergo surgery to the ear, and agreement to signing a consent form. We excluded patients with signs and symptoms of vestibular central origin, those with musculoskeletal abnormalities that impair the performance of the maneuvers (diagnostic and therapeutic), individuals who began vestibular rehabilitation before completing the questionnaire, and patients undergoing vestibular rehabilitation lasting less than 5 sessions, considering the research period. The sessions were held once a week individually, with each session lasting 1 hour. VR started with the

Chart 1. Dizziness Handicap Inventory (DHI) - Brazilian version. Questions 1. Does looking up increase your problem? 2. Because of your problem, do you feel frustrated? 3. Because your problem, do you restrict your travel for business or recreation? 4. Does walking down the aisle of a supermarket increase your problem? 5. Because your problem, do you have difficulty getting into or out of bed? 6. Does your problem significantly restrict your participation in social activities such as going out to dinner, going to movies, dancing, or to parties? 7. Because your problem, do you have difficulty reading? 8. Does performing more vigorous activities such as sports, dancing, or household chores such as sweeping or putting dishes away increase your problem? 9. Because your problem, are you afraid to leave home without having someone with you? 10. Because your problem, have you been embarrassed in front of others? 11. Do quick movements of your head increase your problem? 12. Because your problem, do you avoid heights? 13. Does turning over in bed increase your problem? 14. Because your problem, is it difficult for you to do strenuous housework or yard work? 15. Because your problem, are you afraid people may think you are intoxicated or drunk? 16. Because your problem, is it difficult for you to go for a walk by yourself? 17. Does walking down a sidewalk increase your problem? 18. Because your problem, is it difficult for you to concentrate? 19. Because your problem, is it difficult for you walk around your house in the dark? 20. Because your problem, are you afraid to stay home alone? 21. Because your problem, do you feel handicapped? 22. Has your problem placed stress on your relationship with members of your family or your friends? 23. Because your problem, are you depressed? 24. Does your problem interfere with your job or household responsibilities? 25. Does bending over increase your problem?

Yes ( ) ( ) ( ) ( ) ( )

No Sometimes ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )

( ) ( )

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( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( (

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Legend: Physical aspects - Questions 1, 4, 8, 11, 13, 17 and 25; Functional aspects - Questions 3, 5, 6, 7, 12, 14, 16, 19 and 24, Emotional aspects - Questions 2, 9, 10, 15, 18, 20, 21, 22 and 23. Each YES answer = 4 points; SOMETIMES = 2 points; NO = 0 points. The final score is the sum of points obtained in all aspects. Int. Arch. Otorhinolaryngol., São Paulo - Brazil, v.16, n.4, p. 430-436, Oct/Nov/December - 2012.

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Evaluation of quality of life pre- and post-vestibular rehabilitation in patients with benign paroxysmal positional vertigo associated with Meniere’s disease.

canalith repositioning maneuver of Epley, where the individual sitting on the table adopts a supine position and the therapist rotates the head to the side of the affected labyrinth. After a minute, the head is rotated to the opposite side and the patient is instructed to stay in the same position for another minute, returning to a seated position at the end. This was followed by the Brandt and Daroff habituation exercises. From the seated position on the table, the patient adopts a lateral recumbent position (first on the side that causes the dizziness), maintains the position for 30 seconds or until the dizziness passes, changes to a lateral seated position, waits for the same time period, and then lies on the opposite side and waits for 30 seconds. Each patient was taught the exercises and instructed to repeat them at home 10–20 times a day. In addition, we performed the Cawthorne-Cooksey visual exercises consisting of up and down and side-to-side eye movements as well as extension of an arm and focusing on the finger as it approaches and moves away from the face. All movements were repeated 20 times, starting slowly and becoming progressively faster, with the patient sitting or lying down. In another exercise, with the individual sitting or standing, only the head moved forward and back, after a back and forth motion; these motions were first performed slowly and then rapidly, with eyes open and progressing to accomplishment of each movement and with eyes closed for 1 minute. The Brazilian version of the DHI was completed by participants before undergoing the first session of VR and after the last treatment session. Subjects were instructed to mark the item that best demonstrated their perception of the influence of vertigo on their quality of life at the time, with doubts addressed by the researchers present during the survey. The absence of symptoms/problems was marked “no,” corresponding to 0 (zero), occasional presence of symptoms/problems was reported as “sometimes,” and was scored as 2 points, and the presence of severe symptoms/problems was marked “yes,” and amounted to 4 points. The minimum score of the questionnaire was 0 (zero) and the maximum was 100 points, with 7 items referring to physical aspects, 9 to functional aspects, and 9 to emotional aspects (7). For data analysis, we first used the Shapiro-Wilk test of normality, proceeding with the Wilcoxon test for comparisons between samples before and after vestibular rehabilitation, and the Friedman test to compare the impact of physical, emotional, and functional scores after standardizing the values by calculating the percentage according to the maximum possible score to be obtained on each item. Spearman correlation was used to evaluate the relationship between aspects, the total score, and the characteristics of the sample test. All analyses were processed in 4.0 BioEstat considering significance at p < 0.05.

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RESULTS In the stipulated period for data collection, 12 individuals fulfilled the criteria for inclusion and exclusion. There were 4 (33.33%) men and 8 (66.66%) women, all Caucasian, aged between 35 and 86 years (mean, 53.17 ± 15.75 years). Three (25%) were less than 40 years old, 6 (50%) were aged between 40 and 59 years, and 3 (25%) were aged 60 years or more (Table 1). There was a significant reduction in all DHI values after VR, independent of the aspect. The median final values were 0 (zero) for the physical aspect, 1 for the emotional aspect, and 1 for the functional aspect, demonstrating the favorable impact of VR on the quality of life of our patients (Table 2). Generally, the score must be reduced by at least 18 after treatment to be indicative of benefit (1). In our series, 7 (58.33%) patients showed a reduction greater than 18 points, 5 (41.67%) did not show a reduction greater than 18 points, and 3 (25%) did not achieve a pre-VR score large enough to show such a reduction. In the evaluation of post-VR scores, 2 (16.6%) patients who had scores less than 18 pre-VR, despite showing an improvement in the aspects evaluated, did not show score reductions of the specified magnitude. To compare the effects on the different aspects, the raw score values were normalized as percentage values, with 100% indicating the maximum score in every aspect. Next, we compared the pre- and post-VR scores. In the preoperative evaluation, we noted that the diseases had a greater impact on physical and functional aspects than on the emotional aspect. Although none of the aspects showed a predominant effect of VR, the differences in the pre- and post-VR values showed that VR had the greatest influence on the physical aspect (Table 3). In the first evaluation (pre-VR), the correlation between the physical and functional aspects was moderately positive, and that between the emotional and functional aspects was strongly positive, indicating the interrelationship of these factors on quality of life of the volunteers, i.e., the functional aspect influences and is influenced by physical and emotional aspects. Post-RV, these correlations were not observed. However, analysis of the difference (pre post) showed a weak positive correlation between the emotional and functional aspects (Table 4). In the pre- and post-VR analyses, there was a lack of correlation between age and gender with the DHI scores, indicating that the results of the VR were not affected by these characteristics (Table 5). It should be noted that the sample size did not allow

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Table 1. Characterization of the sample. DHI (Brazilian version) pre- and post-vestibular rehabilitation (n = 12). Patient Age Gender DHI-preDHI-post Difference between DHI pre and post 01 36 Male 60 12 48 02 86 Male 32 08 24 03 64 Male 12 0 12 04 35 Female 62 06 56 05 38 Female 44 22 22 06 50 Female 18 04 14 07 41 Female 14 0 14 08 57 Female 58 14 44 09 74 Female 60 04 56 10 48 Female 24 0 24 11 59 Male 14 0 14 12 50 Female 22 06 16

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Table 2. Median score obtained by completing the DHI questionnaire (Brazilian version) pre- and post-vestibular rehabilitation. MD = median, AIQ = interquartile range (n = 12). Variables Pre Post Physical Aspect MD 12 0* AIQ 09 04 Mínimum - Maximum 0 – 24 0 – 10 Emotional Aspect MD 06 01* AIQ 10 02 Mínimum - Maximum 0 – 22 0 – 06 Functional Aspect MD 11 01* AIQ 15.5 4.5 Mínimum - Maximum 04 – 30 0 – 10 DHI total MD 28 05* AIQ 41,5 09 Mínimum - Maximum 12 – 62 0 – 22 * p < 0.01 when compared to before.

Table 3. Comparison between the influence of each aspect in the total score of DHI (Brazilian version) by means of percentage values obtained after normalization of the actual values for the maximum possible score to be obtained in every aspect pre- and post-vestibular rehabilitation. Where MD = median, AIQ = interquartile range (n = 12). Variables Pre (%) Post (%) Diference (%) Physical Aspect MD 42.85* 0 39.28* AIQ 32.14 14.28 17.86 Mínimum - Maximum 0 – 85.71 0 – 35.71 0 – 64. 29 Emotional Aspect MD 16.66 2.78 13.89 AIQ 27.77 5.56 23.60 Minimum Maximum 0 – 61.11 0 – 16.67 0 – 44.44 Functional Aspect MD 30.55* 2.77 22.22 AIQ 43.05 12.50 34.72 Minimum Maximum 11.11 – 83.33 0 – 27.77 0 – 72.22 *p < 0.05 when compared to emotional aspect

generalization of the results; however, considering the results, the importance of VR is evident. In another study with 15 subjects who were diagnosed as having BPPV associated with Ménière’s disease, the physical aspect was the most affected (4), but there are few studies analyzing both conditions together and using VR for the treatment of this combination.

suggest that the variations in natural hormones in women could be related to this increased incidence, but did not elucidate this theory (11). As for Meniere’s disease (MD) alone, there are reports of an equal distribution between genders (12). The most prevalent age group in this study also coincides with the findings obtained by other authors, who indicated that 48% to 60% of subjects were between 41 and 60 years of age (4, 7).

DISCUSSION

All individuals in the sample were diagnosed with MD and associated BPPV. Other studies have also reported the coexistence of these 2 diseases, with patients initially presenting symptoms of MD followed by symptoms of BPPV (13, 14). One hypothesis for this relationship between the 2 diseases is the possible release of otoconia by

Regarding gender, there was a predominance of women (75%) in the sample, which agrees with previous studies that found a prevalence of dizziness and BPPV in 61.3% to 62.5% of female patients (8, 9, 10). Some authors

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Table 4. Correlation between the physical, emotional and functional aspects assessed in the DHI (Brazilian version) pre- and postvestibular rehabilitation, as well as the difference between these steps. Where FIS = physical aspect, EM = emotional aspect, FUN = functional aspect, R = Spearman correlation coefficient (n = 12). Pre Post Diference EM FUN EM FUN EM FUN (R) (p) (R) (p) (R) (p) (R) (p) (R) (p) (R) (p) FIS 0.47 0.12 0.60 0.04* 0.46 0.13 0.57 0.06 0.55 0.06 0.47 0.12 EM

0.87

0.002*

0.34

0.27

0.71

0.01*

* where p < 0.05

Table 5. Correlation between the score of DHI (Brazilian version) and the variables age and gender in pre- and post vestibular rehabilitation. Where R = Spearman correlation coefficient (n = 12). Variable Dizziness Handicap Inventory (DHI)–Brazilian version Pre Post R p R P Age 0,147 0,647 -0,213 0,506 Gender -0,308 0,329 -0,157 0,626

damage to the utricle by endolymphatic hydrops and hypertension (3). The DHI-Brazilian version was used to assess the impact of VR on the quality of life of patients and, based on the significant score decrease in most patients, it is argued that VR is favorable for these patients. The dizziness and other symptoms that often accompany vestibular disorders may manifest during social, familial, and professional activities, thus causing physical, financial, and psychological distress to the patients (15,16,17) and necessitating interventions to eliminate or minimize these symptoms. Individuals end up restricting their head movements and activities to prevent vertigo, thereby imposing physical constraints that lead to functional loss and consequent emotional turmoil, which explains the damage caused by these disorders. We found that pre-VR, the greatest impact was noted on the physical and functional aspects while after VR, the greatest influence was noted on the physical aspect, despite the reduction of the values in the functional and emotional aspects as well. It was noted that after the improvement in physical symptoms, individuals were able to resume their routine activities that were previously restricted due to dizziness or fear of symptoms, and this improvement consequently improved functional and emotional aspects, which are dependent on the physical

aspects. This result contrasts the results of a previous study (18), where a sample of 6 patients, aged 43–70 years, with complaints of dizziness and tinnitus showed no significant improvement in the functional and emotional aspects and no improvement in the physical aspect after VR. It should be noted that apart from vertigo, some individuals had age-related comorbidities (such as osteoarthritis and osteoporosis), which by itself has limited some of the emotional issues such as fear of high places and fear of being alone at home or going out unaccompanied. Therefore, it is likely that the answers to these questions were influenced by comorbidities, so it is not possible to separate them from the symptom of vertigo/dizziness. This situation indicates that the analysis of the emotional aspect should be undertaken with care, because if the individual is unable to perform some physical activity for problems not related to dizziness, even after the improvement of vertigo, he/she will be unable to do the same. The correlation between the physical and functional aspects and between emotional and functional aspects in pre-VR assessments demonstrates the interrelationship of these factors with the quality of life of individuals, i.e., the functional aspect influences and is influenced by the physical and emotional aspects. However, this effect appears to be greater when the symptoms are exacerbated by vertigo, since after VR, no such correlation was observed. The relationship between the functional and physical aspects is also highlighted in other studies, where the similar scores for these aspects were explained by the fact that in BPPV, onset of symptoms is closely related to certain positions or head movements, the relevant questions for which are contained in both aspects of IHL-Brazilian version (19, 20). Similarly, studies involving individuals with MD associated with higher scores on the physical and functional aspects to the chronic nature of the disease with clinical manifestations floating, recurrent and lasting, that can

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compromise not only physical, but also the functionality of these patients (4, 21). In another study with 6 patients aged 43–70 years, the analysis of the DHI questionnaire after VR showed that patients experienced an improvement in functional and emotional aspects, although the difference was not significant (18). Furthermore, the relationship of the functional to the emotional aspects can be understood by the rationale that when there is improved functionality, the individual returns to his/her daily habits, accomplishing all movements restricted before the onset of vertigo. Thus, the individual becomes more confident with regard to leaving the house without company and can simply raise the head or turn over in bed without being afraid of triggering symptoms. The results of VR were not affected by age and/or gender, similar to previous studies that indicate no relationship between improvement in patients with vertigo and after VR with these variables (20, 22). In this context, the geriatric population responds to treatment as well as a younger population, but most of the elderly patients require a greater number of treatment sessions to achieve the same result as the young (23). Moreover, other studies describe that age is not necessarily associated with loss of independence in activities of daily living, and therefore, it is not possible to relate the age-diminished ability with greater independence or improvement in vertigo after vestibular alteration (24). On the other hand, dizziness has a more detrimental effect on quality of life of elderly than in younger adults, according to studies with these populations (25, 26, 27, 28). Regarding gender, some authors report that the variable is not related to any advantage or disadvantage in relation to response to treatment (7), a fact verified by the results presented here. As individuals in the sample were out of the crisis period during the questionnaire analysis and underwent VR, the results discussed are restricted to perception of symptoms by individuals on a daily basis, whereas in vertigo, the symptoms are exacerbated. Finally, we would like to point out the importance of multidisciplinary medical and physiotherapy in the diagnosis and treatment to achieve greater security and adherence to this treatment modality.

CONCLUSIONS The results obtained through the DHI Brazilian version show that the quality of life of patients with BPPV associated with MD improved after 5 sessions of VR in all aspects analyzed. We noticed that the diseases had a greater impact on the physical and functional aspects of quality of life before VR, with the highest rate of improvement noted in the perception of physical

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appearance after the therapy. Age and gender did not affect the response to treatment. Although the sample consisted of a small number of patients, the results obtained with VR were surprising and further studies need to be developed, especially involving the 2 pathologies. Moreover, the VR was well accepted by volunteers who showed increased enthusiasm and confidence with the evolution of treatment and reduction of symptoms.

REFERENCES 1. Ganança FF, Castro ASO, Branco FC, Natour J. Interferência da tontura na qualidade de vida de pacientes com síndrome vestibular periférica. Rev. Bras. Otorrinolaringol. [online]. 2004, 70:94-101. 2. Ganança MM, Caovilla HH, Munhoz MSL, Ganança CF, Silva MLG, Serafini F, Ganança FF. Otimizando o componente farmacológico da terapia integrada da vertigem. Rev. Bras. Otorrinolaringol.[online]. 2007, 73:128. 3. Boaglio M, Soares LCA, Ibrahim CSMN, Ganança FF, Cruz OLM. Doença de Ménière e vertigem postural.Rev. Bras. Otorrinolaringol. [online]. 2003, 69:69-72. 4. Handa PR, Kuhn AMB, Schaffleln R, Ganança FF. Qualidade de vida em pacientes com vertigem posicional paroxística benigna e/ou doença de Ménière.Rev. Bras. Otorrinolaringol. [online]. 2005, 71:776-783. 5. Mantello EB, Moriguti JC, Rodrigues-Junior AL, Ferrioli E. Efeito da reabilitação vestibular sobre a qualidade de vida de idosos labirintopatas.Rev. Bras. Otorrinolaringol. [online]. 2008, 74:172-180. 6. Andre APR. Reabilitação vestibular da vertigem postural paroxística benigna de canal posterior em idosos. Ribeirão Preto, 2003, p.102, (Dissertação de Mestrado - Faculdade de Medicina de Ribeirão Preto/USP). 7. Moreira DA, Bohlsen YA, Momensohn-Santos TM, Cherubini AA. Estudo do Handicap em Pacientes com Queixa de Tontura, Associada ou Não ao Sintoma Zumbido. Arq. Int. Otorrinolaringol. São Paulo, 2006, 10:270-277. 8. Caovilla HH. Autorotação cefálica no diagnóstico da disfunção vestibular. RBMORLOtologia. 2000, 57:8-11. 9. Cusin FS, Silva SMR, Ganança CF. Achados na vestibulometria de pacientes com Vertigem Posicional Paroxística Benigna submetidos à Manobra de Epley. Acta ORL [online]. São Paulo, 2006, 24:69-74.

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Evaluation of quality of life pre- and post-vestibular rehabilitation in patients with benign paroxysmal positional vertigo associated with Meniere’s disease.

10. Koga KA, Resende BA, Mor R. Estudo da prevalência de tontura/vertigens e das alterações vestibulares relacionadas à mudança de posição de cabeça por meio da vectoeletronistagmografia computadorizada. Rev CEFAC. São Paulo, 2004, 6:197-202. 11. Bittar RSM. Sintomatologia auditiva secundária à ação dos hormônios. Femina. São Paulo, 1999, 27:739-741. 12. Fetter M. Disfunções do Sistema Vestibular. In: Herdman SJ. Reabilitação Vestibular. 2.ed. Barueri: Editora Manole, 2002, pp91-101. 13. Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope. 1997, 107:607-613. 14. Gross EM, Ress BD, Viirre ES, Nelson JR, Harris JP. Intractable benign paroxymal positional vertigo in patients with Ménière’s disease.Laryngoscope. 2000, 110:655-659. 15. Pedalini MEB, Bittar RSM. Reabilitação vestibular: uma proposta de trabalho. Pró-Fono, 1999, 11:140-144. 16. Knobel KAB, Pfeilsticker LN, Stoler G, Sanchez TG. Contribuição da reabilitação vestibular na melhora do zumbido: um resultado inesperado.Rev. Bras. Otorrinolaringol. [online]. 2003, 69:779-784. 17. Segarra-Maegaki JAS, Taguchi CK. Estudo do benefício da reabilitação vestibular nas síndromesvestibulares periféricas. Pró-Fono, 2005, 17:3-10. 18. Zeigelboim BS, Rosa MRD, Klagenberg KF, Jurkiewicz AL. Reabilitação vestibular no tratamento da tontura e do zumbido. Rev. Soc. Bras. Fonoaudiol. [online]. 2008, 13:226232. 19. Castro ASO, Gazzola JM, Natour J, Ganança FF. Versão brasileira do Dizziness Handicap Inventory.Pró-Fono R. Atual. Cient. [online]. 2007, 19:97-104.

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20. Patatas OHG, Ganança CF, Ganança FF. Qualidade de vida de indivíduos submetidos à reabilitação vestibular. Rev Bras Otorrinolaringol. [online]. 2009, 75:387-394. 21. Cunha F. Interferência da tontura na qualidade de vida em pacientes com doença de Ménière. São Paulo, 2003, p.85, (Tese de Mestrado - Universidade Federal de São Paulo). 22. Cohen HS, Kimball KT. Increased independence and decreased vertigo after vestibular rehabilitation. Otolaryngol Head Neck Surg., 2003, 128:60-70. 23. Bittar RSM, Pedalini MEB. Síndrome do desequilíbrio do idoso. Pró-Fono, 2002; 14:119-128. 24. Nishino LK, Granato L, Campos CAH. Aplicação do Questionário de Qualidade de Vida Diária em Pacientes Pré e Pós – Reabilitação vestibular. Arq. Int. Otorrinolaringol. 2008, 12:517-522. 25. Resende CR, Taguchi CK, Almeida JG, Fujita RR. Reabilitação vestibular em pacientes idosos portadores de vertigem posicional paroxística benigna. Rev. Bras. Otorrinolaringol. [online]. 2003, 69:535-540 26. Whitney SL, Wrisley DM, Marchetti GF, Furman JM. The effect of age on vestibular rehabilitation outcomes. Laryngoscope. 2002, 112:1785-90. 27. Simonceli L, Bittar RMS, Bottino MA, Bento RF. Perfil diagnóstico do idoso portador de desequilíbrio corporal: resultados preliminares.Rev. Bras. Otorrinolaringol. [online]. 2003, 69:772-777. 28. Gazzola JM, Perracini MR, Ganança MM, Ganança FF. Fatores associados ao equilíbrio funcional em idosos com disfunção vestibular crônica.Rev. Bras. Otorrinolaringol. [online]. 2006, 72: 683-690.

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Int. Arch. Otorhinolaryngol. 2012;16(4):437-444. DOI: 10.7162/S1809-97772012000400003

Original Article

Epidemiological profile of 277 patients with facial fractures treated at the emergency room at the ENT Department of Hospital do Trabalhador in Curitiba/PR, in 2010 Renier Barreto Arrais Ykeda1, Carlos Roberto Ballin2, Rafael Souza Moraes3, Ronnie Barreto Arrais Ykeda4, Alana Farias Miksza5. 1) 2) 3) 4) 5)

Medical. Medical Resident. Master. Chief of the Skull Maxillofacial Surgery Service of Otorhinolaryngology UFPR. Postgraduate. Skull Maxillofacial Surgeon in the Department of Otorhinolaryngology, Hospital do Trabalhador-PR. Graduation. Medical. Academic. Doctoral student in the 6th year medical UFPR.

Institution:

Hospital do Trabalhador de Curitiba / PR. Curitiba / PR – Brazil. Mailing address: Renier Barreto Arrais Ykeda - Rua Augusto Zibarth, 1081 - Uberaba, 81560-360 - Curitiba / PR - Brazil - Telephone: (+55 41) 3360-6588 - E-mail: ykedabarreto@yahoo.com.br Article received in March 3, 2012. Article approved in June 7, 2012.

SUMMARY Introduction: Epidemiological studies that focus on facial injuries are of great interest for the knowledge of occurrence and severity of presentation. Aim: To study the epidemiological profile of 277 patients who suffered facial fractures at the Hospital do Trabalhador (HT), with an emphasis on variables such as sex, age, cause, and anatomical sites of fractures, comparing the clinical findings with other studies. Method: Retrospective nonrandomized chart review of 277 patients who were treated at HT by the ENT service during the full year 2010, victims of facial fractures. Results: Of 277 patients, 74.72% were male and 25.27% female (ratio 3:1). According to age, the fractures were distributed as follows: 0–9 years: 4.69%, 10–19 years: 17.32%, 20–29 years: 23.82%, 30–39 years: 20.21%, 40–49 years: 16.24%, 50–59 years: 10.83%, 60–69 years: 3.97%, and 60–79 years: 2.88%. The cause of trauma was most frequently interpersonal violence, 36.45%, followed by falls, 23.09%, and motor vehicle crashes with 17.32%. Regarding location, nasal fracture was the most common, with 44.75%, followed by the mandible, 14.32%, orbit, 12.78%, maxillary, 12.02%, zygomatic, 9.97%, 3.32% and front Le Fort 2.88%. Conclusion: The patients were mostly males, aged 21–30 years, victims of aggression with the most commonly fractured bone being the nose. The adoption of personal and public strategies and measures may prevent facial fractures. Keywords: epidemiology; maxillofacial injuries; face.

INTRODUCTION The present study aims to evaluate the epidemiological profile of the 277 patients who suffered facial fractures and were treated at the Hospital do Trabalhador in Curitiba in the state of Parana, in 2010, with an emphasis on variables such as gender, age, cause, and anatomical sites of fractures, and compared with clinical findings of other studies in the literature. Maxillofacial trauma can be considered as a devastating assault found in trauma centers because of the emotional consequences and the possibility of deformity, in addition to its economic impact on a healthcare system (1). A maxillofacial injury involves not only the soft tissues and bones but also, by extension, can affect the brain, eyes, sinuses, and teeth.

Therefore, it is a trauma of a multidisciplinary approach, involving mainly the specialties of otolaryngology, ophthalmology, plastic surgery, maxillofacial, and neurosurgery (6). Severe facial injuries may, in addition to psychological disorders, result in decreased productivity due to visual loss and damage during swallowing and phonation, increasing the costs arising from the trauma. The group most affected, men of working age, commonly found in many studies, partly explains the impact on productivity (2). In the last 4 decades, the incidence of facial trauma has increased, mainly due to increased traffic accidents and urban violence, especially in young individuals (21). They are very common in emergency rooms around the world and assume a prominent role in the care to polytrauma patients.

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Epidemiological profile of 277 patients with facial fractures treated at the emergency room at the ENT Department of Hospital do Trabalhador in Curitiba/PR, in 2010.

The maxillofacial region is very prone to injury because of its prominence and little protection in the region. Further, it is the first area of attack in cases of interpersonal violence (5). Today the association of alcohol, drugs, car driving, and increased urban violence are increasingly present as causal factors of facial trauma, and what is worse, increasing its complexity (7). The medical literature is rich in epidemiological studies related to trauma and facial fractures. However, the epidemiology of craniofacial fractures can vary in type, frequency, severity, and cause, depending on the medical center studied and the period considered (3), because many factors influence the cause of maxillofacial injuries around the world, for example, cultural, economic, social, religious and geographical factors (4). Therefore, epidemiological studies focused on facial injuries are of great interest as to the knowledge of the occurrence and quantity and severity of presentation, allowing the adoption of preventive measures for its control and management of patients.

REVIEW The medical literature is rich in epidemiological studies related to trauma and facial fractures. TABLE 1 shows the summary of several epidemiological studies of facial fractures in the literature in several cities. The table was divided according to the author, publication year, study site, number of patients suffering from facial fractures, male prevalence, age more acomentida, main causes of fractures and other broken facial bones.

METHOD We conducted a non-randomized retrospective study, of 277 patients with confirmed facial fractures diagnosed on radiographs and/or computed tomography, from the Otolaryngology Service at the Hospital do Trabalhador (HT) located in the city of Curitiba in Paraná during the year 2010. The study included all patients treated at the Emergency Room of HT, attended by the Department of Otolaryngology, who were victims of facial trauma in the period from January 1 to December 31. We prepared a protocol for data collection performed by analysis of records and records of emergency in the sector of the medical file of the HT. This protocol included the following variables: medical record number, patient

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name, age, sex, origin, birth date, location of facial fracture, and cause. The cause of the fractures was studied according to: motor vehicle crashes (combinations of collisions with cars, motorcycles, trucks/buses, and others), fall/bicycle accident, interpersonal violence with or without a firearm, drops own height or level falls, fractures arising from sports practices and impact/collisions with objects from accidental causes. The locations of the fractures were classified into facial: fractures of the nasal bone, mandible, orbital, maxillary, frontal, zygomatic bone fractures, and Le Fort I, II, or III. Data were analyzed with the aid of Microsoft Office Excel 2007. ®

This research project was approved by the Ethics Committee of Hospital do Trabalhador.

RESULTS Of the 277 patients treated in 2010 evaluated in this study, 207 were male (74.72%) and 70 female (25.27%); the male to female ration was 3:1 (Figure 1). The patients’ ages ranged from 1 to 79 years with a mean of 33.57 years. The most affected age group was 20 to 39 years with 44.03% (Figure 2). The extremes of age, younger than 10 years and older than 70 years, accounted for respectively 13 (4.69%) and 8 (2.88%) patients. The merits, 88.44% were residents of the city of Curitiba, 10.83% of the Metropolitan Region of Curitiba, and 0.72% from the interior the State of Paraná. The number of patients treated per month ranged from 16 to 27, average of 23, September being the month with the highest number of visits (Table 2). Regarding occupation, 55.23% had a professional activity, 16.96% were students, 5.77% were dependents, 5.41% were retirees, and 16.60% were unemployed or had indeterminate profession. Regarding the cause of facial fractures, our chart review showed that the cause of fractures was interpersonal violence without firearm in 84 (30.32%) cases, interpersonal violence with a firearm in 17 (6.31%), motor vehicle accidents (car, truck, bus, motorcycle) in 48 (17.32%), injuries while walking in 11 (3.97%), from falls from a height in 48 (17.32%), due to drop in level in 16 (5.77%), due to impact/collisions with objects in 35 (12.63%), fall/

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Table 1. Summary of epidemiological studies of facial fractures Author

Year of Publication

Location of Study

No. of patients

Frequent in males

Most affected age group

Main causes of facial fractures

Facial fractures most commonly found

Palma et al (9) 1995

Dr. Arthur Saboya Municipal Hospital in Sao Paulo

296

78%

21–30 years

Falls (34%), followed by assault (26%)

Nasal bone (36%), zygomatic complex (22.3%), mandible (21.9%)

Falcão et al (10)

2005

Restoration Hospital, Recife - PE

1486

84%

21–30 years

Road traffic accidents (31.83%) physical assault (22.21%), assaults with firearms (18.71%)

Jaw (55%), zygomatic (17%), maxillary bone (16%), and nasal bone (7%)

Portolan et al (11)

2005

Santa Casa de 745 Misericordia and Maxillofacial Rehabilitation Center for the Study of Pelotas

83%

21–30 years

Assault (33.55%), traffic accidents (26.04%), falls (23.62%), sports accidents (9.65%)

Nasal (35.84%), zygomatic (21,74%), mandible (20,54)%

Wulkan et al (18),

2005

Central 164 Emergency Room of the Brotherhood of Santa Casa de São PauloSP

78%

20–39 years

Interpersonal violence (48.1%), followed by fall (26.2%), trampling (6.4%), and sports (5.4%)

Mandible (21.9%), Le Fort/pan facial/ complex (17.8%), nasal (11.6%), zygoma (10.3%), orbit (4.9%), and maxilla (0,6%).

Silva et al (13) 2007

Instituto Dr. José Frota – Fortaleza, CE

105

79%

21–30 years

The main cause was traffic accidents (49.5%), followed by interpersonal violence (28.5%) and falls (12.3%)

Nasal (29.3%), mandibular (24.6%), and zygoma (23.0%)

Macedo et al, 2007 (12)

Emergency room of HRAN-DF

177

72,8%

21–30 years

The predominant Nasal (76.8%) physical aggression and (48.0%), followed zygoma (9.6%) by accidents with vehicles/motorcycles (15.8%).

Pereira et al (8)

2008

Hospital Sao Paulo-SP

912

76%

20–29 years

Physical aggression (29%), traffic accidents (26%) and falls (24%)

Orbits (48%) nasal (33%) and mandible in 24%

Freitas et al (22)

2009

Hospital 139 Santa Casa de Misericordia Hospital and Aroldo Tourinho in Montes Claros/MG

79%

20–29 years

Automobile accidents (17%) and motobilístico and fall at home were the most common causes of injuries

Jaw (45%), zygoma (22%) and jaw (16%)

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Epidemiological profile of 277 patients with facial fractures treated at the emergency room at the ENT Department of Hospital do Trabalhador in Curitiba/PR, in 2010. %

% 80,0

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74,72

23,82

25

20,21

70,0

20

17,32

16,24

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50,0

10,83

40,0

10

25,27

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4,69

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20,0

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(0-9)

(10-19)

(20-29)

(30-39)

(40-49)

(50-59)

(60-69)

(70-79)

AGE

Figure 1. Distribution of patients with facial fractures according to sex in percentage (n = 277).

Figure 2. Distribution of patients with facial fractures according to age in percent (n = 277).

bicycle accidents in 10 (3.61%), and sports injuries in 8 (2.88%) (Table 3).

Table 2. Shows the monthly distribution fractures during the year 2010. Month N January 25 February 26 March 27 April 23 May 19 June 26 July 22 August 17 Setember 27 Octuber 26 November 16 December 23 Total 277

The etiologic distribution by age showed a prevalence of violence without firearm in all age groups from 10 to 59, with a peak incidence in the age group 30–39 years with 41%. Falls from height predominated in the age groups 0–10 and 60–79, representing 57.9% of the causes of facial fractures in the latter. The motor vehicle crashes were the second most common cause in the age group 20–39 years with 22.13% of cases (Table 3). The motorcycles were involved in 47% of automobile accidents. Regarding the cause and gender, falls from height were the main cause of facial fractures in women, corresponding to 23 (32.85%) cases in females followed by violence without firearm in 15 (21.42%) cases, and third, vehicle accidents with 12 (17.14%) cases. In the males, the main cause was violence without firearm in 69 (33.33%) cases, followed by motor vehicle accidents in 36 (17.39%), and third, by impact/collision with objects in 26 (12.56%) cases (Table 4 and Figure 3). Patients had a total of 391 facial fractures, which were isolated in 205 (74%) cases and associated with 2 or more locations in 72 (26%). The nasal region was most affected, with 175 (44.75%) cases. Mandibular fracture was the second most common, found in 56 (14.32) cases, followed by the orbit with 50 (12.78%). Fracture of the maxilla was the fourth most frequent with 47 (12.02%), followed by the zygomatic bone with 39 (9.97). The more complex fractures Le Fort I, II, and III corresponded to 11 (2.81%) cases (Figure 4). Table 5 Shows the distribution of fractures by cause and anatomic site of fracture.

of patients with % 9.02 9.39 9.74 8.3 6.85 9.39 7.94 6.13 9.74 9.38 5.78 8.3 100

DISCUSSION The face is susceptible to a variety of possible traumas, and it is important to note that aggression between facial injuries, especially fractures, plays a major role in emergency care worldwide. Our study revealed a predominance of male patients with facial fractures corresponding to 74.72%, a 3:1 ratio, compatible with the literature including Palma et al, 78%, Falcon et al (10) , 84%, and Macedo et al, 72.8%. This higher incidence in males may be linked to cultural and social factors, considering that the males represent most of the economically active population, exhibit more abuse of alcohol and drugs, practice more contact sports, are involved in the majority in traffic, and thus are more exposed to the factors responsible for facial injuries. However, the incidence of trauma among women has increased in recent years due

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Epidemiological profile of 277 patients with facial fractures treated at the emergency room at the ENT Department of Hospital do Trabalhador in Curitiba/PR, in 2010.

Table 3. Distribution of patients with facial fractures by age and cause. Cause Age (Years) (0-10) (10-19) (20-29) (30-39) (40-49) (50-59) (60-69) Vehicle accident/moto 1 6 17 10 8 3 1 Violence without firearm 0 18 21 23 13 7 2 Violence with firearm 0 5 7 4 1 0 0 Running over 0 0 3 2 3 3 0 Sports activities 0 3 2 1 1 1 0 Impact/collision with object 4 8 8 7 3 5 0 Fall of own height 4 5 4 6 10 6 7 Fall from another level 3 3 2 1 4 2 1 Fall/bicycle accident 1 0 2 2 2 3 0 Total (%) 13(4,69) 48(17,32) 66(23,82) 56(20,21) 45(16,24) 30(10,83) 11(3,97)

Table 4. Distribution of patients with facial fractures by sex and cause. Cause (n) male % (n) female Vehicle accident/moto 36 17.39 12 Violence without firearm 69 33.33 15 Violence with firearm 16 7.72 1 Running over 8 3.86 3 Sports activities 8 3.86 0 Impact/collision with object 26 12.56 9 Fall of own height 25 12.07 23 Fall from another level 11 5.31 5 Fall/bicycle accident 8 3.86 2 Total 207 100 70

68

70

3,32

% 17.14 21.42 1.42 4.28 0 12.85 32.85 7.14 2.85 100

total 48 84 17 11 8 35 48 16 10 277

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Total (%) (70-79) 2 0 0 0 0 0 6 0 0 8(2,88)

48 (17.32) 84 (30.32) 17 (6.31) 11 (3.97) 8 (2.88) 35 (12.63) 48 (17.32) 16 (5.77) 10 (3.61) 277 (100)

% 17.32 30.32 6.13 3.97 2.88 12.63 17.32 5.77 3.61 100

2,83

60 50

Nasal

9,97

40

Mandible

36

Orbit 27

30

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20

23

44,75

12,02

16

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10

8

8 3

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Figure 3. Distribution of patients with facial fractures by cause and gender (n = 277).

Figure 4. Distribution of fractures by anatomic location.

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Epidemiological profile of 277 patients with facial fractures treated at the emergency room at the ENT Department of Hospital do Trabalhador in Curitiba/PR, in 2010.

Table 5. Distribution of facial fractures by cause and anatomical site. Cause anatomical site Nasal mandible orbit maxillary zygomatic Vehicle accident/moto 28 12 13 13 7 Violence without firearm 57 12 18 10 14 Violence with firearm 0 13 2 9 3 Runnig over 5 2 4 2 1 Sports activities 7 0 2 1 0 Impact/collision with object 29 3 5 5 4 Fall of own height 35 10 2 4 5 Fall from another level 8 3 2 1 2 Fall/bicycle accident 6 1 2 2 3 Total (%) 175 (44.75) 56 (14.32) 50 (12.78) 47 (12.02) 39 (9.97)

to the increased participation of women in the commercial workforce (16,17,18). The patients’ ages ranged from 1 to 79 years with a mean of 33.57 years. The most affected age group was 20 to 29 years, with 23.82% of cases. The age group also is in agreement with the findings of other authors such as Silva et al (13). The age group of 21–30 years in their study corresponds to 36.2% of cases. This is because young people are more prone to violence and psycosocioeconomic urban conflicts (13). It is understandable that violence occurs more among young people by their restlessness and risk taking behaviors, including traffic risks influenced by extremely fast behavioral and moral changes (16). At the extremes of age, patients younger than 10 years and older than 70 years accounted for respectively 13 (4.69%) and 8 (2.88%) patients, consistent with the literature findings (6-12) There are studies that show low incidence of facial trauma in children and the elderly due to the attention of family, stay at home, and care of children, as well as the characteristics of aging such as lessened social activity and sport, leaving little infrequently, and usually accompanied when they do. (14,15). With regard to professional activity, our study showed that 55.23% had jobs and 16.96% were students, similar to studies by Macedo et al (12) JCM Junior et al in 2010 (6), and Brazil et al 2006 (16 ), the latter, which showed 60.5% of patients and 16.9% economically active students. This presents a problem because it is the predominant socioeconomically productive group. Regarding the cause of facial fractures, our study showed the main causative agent of facial fractures was interpersonal violence without firearm with 84 (30.32%), and the second leading cause motor vehicle accidents (car, truck, bus, motorcycle) with 48 (17.32%) cases, as well as falls from height with the same values. These

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total (%) frontal 4 2 1 3 0 1 0 1 1 13 (3.32)

le fort 4 5 0 0 0 0 0 2 0 11 (2.81)

81 (20,71) 118 (30,18) 28 (7,16) 17 (4,34) 10 (2,55) 47 (12,02) 56 (14,32) 19 (4,86) 15 (3,83) 391 (100)

data are compatible with the current literature, which shows a growing share of violence as a cause of facial fractures, surpassing automobile accidents. This confirms the tendency of most recent national studies to show an increased incidence of interpersonal violence and suggest that this is the main cause in facial trauma (6,8,12,18). This is mainly due to an increase in urban violence and a drop in severity of motor vehicle accidents due to public policies aimed at greater control speeding on the roads and encouraging the use of seat belts. Moreover, the ban on drunk driving and the introduction of air bags and side protection bars have decreased the incidence of facial fractures, as well as the complexity (17,20). However, it calls attention to the involvement of 47% of motorcycles in traffic accidents, owing to the fact that unsafe vehicle speed abuse is practiced on the streets and that these vehicles are increasingly used because they are a means of lowcost transport. Injurt from falls dominated as the cause in people aged under 10 and over 60, As these are extremes of age, because locomotion and balance are directly proportional to age. The consciousness of appearance of the face and its social importance increases with age (during a fall, older children and adults consider to protect the face) (14,15). In the case of elderly physiological mechanisms such as altered proprioception, weakness, tremor, and decreased reflexes facilitate queda. Infecção urinary tract and lung, and alcohol are also referred to (18). With the number and location of the fracture, a total of 391 facial fractures, being isolated in 205 (74%) cases, and 2 or more locations associated in 72 (26%). Fractures are isolated mainly caused by low-energy trauma and interpersonal aggression. The nasal region was the most affected 44.75% of cases. Mandibular fracture was the second most commonly found in 14.32%

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cases, followed by 12.78% of the fractures in the orbit; maxilla fracture was the fourth most frequent with 12.02% followed by the zygomatic bone with 9.97%. The more complex fractures Le Fort I, II, and III accounted 2.81% of cases. These data differ widely in the literature, which show that in many cases, the jaw is the main bone fractured because it is the only mobile bone of the face and thus is more vulnerable to strong impact and fracture (10,16). On the other hand, studies like those by Silva et al. (13) and Leite et al. (19) corroborate our data demonstrating the nasal bone as the main fractured bones due to its prominent position, location on the mid-face, as well as the thin structures of the bones that constitute it.

2. Girotto JA, Mackenzie E, Fowler C, Redett R, Robertson B, Manson PN. Long-term physical impairment and functional outcomes after complex facial fractures. Plast Reconstr Surg. 2001;108(2):312-27.

The most serious fractures such as Le Fort occurred in 2.81% of cases. Of the total number of Le Fort fractures, 45% were due to interpersonal violence without firearm; trauma and morbidity are high in this type of fractures, and the cause is easily avoidable.

5. Gandhi S, Ranganathan LK, Solanki M, Mathew GC, Singh I, Bither S. Pattern of maxillofacial fractures in northern India. a 4-year retrospective study of 718 patients.Dental Traumatology 2011; 27: 257–262;

CONCLUSIONS Facial fractures are commonly reported in emergency departments worldwide. They are major causes of morbidity and socioeconomic prejudicial. The study of the epidemiology of facial trauma is important for the studying the cause and effects of facial trauma, assist in the initial care of these patients, and publishing preventive policies. Our study showed that males are more affected and the main causes of facial fractures are assaults, motor vehicle accidents, and falls. They are more common in young patients aged 20–29 years followed by those aged 30–39 years. In the vast majority are isolated fractures and the most affected bone is the nose, followed by the lower jaw, orbit, maxillary, and zygomatic. For the prevention of facial fractures, we must bear in mind the respect for traffic laws and routinely use seatbelts and helmets. Furthermore, the incidence of facial fractures can be reduced by strategies for dealing with falls in children and the elderly, avoiding hostile situations, and creating stricter laws and public policies to reduce traffic accidents and reduce interpersonal violence.

REFERENCES 1. Sastry SM, Sastry CM, Paul BK, Bain L, Champion HR. Leading causes of facial trauma in the major trauma outcome study. Plast Reconstr Surg. 1995, 95:196-7.

3, Subhashraj K,Nandakumar N, Ravindran C. Review of maxillofacial injuries in Chennai, India: A study of 2748 cases. British Journal of Oral and Maxillofacial Surgery. 2007;45: 637–639. 4. Gabrielli MAC, Gabrielli MFR, Marcantonio E, HochuliVieira E. Fixation of mandibular fractures with 2.0-mm miniplates: review of 191 cases. J Oral Maxillofac Surg. 2003;61(4):430-6.

6. Junior JCM, Keim FS, Helena ETS. Aspectos Epidemiológicos dos Pacientes com Traumas Maxilofaciais Operados no Hospital Geral de Blumenau, SC de 2004 a 2009. Arq. Int. Otorrinolaringol. 2010;14(2):192-198 7. Montovanijc JC, Campos LMP, Gomes MA, Moraes VRS, Ferreira FD, Nogueira EA. Etiologia e incidência das fraturas faciais em adultos e crianças: experiência em 513casos. Rev Bras Otorrinolaringol 2006;72(2):235-41 8. Pereira MD, Kreniski T, Santos RA, Ferreira LM. Trauma craniofacial: perfil epidemiológico de 1223 fraturas atendidas entre 1999 e 2005 no Hospital São Paulo – UNIFESP-EPM Rev Soc Bras Cir Craniomaxilofac 2008; 11(2): 47-50 9. Palma VC, Luz JGC, Correia FAS. Frequência de fraturas faciais em pacientes atendidos num serviço hospitalar.Rev Odontol Univ São Paulo. 1995; 9(2):121-6. 10. Falcão MFL, Segundo AVL, Silveira MMF. Estudo epidemiológico de 1758 fraturas faciais tratadas no Hospital da Restauração, Recife/PE. Rev Bras Cir Traumatol BucoMaxilo-Fac. 2005;5(3):65-72. 11. Portolan M, Torriani M. Estudo de prevalência das fraturas bucomaxilofaciais na região de Pelotas. Rev Odonto Ciênc. 2005;20:47. 12. Macedo JLS, Camargo LM, Almeida PF, Rosa SC. Perfil epidemiológico do trauma de face dos pacientes atendido no pronto socorro de um hospital público. Rev. Col. Bras. Cir. 2008;35(1):009-013. 13. Silva JJL, Lima AAAS, Torres SM. Fraturas de face: análise

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Epidemiological profile of 277 patients with facial fractures treated at the emergency room at the ENT Department of Hospital do Trabalhador in Curitiba/PR, in 2010.

de 105 casos. Rev Soc Bras Cir Craniomaxilofac 2007;10(2): 41-50 14. Haug RH, and Foss J. Maxillofacial injuries in the pediatric patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:126-34 15. Lucht UA. A prospective study of accidental falls and resulting injuries in the home among elderly people. Acta Soc Med Scand. 1971, 2:105-9. 16. Brasileiro BF, Passeri LA, Epidemiological analysis of maxillofacial fractures in Brazil: A 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 12006;102:28-34. 17. Montovani JC, Campos LMP, Gomes MA, Moraes VRS, Ferreira FD, Nogueira EA. Etiologia e incidência das fraturas faciais em adultos e crianças: experiência em 513 casos. Rev Bras Otorrinolaringol. 2006;72:235-41.

Ykeda et al.

19. Segundo AVL, Campos MVS, Vasconcelos BCE. Perfil epidemiológico de pacientes portadores de fraturas faciais. Rev. Ciênc. Méd., Campinas 2005;14(4):345-350. 20. Barros TE, Campolongo GD, Zanluqui T, Duarte D. Facial trauma in the largest city in Latin America, São Paulo, 15 years after the enactment of the compulsory seat belt law. Clinics (Sao Paulo). 2010;65(10):1043-7. 21. Cardozo DD, Bergoli RD, Torriani MA. Levantamento epidemiológico dos traumatismos faciais em pacientes pediátricos assistidos no pronto socorro municipal de Pelotas. Trabalho de Conclusão de Curso – Faculdade de Odontologia, Universidade Federal de Pelotas, Pelotas, 2004. 22. Freitas DA, Caldeira LV, Pereira ZM, Silva AM, Freitas VA, Antunes SLNOC. Estudo epidemiológico das fraturas faciais ocorridas na cidade de Montes Claros/MG. Rev Bras Cir Cabeça Pescoço 2009;38(2):113-5.

18. Wulkan M, Júnior JGP, Botter DA. Epidemiologia do trauma facial. Rev Assoc Med Bras. 2005;51(5):290-5.

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Int. Arch. Otorhinolaryngol. 2012;16(4):445-451. DOI: 10.7162/S1809-97772012000400004

Original Article

Rhinoplasty and facial asymmetry: Analysis of subjective and anthropometric factors in the Caucasian nose Bettina Carvalho1, Annelyse Christine Ballin2, Renata Vecentin Becker3, Cezar Augusto Sarraff Berger4, Johann G. G. Melcherts Hurtado5, Marcos Mocellin6. 1) 2) 3) 4) 5) 6)

Medical Doctor. ENT Resident at HC/UFPR. ENT (ABORL) . ENT Doctor. Medical student at UFPR. ENT (ABORL) . Teacher in the Rhinology department of HC/UFPR. MD Education, Clinical Psychology and Physical Education. Coordinator of Medical Scientific Research at HC/UFPR. PhD in ENT (Escola Paulista de Medicina, Brazil. Professor and Head of Department, at UFPR, Brazil.

Institution:

Hospital de Clinicas da UFPR. Curitiba / PR â&#x20AC;&#x201C; Brazil. Mail address: Bettina Carvalho - Rua General Carneiro, 181 - Center - Curitiba / PR - Brazil - Zip code: 80060-900 - Telephone: (+55 41) 3264-9976 - E-mail: bettinacarvalho@yahoo.com.br Article received in March 5, 2012. Article approved in July 22, 2012.

SUMMARY Introduction: Anthropometric proportions and symmetry are considered determinants of beauty. These parameters have significant importance in facial plastic surgery, particularly in rhinoplasty. As the central organ of the face, the nose is especially important in determining facial symmetry, both through the perception of a crooked nose and through the determination of facial growth. The evaluation of the presence of facial asymmetry has great relevance preoperatively, both for surgical planning and counseling. Aim/Objective: To evaluate and document the presence of facial asymmetry in patients during rhinoplasty planning and to correlate the anthropometric measures with the perception of facial symmetry or asymmetry, assessing whether there is a higher prevalence of facial asymmetry in these patients compared to volunteers without nasal complaints. Methods: This prospective study was performed by comparing photographs of patients with rhinoplasty planning and volunteers (controls), n = 201, and by evaluating of anthropometric measurements taken from a line passing through the center of the face, until tragus, medial canthus, corner side wing margin, and oral commissure of each side, by statistical analysis (Z test and odds ratio). Results: None of the patients or volunteers had completely symmetric values. Subjectively, 59% of patients were perceived as asymmetric, against 54% of volunteers. Objectively, more than 89% of respondents had asymmetrical measures. Patients had greater RLMTr (MidLine Tragus Ratio) asymmetry than volunteers, which was statistically significant. Discussion/Conclusion: Facial asymmetries are very common in patients seeking rhinoplasty, and special attention should be paid to these aspects both for surgical planning and for counseling of patients. Keywords: nose; anthropometry; rhinoplasty; facial asymmetry.

INTRODUCTION Proportions, harmony, and symmetry of facial features are considered determinants of the perception of beauty (1,2,3,4). Symmetry refers to the fact that one side is similar to the other. Evolutionary biologists predict that facial symmetry should be attractive, since it represents a sign of health and genetic quality (5,6). Symmetry must, therefore, be regarded as a major factor of facial attractiveness (4). Anthropometry is the science that studies the measures, weights, and proportions of the human body, providing objective data to assess morphology (7).

Craniofacial anthropometry started when anthropologists measured human skulls in order to categorize and classify them by race. It was discovered then that the nasal index was the best index in order to distinguish the various human races (8) . The clinical application of craniofacial measures was initially focused on cases of congenital and disfiguring facial trauma. In situations in which the surgeon needed to know standard measures, anthropometric studies served as an excellent base (9) . Currently, these findings have great significance in rhinoplasty, as this surgery aims to improve facial aesthetics by changing the dimensions and proportions of the central element of the face: the nose (1). These dimensions and

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proportions, which can be corrected by rhinoplasty, have a very important role in the general perception of the face as symmetrical or asymmetrical (10,12,13). The presence of asymmetries should be recognized preoperatively in all views of the nose (13). Furthermore, detection and discussion of the presence of pre-existing facial asymmetry, both in patient education and in surgical planning are extremely important in the preoperative evaluation of a rhinoplasty, since they can reduce the impact of the changes in the form the nose after surgery (1). The concept of beauty and facial proportions suffers considered normal variation with time and different cultures, so the notion of a universal aesthetic standard is not correct and should be tailored to each ethnic group. With the increasing demand for aesthetic nasal surgery, it is essential that the surgeons know the standards of the population with whom they are dealing, in order to maintain the characteristics of that population (3). To better define norms and standards of facial aesthetics, population studies are needed. There are insufficient studies of nasal and facial measurements of the Brazilian population, especially regarding the presence of facial asymmetry, as well as objective measures for their identification. To evaluate the presence of facial asymmetry by anthropometric measurements in conjunction with a subjective evaluation, of patients in preoperative rhinoplasty and volunteers without complaint, to verify whether patients with nasal complaints (aesthetic or functional) have greater facial asymmetry than those without it.

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and persons of black, Asian or mixed race (non-Caucasian noses) to minimize ethnic variations. All photographs were taken by the same researcher, with the same camera and same standardization. Camera Model Sony Cyber-shot DSC-W125 7.2 Megapixels in size with zoom fixed at 6.0, at a distance of 1.5 m between the machine and volunteer, to account for uniformity of scale and measures. The incidence was anterior–posterior position in Frankfurt. The photographs were subjected to analysis of facial action parameters by using the program Adobe Photoshop CS3, as in Figure 1. Anthropometric measurements were obtained based on facial soft tissue landmarks, starting with an imaginary sagittal line originating at the midpoint of the hair line, crossing the midpoint of the nasal bridge, the central point of cupid’s bow, upper lip, and the lowest point of the chin toward the medial canthus (MC), lateral canthus (LC), lateral alar margin (LAM), oral commissure (OC), and tragus (Tr), as shown in Figure 1. Measurements were taken in pixels, and included the ratio of the measurement of one side divided by the measurements of the other side. The ratios are as follows: RLMTr = midline–tragus ratio; RLMCL = midline–lateral corner ratio; RLMCM = midline–medial canthus ratio; RLMMAL = midline–lateral alar margin ratio; RLMCO = midline–oral commissure ratio. We calculated the percentage of asymmetry using the following formula: (Ratio - 1) x 100, and degrees of asymmetry were defined: >2.5%, >5%, and >10% for RLMMAL.

METHOD This study was approved by the Ethics Committee on Human Research of UFPR (CAAE: 0197.0.208.000-11, registered at CEP: 2595.202/2011-08). A prospective cohort study was performed by a protocol and photographs of volunteers recruited from among students of medicine, Federal University of Parana and professionals engaged in health care at the hospital and pre-operative rhinoplasty patients of both sexes and aged between 18 and 55 years. The sample amounted to n = 201. Exclusion criteria were age less than 18 years and more than 55 years, previous history of trauma, history of nasal or facial surgery, presence of craniofacial anomalies,

Figure 1. Representation of the landmarks of the facial anthropometric measurements.

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The photographs of rhinoplasty patients and volunteers were evaluated by 3 evaluators (researchers) related to Plastic Facial Surgery in order to analyze the subjective presence of facial asymmetry. The face was considered asymmetric if all the 3 researchers considered thus.

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90 80 70 60 50 Patients

40

Data were statistically analyzed using the Z test and Odds ratio for calculation of risk (chance or probability of results happening in each group), considering p < 0.05 significant.

Volunteers

30 20 10 0 >2,5%

RESULTS We evaluated 101 volunteers and 100 patients in preoperative rhinoplasty (n = 201), 64% women and 36% men.

>5%

>10%

Chart 1. Degree of asymmetry in relation to RLMLAM: for >2.5%, OR = 1.44 (CI 1.35 to 1.53); for >5%, OR = 2.08 (CI 1.884 to 2.276); and >10%, OR = 1.43 (CI 1.332 to 1.528).

The results are given in Tables 1 and 2 and Figures 1 and 2.

60 50 40

DISCUSSION

Symmetric

30

The ability to alter the outcomes in facial surgery requires a deep understanding of the evaluation of facial aesthetics, proportion, and symmetry by the surgeon.

Asymmetric 20 10

Many direct surgical procedures correct facial symmetry or balance, including rhinoplasty. Symmetry means more than one face side should be identical to the other, it is the overall balance of structures

0 Patients

Volunteers Volunteers

Chart 2. Subjective evaluation of facial asymmetry: patients (n = 100) x volunteers (101). OR = 1.2 (CI 1.15 to 1.25).

Table 1. Degree of facial symmetry between the population of volunteers (n = 101) and patients (n = 100). Ratio RLMTr RLMCL RLMCM RLMMAL RLMCO Mean (sd) Volunteers 0.9127 (0.05) 0.9433 (0.04) 0.8748 (0.08) 0.9422 (0.04) 0.9032 (0.06) Patients 0.95 (0.04) 0.95 (0.04) 0.89 (0.07) 0.94 (0.04) 0.91 (0.06) p value p~0 p = 0.119 p = 0.076 p = 0.352 p = 0.212 RLMTr = midline–tragus ratio; RLMCL = midline–lateral canthus ratio; RLMCM = midline–medial canthus ratio; RLMMAL = midline–lateral alar margin ratio; RLMCO = midline–oral commissure ratio.

Table 2. Percentage of patients with symmetric means (ratio = 1) between 2 sides of the face in each anthropometric measure: volunteers (n = 101) × patients (n = 100). Ratio RLMTr RLMCL RLMCM RLMMAL RLMCO Ratio = 1 (%) Volunteers 0.99% 6.93% 6.93% 10.89% 5.94% Patients 5% 8% 3% 3% 2% OR(CI) 0.19(0.16–0.22) 0.77(0.72–0.82) 2.17(1.974–2.366) 3.95(3.53–4.38) 3.09(2.76–3.42) OR = Odds ratio, CI = confidence interval. Int. Arch. Otorhinolaryngol., São Paulo - Brazil, v.16, n.4, p. 445-451, Oct/Nov/December - 2012.

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of the face, with all the parts working in harmony and addresses to the fact that the face or opinion of it is unbalanced. In a face symmetrical and balanced, and therefore pleasant, the vision should flow imperceptibly and continuously between the different subunits, nasal and facial (14) . The main goal of surgery is to achieve an aesthetic nasal anatomy, which allows a harmonious relationship where no facial feature steals the attention of others and each structure enhances the beauty of the whole. Rhinoplasty can change the angle of the nose with the face, the length, the width of the nostrils; changes in shape, size, and width change both the intrinsic proportions of the nose and its relations with the other elements of the face (10). All parts of the face have a role in creating facial symmetry, but some parts contribute more than others. The nose and chin are the major determinants of facial symmetry, mainly because they are at the center of the face and protrude from the face. The nose is the center of the face, and therefore the focal point of the face. The shape and size of the nose can vary greatly from person to person and can significantly affect facial symmetry (1, 3, 10, 11). In a study by Nouraei et al., measurements in preoperative and postoperative patients undergoing rhinoplasty showed improved symmetry in the nose postoperatively. This also corresponds to perceptual analyses of the face, as a whole, which became more symmetrical (12). This demonstrates the role that the nose has in the perception of facial symmetry. The nose itself may still not be symmetrical, due to congenital defects or acquired, which can change the shape of the nose and also facial symmetry. Correction of nasal asymmetry should be the goal of any surgical procedure that aims to change the nasal contour (13). Hafezi et al. (15), studying photographs of rhinoplasty patients, found a high rate of facial asymmetry and rhinoscoliosis (crooked or deviated nose). They noted a slight contraction in appearance from the concave side of the nasal deviation, concluding that there is a strong relationship between growth retardation and rhinoscoliosis, causing facial asymmetry.

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The finding of similar asymmetrical faces among family members supported the notion that genetics determines facial deformities such as asymmetry by controlling the growth of the face and nose, going against the theory that the deformities are acquired by trauma or developmental disorders (15). Moreover, Kim et al. (16), analyzing the mechanisms of association between septal deviation and deviation and asymmetry in other parts of the facial skeleton, through evaluation of external and internal parameters of the face (computed tomography), concluded that differences in the growth of bones around the nose may be associated with septal deviation in patients who have suffered nasal trauma. That is, they believe that the septal deviation occurs as a result of asymmetric growth of the jawbones. Patients with a desire to seek rhinoplasty usually present to the rhinologist with aesthetic and/or functional complaints. The functional complaints may include septal deviation causing nasal obstruction. In this study, we have been evaluating and documenting the presence of facial asymmetry in patients desiring rhinoplasty by anthropometric measurements and correlated with perception of facial symmetry or asymmetry, assessing whether there is a higher prevalence of facial asymmetry in patients planning rhinoplasty compared with controls. Anthropometric measurements of the nose provided objective data about the shape and size of the nose (8). Since the nose is one of the most important components of facial aesthetics, the study of its form and attributes is of great importance not only in rhinoplasty, but also in other areas such as facial reconstruction and forensics (2). The use of absolute values of the facial measurements can be misleading. Therefore, the evaluation of facial proportions is recommended (17). In our study, we analyzed the ratio between the measurements of each side of the face, i.e., dividing the absolute measure on one side by the other. In order to avoid errors in some patients who are more asymmetric on the left side and others the right, the ratios were always calculated by dividing the side showing more asymmetry by the side showing the lower asymmetry. The was therefore considered totally symmetrical if the ratio was equal to 1. As in a similar study carried out by Chatrath et al. (1), none of the patients had a perfectly symmetrical nose or face. However, this does not mean that the nose or face is

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imperfect. However, the surgeon and patient must always be aware of these differences. Freng et al. (18) compared the facial growth of patients with and without septal deviation, and found significant problems with growth in areas surrounding the nose. The deformities resulting from these growth problems usually do not attract the attention of surgeons and rhinologists (orbits dystopian, raised lip corners, asymmetric zygomatic arches, nasal wings asymmetric and poorly positioned, growth of non-parallel sides of the nose). In our study, with regard to the mean of the measures, we found a statistical significance only insofar as the ratio of the midline to tragus (RLMTr = 0.9127 x 0.95) (Table 1). In the objective evaluation, by ratios of the measures, we found a large percentage of individuals with asymmetry measures. In all measurements, more than 89% of patients were found with asymmetrical measurements. Except for the measurement of RLMTr and RLMCM, all others presented a larger percentage of asymmetry in patients than in healthy volunteers, and RLMMAL showed the greatest OR (3.95) (Table 4). Chatrath et al. (1) in their study found more than 90% asymmetry in facial measurements of ratios. We also found high levels of asymmetry of the RLMMAL (See chart 1), and 25 patients (25%) and 19 volunteers (18%) had levels of up to >10% asymmetry from one side to another. Lesser degrees of asymmetry (>2.5%) were found in up to 79% of patients and 72% of volunteers. Reitzen et al. (13) assessed the same ratios and found similar results for patients with bulbous tips. Given a degree of asymmetry of >5%, there was a higher OR, 2.08 (CI = 1.884 to 2.276). These measurements show asymmetries in other parts of the face (orbits and lips), which reflect possible changes in facial growth changes due to nasal or facial asymmetric growth leading to nasal affections. Because the nose is located on the jaw, the changes in the symmetry of the jaw elements reflect changes in nasal axis, and vice versa, and consequently in its symmetry (11,15). There are also studies correlating the convexity of nasal septum deformities accompanying adjacent facial structures (16). As we did not evaluate the presence or absence of septal deviation or other intranasal changes, we cannot conclude with certainty, but this should be studied in future research. In the subjective evaluation of the presence of facial

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asymmetry, in the rhinoplasty group, 59 patients of 100 patients were considered asymmetrical (59%), compared to 55 volunteers (54%) (Chart 2), obtaining an OR of 1.2 (CI 1.15 to 1.25), i.e., the group of patients had a 20% increase in asymmetry relative to the group of volunteers. In their study, Chatrath et al. (1) found subjective perception of facial asymmetry of less than 40% in patients with preoperative rhinoplasty. However, subjective assessment by the researchers is not able to find all the asymmetries found through objective measures. Several authors (1,11,15,16) have studied the presence of facial asymmetry in rhinoplasty patients, but there was no comparison with controls (patients without indication or desire for rhinoplasty). There is a high incidence of asymmetry in the general population, even in those without facial aesthetic complaints, and we believe this is of great importance to our studies. Chatrath et al. observed that individual objective measures were poor determinants of subjective perception of facial asymmetry, and were unable to determine a level of asymmetry in the measurements (1). Therefore, together with the anthropometric measurements there should be a subjective evaluation, by common sense and aesthetic knowledge of the surgeon. Also in their study, it was considered that the measure that best correlated with the subjective presence of facial asymmetry was RLMMAL. Several studies cited by Zaidel et al. (6) indicate that in humans, unlike in other species, symmetry and attractiveness are not confused. However, assessment of the presence of asymmetries in the nose and face is not intended to achieve a perfectly symmetrical face or nose. The evaluation of the asymmetry of the face as a whole is intended to help surgeons to better plan the surgery and inform patients about the limitations of the surgical procedure, which results in greater satisfaction with the results (15). Reitzen et al. (13) evaluated the presence of asymmetries between the nostrils in patients with bulbous tips, and believes that the discrepancies found in the measures become more apparent after surgical tip refinement, leading to unexpected cosmetic imperfections and lack of patient satisfaction. Therefore, measuring the asymmetry in this case the nose and nares of the base is also important.

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The use of anthropometric measurements and calculation of these ratios, together with the judgment of the surgeon, may be useful in the evaluation of facial asymmetry in patients with preoperative rhinoplasty in order to assess the presence of nasal and facial asymmetries. In the final evaluation, which measures more than aesthetic standards, what should prevail is the desire of the patient in harmony with the aesthetic surgeon (8). Therefore, we suggest the use of anthropometric measurements in conjunction with the subjective evaluation of the surgeon.

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3. Patil SB, Kale SM, Jaiswal S, Khare N, Math M. The Average indian Female Nose. Aesthetic Plast Surg 2011 May 5 4. Meyer-Marcotty P, Stellzig-Eisenhauer A, Bareis U, Hartman J, Kochel J. Three-dimensional perception of facial asymmetry. The European Journal of Orthodontics Advance Access. February, 2011. 5. Rhodes G, Proffitt F, Grady JM, Sumich A. Facial symmetry and the perception of beauty. Psychonomic Bulletin & Review 1998, 5 (4), 659-669. 6. Zaidel DW, Cohen JA. The face, beauty, and symmetry: perceiveing asymmetry in beautiful faces. Intern. J. Neuroscience, 115:1165-1173, 2005.

CONCLUSION Anthropometric evaluation of facial asymmetry in patients with preoperative rhinoplasty at the Hospital de Clinicas da Universidade Federal do Paraná found high prevalence of asymmetry among both pre-rhinoplasty patients and volunteer subjects. Although average measures of RLMTr were the only statistically significant and higher values in the group of patients than in the volunteers, we found a higher prevalence of asymmetry in the patients for the RLMCL (93.07%), RLMMAL (97%), and RLMCO (98%), and higher RLMTr (99.01%) and RLMCM (93.07%) in volunteers. In the subjective evaluation, a greater percentage of patients (59%) considered themselves asymmetric than volunteers (54%), and in the objective evaluation of the measures, for all measurements the great majority of patients had asymmetry (>89%), and in 25% of patients and 18% of volunteers, we found a degree of >10% asymmetry between sides. The evaluation of the patient’s face as a whole before rhinoplasty is important, both for surgical planning and guidance of the patient. Anthropometric measurements can assist in this evaluation because they are able to detect and validate the presence of asymmetry with greater detail than the subjective assessment of the researcher.

7. Farkas LG. Examination. In: Farkas LG, editor. Anthopometry of the head and face. 2nd Ed. New York: Raven Press; 1994. p. 3-56. 8. Doddi NM, Eccles R. The role of anthropometric measurements in nasal surgery and research: a systematic review. Clinical Otolaryngology 2010,35:277-283. 9. Farkas LG, Katic MJ, Forrest CR. International anthropometric study of facial morphology in various ethnic groups/races. The Journal of craniofacial surgery. V. 16, n. 4 July 2005. 10. American Society of Plastic Surgeons (2007). Nose Surgery (Rhinoplasty). http://www.plasticsurgery.org/ patients_consumers/procedures/Rhinoplasty.cfm 11. Yao F, Lawson W, Westreich RW. Effect of Midfacial Asymetry on Nasal Axis Deviation. Arch Facial Plast Surg. 2009;11(3):157-164. 12. Nouraei SAR, Pulido MA, Salch HA. Impact of Rhinoplasty on Objective Measurement and Psychophysical Appreciation of Facial Symmetry. Arch Facial Plast Surg. 2009;11(3):198-202. 13. Reitzen SD, Morris LGT, Davis RE. Prevalence of Occult Nostril Asymmetry in the Oversized Nasal Tip. A Quantitative Photographic Analysis.Arch Facial Plast Surg. 2011;13(5):311-315.

REFERENCES 1. Chatrath P, De Cordova J, Nouranei R, Ahmed J, Saleh HA. Objective Assessment of Facial Asymmetry in Rhinoplasty patients. Arch Facial Plast Surg. 2007,9:184187.

14. ESPINOSA REYES JA, PALACIO M. Plástica Colômbia. La Punta Nasal. http://www.plasticacolombia.com/articulos/ anatomia_punta_nasal.php

2. Pazos JAT, Galdanes ICS, Lopez MC, Matamala DAZ. Sexual dismorphism in the nose morphotype in adult chilean.Int. J. Morphol., 26(3):537-542, 2008.

15. HAFEZI F, NAGHIBZADEH B, NOUHI A, YAVARI P. Asymmetric facial Growth and Deviated Nose. Ann Plast Surg 2010;64:47-51.

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16. KIM YM, RHA KS, WEISSMAN JD, HWANG PH, MOST SP.Correlation of Asymmetric Facial Growth with Deviated Nasal Septum. Laryngoscope, 121:1444-1148, 2011.

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18. FRENG A, KVAM E, KRAMER J. Facial skeletal dimensions in patients with nasal septal deviation. Scand J Plast Reconstr Surg Hand Surg. 1988;22:77-81.

17. NAINI FB, MOSS JP, GILL DS. The enigma of facial beauty: Esthetics, proportions, deformity, and controvery. American Journal of Orthodontics and Dentofacial Orthopedics, September 2006, 277-281.

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Int. Arch. Otorhinolaryngol. 2012;16(4):452-459. DOI: 10.7162/S1809-97772012000400005

Original Article

Profile of cochlear implant users of the city of Manaus Mariana dos Santos Pedrett1, Sandra Costa Moreira2. 1) Specialist. Masters degree student in Language Studies at the Federal University of Amazonas - UFAM. Bolsita Foundation for Research Support of the Amazon-FAPEAM. - (Phonoaudiologist Center of Manaus City Department of Education. Professor of Phonoaudiology University Center North.). 2) Specialist. - (In Time Phonoaudiologist TV. Professor at the University Center North. Institution:

Centro UniversitĂĄrio do Norte - UNINORTE Manaus / AM - Brazil. Mailing address: Mariana dos Santos Pedrett - Rua Dez de Julho, 873 - Center - Manaus / AM - Brazil - Zip code: 69010-060 - Telephone: (+55 92) 3671-8046 E-mail: mariana.pedrett@hotmail.com Article received in March 23, 2012. Article approved in June 7, 2012.

SUMMARY Introduction: The cochlear implant is a device that is intended to substitute for the function of cochlear hair cells, electrically stimulate auditory nerve fibers, and contribute to the perception of speech sounds. However, the surgical procedure alone is not enough for the user to achieve favorable results in habilitation/rehabilitation. Objective: To characterize the patients from Manaus who have received cochlear implants based on the criteria for surgery. Methods: We conducted a retrospective cross-sectional study of 15 cases and recorded etiological aspects of deafness, age, gender, duration of implant use, use of hearing aids, and participation in individual therapy. Data were recorded in a protocol designed specifically for this purpose. All patients were natives of Manaus. Results: The leading etiological aspect was ototoxicity associated with prematurity in newborns undergoing treatment in the neonatal intensive care unit. The age at surgery is carefully observed in the evaluation of implant centers, as well as if the candidate is pre-or post-lingual. In this study, 73% of patients were pre-lingual and did not benefit from hearing aids. As to the degree and type of hearing loss, 93% had audiological reports indicating profound bilateral sensorineural hearing loss and 7% had severe bilateral sensorineural hearing loss. This latter finding confirmed one of the basic principles of implant placement. Conclusion: This study allowed us to verify that there are reduced number of cochlear implant recipients in Manaus, but they have met the criteria required by implant centers located in other states of Brazil. Keywords: cochlear implants; deafness; population characteristics.

INTRODUCTION The cochlear implant is a device that tries to replace the function of cochlear hair cells and electrically stimulates the auditory nerve fibers, creates the sensation of hearing in children with hearing loss, and allows the perception of speech sounds to occur more easily. However, surgery alone is not enough for users to achieve favorable results in habilitation/rehabilitation. Patients selected to receive the implant must meet a number of criteria, including severe or profound bilateral sensorineural hearing loss and trial of conventional hearing aids with no benefit. The SUS (Unified Health System) does not provide this service in Manaus, which is why candidates migrate to implant centers in other states for the surgery.

However, one of the specific requirements of these centers is the availability of specialized therapeutic services in the city of origin, without which the surgery is not feasible. A large majority of these patients, if SUS performs the implantcannot afford to make up a team of rehabilitation specialists. The primary objective of this study was to characterize the profile of recipients of cochlear implant devices in Manaus, analyzing the medical records and protocols of the Association of Support for Hearing and Cochlear Implant Users of the Amazon (AMADA) with regard to the patients who received implants at implant centers and other points. AMADA is an institution that provides support to people who need to use this technology, so a customer is not characterized. We considered etiological aspects of deafness, age, sex, proportion of patients pre-and post-lingual, previous use of a hearing aid, time of use of the implant, and also consistent follow-up with specialized speech therapists.

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Cochlear Implant Thanks to changes in public health policy on hearing, there has been an increase in the number of facilities for cochlear implant surgery in Brazil, especially after the creation of ordinances of October 20, 1999, marking the surgical procedure as a treatment option for hearing and an ordinance from 2004 that defined the National Policy of Hearing Health Care and provided the grounds for basic-, medium-, and high-complexity care. These specifics maintain and justify the character of this research in an attempt to characterize the study population and allow the reflection of the inclusion of this service in the city of Manaus. For Pinto (2007, p.43) the evolution of language in these children does not always occur as expected and is influenced by a number of factors such as age, degree of hearing loss, language skills pre-implantation, etiology of hearing loss, and therapeutic approach among others.

Ototoxicity Acquired hearing loss by ototoxic substances can occur at any age, but in this work, we refer to those substances that affect newborns who need to stay in the Neonatal Intensive Care Unit (NICU). According to Russo and Santos (1989, p.73), these are “high-risk infants who fall under some conditions, such as family history of hearing loss, [...] weight babies at birth less than 1500g.” Also in Russo and Santos (1989, p. 44) is that “the ingestion of drugs considered ototoxic, by a woman during pregnancy, can cause hearing loss in infants it has generated.” As per Jornada (2009, p. 27) “ototoxic drugs can affect the system cochlear or vestibular system, or both, changing two important functions in the body: hearing and balance.” The degree of hearing impairment is subject to variations and depends on the gestational period in which the drug was used, i.e., if it occurred in the first trimester or between the seventh and eighth weeks, the effects to the embryo are devastating.

Meningitis As per Porto (2002, p. 89) “meningitis presents high prevalence in Brazil and worldwide, constituting one of the most important causes of profound hearing loss.” Another author reinforces the fact:

The main etiology of hearing loss in childhood are the genetic cause (non-syndromic or syndromic) congenital infections (eg, rubella, cytomegalovirus, toxoplasmosis), perinatal causes and infections acquired (eg sequelae of meningitis) [...] among the infectious diseases which is hearing the sequel, the most serious is meningitis. (Ramalho, 2008, p. 01).

Rubella Research in Manaus point of rubella cases reported with suspected pregnancy and risk of silent congenital rubella syndrome. As Mota (2004, p.43) of the 3.818 reported cases were recorded in the field of research sheet 103 cases of suspected pregnancy or 3%. The possibility of underreporting of the disease, these records probably represent a small portion of reality, but is not always essential to the total number of disease to establish the system of prevention and control measures, since for these 103 cases, 83 (80.6%) conducted tests and confirmed 42 (50.6%) and discarded 41 (49.4%). To Russo and Santos (1989, p. 45) “maternal rubella syndrome can present a variety of defects with various degrees of severity. [...]” Presents an auditory manifestation of the disease in 50% of cases.”

Aspects Relevant To Use Cochlear Implants Pre-lingual deafness and post-lingual According to Kozlowski (2000, p. 42) “pre-lingual deafness occurs in individuals who have acquired hearing loss before the development of language. In cases of post-lingual deafness, we classify all those individuals who lost their hearing after the development of language.” It is important to identify such features to track goals in caring for patients using the device. According to Moret (2005, p. 78), for children with hearing impairment prelingual deployment depends on information provided by the cochlear implant to acquire oral language. Age and duration of auditory deprivation Research by Leal (2010, p. 189) showed that “patients aged 0-3 years are patients pre-and peri-lingual with greater potential benefit to the CI.” According to Sant’Anna (2008, p. 58) “For children with pre-lingual hearing loss, surgery should preferably be made up to 6 years of age and the prognosis is better for those implanted until 4 years. Children over 6 years will have more limited prognosis.”

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Type and degree of hearing loss

Material

Thus, several studies have been conducted regarding the criteria for cochlear implant use. For Porto (2002, p. 14) “in cases of profound sensorineural hearing loss, the implant is indicated as a treatment method recognized worldwide as an effective aid in the rehabilitation of hearing sequel.”

After signing an informed consent for the presidency for the authorization of the survey, data were collected through review of 15 randomly selected medical records of patients using the device. The data were recorded in the protocol developed specifically for this purpose. Data were analyzed for the most common etiology of deafness, number of patients with cochlear implant pre-lingual versus post-lingual, age and gender of the informants, the degree and type of hearing loss, duration of use of the device and participation in therapy with a speech therapist. After data collection was carried out, data analysis was performed including computation and aggregation of data and subsequent statistical analysis of the descriptive data, with the results organized in tables and graphs.

Criteria for selection and rejection of patients for the cochlear implant is constantly changing as the research proceeds. Any patient with severe hearing loss and / or deep it will not benefit from the use of hearing aids and has no medical or psychological contraindications for use of the device can be a potential candidate for the CI (LEAL, 2010, p.189). Use of a hearing aid

RESULTS For Sant´Anna (2008, p.58) “children 1 to 17 years with bilateral sensorineural hearing loss severe to profound, provided they have hearing aids and speech therapy done systematically for at least 6 months and show no trend of listening skills.”

METHOD This is a quantitative, cross-sectional study approved on 08/06/2010 by the Ethics and Research Center University of CEP-North (Protocol 243/10)

Casuistry The data were collected from medical records of patients with cochlear implant of AMADA (Association of Amazonian Support for Hearing and Cochlear Implant Users) according to the consent of the responsible institution. The AMADA is located in the Joint Atilio Andreazza, Acari Street, block E, n. 50, Japiim. It is an association that supports patients undergoing cochlear implant surgery by SUS sent to implant centers located in other states, since the procedure takes place in Manaus only by agreement. The inclusion criteria used in this study were: medical records of patients treated with cochlear implant in the institution, native of the city of Manaus, randomly selected, not to exceed a total of 15. Exclusion criteria were: medical records of patients without cochlear implant, not born in the city of Manaus, and exceeding the total of 15 randomly selected records.

Characterization of the population We analyzed medical records of 15 patients of AMADA. Of the 15 randomly selected, 53.3% (n = 8) patients were male and 46.6% (n = 7) were female. The minimum age was 3 years, the maximum was 71 years. The largest population was aged 4–6 years, as can be seen in Table 1. Otological history: Use of hearing aids for prelingual patients Image 1 shows that 55% (n = 6) used hearing aids 2 to 3 years prior to implant surgery, 36% (n = 4) 0 of 1 year, and 9% (n = 1) did not respond. Characteristics of the subjects second language acquisition 73% (n = 11) of patients were pre-lingual, and 27% (n = 4) post-lingual (Image 2).

Table 1. Distribution of patients according to age and gender. Age group Male Female Total N % N % N % 1–3 years 00 0% 01 6.6% 01 6.6% 4–6 years 04 26. 8% 02 13. 4% 06 40. 2% 7–9 years 03 20% 01 6.6% 04 26. 6% 10–13 years 00 0% 01 6.6% 01 6.6% Above 18 years 01 6.6% 02 13. 4% 03 20% Total 08 53. 4% 07 46. 6% 15 100%

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1.0 a 1 year

2.2 a 3 years

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Pre-lingual

Not reported

Post-lingual

9% 27%

36% 73%

55%

Image 1. Time of use of hearing aid

1 to 3 years

4 to 6 years

Image 2. Characterization of pateintsâ&#x20AC;&#x2122; second language acquisition.

7 to 9 years

7 to 9 years

18%

Above 18 years

25%

46% 75%

36%

Image 3. Age of pre-lingual patients at the time of surgery.

Image 4. Age of post-lingual patients at the time of surgery.

Age factor in pre-lingual patients at the time of surgery

with the association for speech therapy twice a week and 20% (n = 3) once during the week.

In Image 3 we see that 46% (n = 05) were prelingual patients who underwent surgery between 1 and 3 years, 36% (n = 04) between 4 and 6 years, and 18% (n = 02) between 7 and 9 years.

Time of use of cochlear implants

Age factor in post-lingual patients at surgery Of the patients surveyed, 75% (n = 03) underwent cochlear implant over the age of 18 years, and 25% (n = 01) from 07 to 9 years (Image 4). Speech and Hearing Pathology We found that 80% (n = 12) of patients participated

53% (n = 8) to have 01 years of use of the device, 40% (n = 6) make use of the implant for 2 to 3 years, and 7% (n = 1) benefits from the system for over 3 years. (Image 6). The above data show that the incidence of ototoxicity is more common in male patients (n = 5), whereas meningitis appeared more prevalent in females (n = 3). The other root causes were isolated cytomegalovirus (n = 1), genetic factors (n = 1), auditory nerve damage (n = 1), traumatic brain injury (n = 1), and 1 undiagnosed case (n = 1).

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Once a week

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Twice a week

1.0 a 1 year

3. Over 3 years

7%

20%

40%

80%

Image 5. Frequency of speech therapy.

Meningitis

2.2 a 3 years

Ototoxicity

53%

Image 6. Distribution of subjects according to duration of implant use.

Bilateral sensorineural hearing loss severe deep

Other

Severe bilateral sensorineural hearing loss

7% 33%

27%

93%

40%

Image 7. Main etiological agents found in the studied population.

Image 8. Distribution of subjects hearing loss.

General distribution of subjects according to the etiologic agents.

report that we find other etiologies isolated whose percentage was 33% (n = 5), among which we quote: cytomegalovirus, head trauma, congenital deafness, damage to the auditory nerve and one undiagnosed case (Image 7).

The agent that causes deafness ototoxicity highest incidence was 40% of cases (n = 6), coupled with the fact that all respondents for that item were infants with a history of prematurity, low birth weight, and submission to treatment in neonatal NICU. The second-most relevant data with meningitis was 27% (n = 4). It is important to

by degree and type of

š Associated with prematurity and low birth weight. Newborns undergoing treatment in the NICU.

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Table 2. Distribution of subjects according to the etiology and sex. Etiology Male Female Total N N 1. Congenital Rubella 00 00 00 2. Meningitis 01 03 04 3. Ototoxicity¹ 05 01 06 4. Cytomegalovirus 00 01 01 5. Genetic factors 01 00 01 6. Lesions in the auditory nerve 00 01 01 7. Traumatic brain injury 00 01 01 8. Undiagnosed 01 00 01

DISCUSSION

period 1998 to 2002. Of these, 103 cases (80.6%) underwent tests being confirmed. (Mota, 2004). Rubéola was considered as likely to be confirmed in this group; however, we did not find a single individual with hearing loss, cochlear implant user who submit the etiological cause (n = 0). This fact is justified compared to the study in Manaus, because according to Mota (2004) avigilância, the Rubella Surveillance System in Manaus could only develop prevention and control when double viral vaccine (measles/rubella) was introduced in 2000, and MMR in 2003, during routine Public Health Unit Surveillance System for the City of Manaus, with the knowledge of this information, developed with state support, activities to structure the care of pregnant women positive for rubella as well as negative pregnant women in maternity wards in Manaus. These discussion regarding the policies adopted in the city of Manaus to the prevention of infectious diseases and, consequently, to minimize its effects on hearing.

The findings showed that 80% of the individuals within the criteria of holding speech therapy in his home town. Lima, Marba, and Santos (2006, p. 115, emphasis added) found significant results in people “weighing less than 1000g, the presence of genetic syndrome, [...] the occurrence of meningitis, use of ototoxic medication for more Meningitis arises 27% (n = 4). According Lichtig and Carvalho (1997, p. 245) and bacterial meningitis is responsible for 6-40% of acquired sensorineural hearing impairments that occur in school-age population.” A study corroborates the findings of the research. According to Santos (2005) in Amazonas State, there were 640 cases and 104 deaths from 1998 to 2002 (data provided by the Health Department of the State of Amazonas SUSAM), and in Manaus; in the same period, 532 cases were confirmed and 74 deaths of meningococcal disease, according to data from the Municipal Health authority. In screening patients registered in the Central Brazilian Cochlear Implants registry for surgery, among the causes examined, it was found that rubella, followed by meningitis, is the most frequently reported etiology. Such research points to the high incidence of these 2 diseases still present in the population with some type of hearing loss. (FAIR, 2010) There were 3,818 reported cases of rubella with suspected pregnancy and risk of silent congenital rubella syndrome identified through the records of the Epidemiological Surveillance System of Manaus in the

CONCLUSION The results indicate that despite the reduced number of cochlear implant users in Manaus, patients meet the criteria required by cochlear implant centers in Brazil, also mentioned by the literature. The determinants to characterize the profile of these patients and the type and degree of hearing loss, etiology causes of deafness, age at surgery, use of individual hearing aids before implantation, duration of use of the device, the process of language acquisition and to check whether the patient had access to habilitation/rehabilitation hearing in the city of origin, were crucial to the profile of the population studied. We found that most of the hearing loss was due to ototoxicity associated with prematurity of newborns undergoing treatment in the NICU, and patients were predominantly pre-lingual (73%). Regarding the degree and type of hearing loss, 93% of respondents have audiological reports indicating profound bilateral sensorineural hearing loss, and 7% have severe bilateral sensorineural hearing loss. As the therapeutic process, all patients have access to speech therapy, with the caveat that are supported largely by the association, thus fulfilling one of the requirements required for successful habilitation/rehabilitation of the patient implanted at the time of selection implantation, but with great difficulty.

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REFERENCES 1. Amantini RCB, Bevilacqua MC, Costa OA. Considerações sobre o implante coclear em crianças. In: Bevilacqua MC, Moret ALM (Orgs.) Deficiência Auditiva: conversando com familiares e profissionais de saúde. São José dos Campos: Pulso, 2005. 2. Bevilacqua MC, Moret AL. Implante Coclear em Crianças. In: LOPES FILHO, O.C. Tratado de Fonoaudiologia. São Paulo, Roca, 1997. 3. Bevilacqua MC et al. Implantes cocleares em crianças portadoras de deficiência auditiva decorrente de meningite. Rev. Bras. Otorrinolaringol. 2003;69(6):760764. 4. Brasil. Ministério da Saúde. Manual de vigilância epidemiológica das doenças exantemáticas. Brasília, DF: FNS, 2003. 5. Brasil. Ministério da Saúde. Portaria n°1278, de 20 de outubro de 1999. Dispõe sobre a necessidade de estabelecer critérios de indicação e realização de implante coclear. Disponível em: <http://www.portal.saude.gov/ portal/sas/sapd/por 22689.shtm.>. Acesso em: 06 jun. 2010. 6. Costa Filho OA. et al. Implante coclear em adultos. In: Campos CAH, Costa HOO. Tratado de Otorrinolaringologia. São Paulo: Roca, 2002. p. 278289. 7. Costa Filho OA, Bevilacqua MC, Moreti ALM. Critérios de seleção de crianças candidatas ao implante coclear do Hospital de Pesquisa e Reabilitação de Lesões Lábio Palatais - USP. Rev. Bras. Otorrinolaringologia. 1996;62(4):306-313. 8. Jakubovicz R. Atraso de Linguagem: diagnóstico pela média dos valores da frase. São Paulo: Revinter, 2002. 9. Jornada AL. Comparação das alterações auditivas em recém-nascidos da UTI neonatal expostos e não expostos a antibióticos, por meio do teste de emissões otoacústicas. 2009.73f. Dissertação (Mestrado em Pediatria). PUCRS, Porto Alegra, 2009.

12. Leal AF. Triagem de pacientes para implantes cocleares através de questionário online: Perfil do grupo de pacientes pré e peri-linguais não convocados. Arq. Otorrinolaringol. 2010;14(2):184-191. 13. Lichtig I, Carvalho RMM. Audição: Abordagens Atuais. Carapicuíba, SP: Pró-Fono, 1997. 14. Lima GML, Marba STM, Santos MFC. - Triagem auditiva em recém-nascidos internados em UTI neonatal. J. Pediatr. 2006;82(2):100-104. 15. Lopes Filho OC. Tratado de Fonoaudiologia. São Paulo: Roca, 1997. 16. Moret ALM. Princípios Básicos da Habilitação da criança Deficiente auditiva com Implante Coclear. In: Bevilacqua MC, Moret ALM, (Orgs.) Deficiência Auditiva: conversando com familiares e profissionais de saúde. São José dos Campos: Pulso, 2005. 17. Mota MFM. Avaliação do Sistema de Vigilância Epidemiológica de Manaus: Comportamento da Rubéola, 1998 a 2002. 2004. 68f. Dissertação (Mestrado em Doenças Tropicais e Infecciosas). UEA/FMTAM, Manaus, 2004. 18. Myamoto RT et al. Language development in deaf infants following cochlear implantantion. In: Pinto ESM. Análise dos procedimentos de seleção de crianças para o implante coclear. (Tese de Doutorado) Campinas, São Paulo: 2007. p. 42-50. 19. Pinto ESM. Análise dos procedimentos de seleção de crianças para o implante coclear. (Tese de Doutorado) Campinas, São Paulo: 2007. p. 42-50. 20. Porto PRC. Avaliação de resultados de implante coclear em pacientes deficientes auditivos secundário à meningite. (Dissertação de mestrado) Campinas, SP: [s.n], 2002. 21. Prestes MLM. A pesquisa e a construção do conhecimento científico: do planejamento aos textos, da escola à academia. São Paulo: Respel, 2007.

10. Kozlowski L. Implantes Cocleares. São Paulo: PróFono, 2000.

22. Ramalho KA. Análise retrospectiva das sequelas de meningite em crianças de uma unidade hospitalar especializada. 2008. 102f. Dissertação (Mestrado) Pontifícia Universidade Católica de São Paulo, São Paulo, 2008.

11. Kumar V, Abbas A, Fausto N. Patologia: bases patológicas das doenças. 7. ed. Rio de Janeiro: Elsevier, 2005.

23. Russo ICP, Momensohn-Santos TM. (Orgs.) Prática da Audiologia Clínica. 5. ed. São Paulo: Cortez Editora, 2005.

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24. Sant’Anna SBG. O implante coclear e a atuação fonoaudiológica. In: Silva PB, David RHF. (Orgs.) Cadernos da Fonoaudiálogo: Audiologia. São Paulo: Lovise, 2008.

26. Segre CAM. Prevalência de perda auditiva em recémnascidos de muito baixo peso. J. Pediatr. 2003;79(2):103104.

25. Santos ML. Doença meningocócica: situação epidemiológica no Município de Manaus, Amazonas, Brasil, 1998/2002. Cad. Saúde Pública 2005;21(6).

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Int. Arch. Otorhinolaryngol. 2012;16(4):460-465. DOI: 10.7162/S1809-97772012000400006

Original Article

Quality of life and deglutition after total laryngectomy Leandro de Araújo Pernambuco1, Jabson Herber Profiro de Oliveira2, Renata Milena Freitas Lima Régis3, Leilane Maria de Lima2, Ana Maria Bezerra de Araújo4, Patrícia Maria Mendes Balata5, Daniele Andrade da Cunha6, Hilton Justino da Silva7. 1) Master in Health Sciences - Federal University of Pernambuco. Professor - Speech, Language and Hearing Sciences Department - Federal University of Rio Grande do Norte. 2) Graduated in Speech, Language and Hearing Science - Federal University of Pernambuco. Speech and Language Pathologist. 3) Specialist in Orofacial Miology. Speech and Language Pathologist. 4) Specialist in Dysphagia - Federal Council of Speech, Language and Hearing Sciences. Speech and Language Pathologist - Cancer Hospital of Pernambuco. 5) Master of Science in Adolescent Health - Pernambuco University. Speech and Language Pathologist. Institute of Human Resources of Pernambuco State. 6) Ph.D in Nutrition - Federal University of Pernambuco. Professor - Estacio Recife. 7) Ph.D in Nutrition - Federal University of Pernambuco. Professor - Speech, Language and Hearing Science Department - Federal University of Pernambuco. Institution:

Universidade Federal de Pernambuco. Recife / PE - Brazil. Mailing address: Leandro de Araújo Pernambuco - Departamento de Fonoaudiologia - Rua General Gustavo Cordeiro de Farias, s/n - Petrópolis - Natal / RN - Brazil Zip code: 59010-180 - Telephone: (+55 84) 3342-9738 - E-mail: leandroape@globo.com Conselho Nacional de Tecnologia e Desenvolvimento Científico (CNPq) - Edital MCT/CNPq/CT-Saúde/MS/SCTIE/DECIT nº 67/2009 - REBRATS. Article received in April 8, 2012. Article approved in August 10, 2012.

SUMMARY Introduction: Total laryngectomy creates deglutition disorders and causes a decrease in quality of life Aim: To describe the impact of swallowing and quality of life of patients after total laryngectomy. Method: A case series study. Patients completed a Swallowing and Quality of Life questionnaire composed of 44 questions assessing 11 domains related to quality of life (burden, eating duration, eating desire, frequency of symptoms, food selection, communication, fear, mental health, social functioning, sleep, and fatigue). The analysis was performed using descriptive statistics, including measures of central tendency and variability. Results: The sample comprised 15 patients who underwent total laryngectomy and adjuvant radiotherapy. Of these, 66.7% classified their health as good and 73% reported no restrictions on food consistency. The domains “communication” and “fear” represented severe impact and “eating duration” represented moderate impact on quality of life. The items with lower scores were: longer time to eat than others (domain “eating duration”), cough and cough to remove the liquid or food of the mouth when they are stopped (domain “symptom frequency”), difficulties in understanding (domain “communication”) and fear of choking and having pneumonia (domain “fear”). Conclusion: After total laryngectomy, patients report that swallowing issues have moderate to severe impact in “communication,” “fear,” and “eating duration” domains. Keywords: quality of life; laryngeal neoplasms; laryngectomy; deglutition; deglutition disorders.

would be used, adjuvant treatments such as radiotherapy and chemotherapy, and comorbidities such as advanced age and depression (5, 6).

INTRODUCTION Recent proposals for treatment of advanced cancer of the larynx emphasize more conservative approaches and make the definition of treatment an even more complex (1). However, total laryngectomy is still frequently adopted in such cases and questionnaires on health conditions and quality of life have been recommended as key promoters of success of treatment planning (2). After total laryngectomy, oropharyngeal dysphagia can compromise the quality of life by requiring the modification of eating habits, affect socialization, and lead to a degree of isolation in activities with family members (3). Oropharyngeal dysphagia is a common symptom in patients with tumors in the head and neck regions (4) and its etiology may be related to how surgical technique

The impact of difficulty in deglutition in quality of life of total laryngectomized has been assessed using generic instruments (3,7-9) or instruments specific to this function (2,10,11). The results of these studies indicate that the overall quality of life after total laryngectomy is approaching the standard of the general population, as opposed to specific domains such as deglutition, which often appear associated with negative aspects (8). Nevertheless, the results are still preliminary, especially owing to the multiple number of existing instruments and because dysphagia is still underdiagnosed in this group of patients (5). The aim of this study was to describe the effect of deglutition in quality of life of patients undergoing total laryngectomy.

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METHOD

rated as good by a significant percentage of volunteers (Graphic 1).

The participants included patients undergoing treatment for esophageal speech acquisition at the Department of Speech Therapy in a cancer referral center located in Pernambuco, northeastern part of Brazil. We included patients who underwent total laryngectomy with neck dissection and postoperative radiotherapy, with completion of treatment for at least 3 months. We excluded patients with neurological disorders and head and neck disease and those subjected to other procedures in the head and neck.

Graphic 2 shows that most participants described the consistency of the food consumed in the last week as difficult to chew. No volunteer used any alternative feeding method at the time of data collection.

The quality of life related to deglutition was assessed using the Swallowing Quality of Life Questionnaire (SWALQOL), which has been validated for Brazilian Portuguese subjects (12). The questionnaire comprises 44 questions that assess 11 domains related to quality of life (burden, feed duration, desire, symptoms frequency, food selection, communication, fear, mental health, social function, sleep, and fatigue). Each question has 5 possible answers. The answers were converted into scores ranging from 0 to 100, divided into quintiles (0 as a minimum score and 100 as a maximum positive score). In each domain, the score values regarding responses were summed and the result was divided by the number of questions in the domain, reaching the end score. The scores 0–49 were interpreted as a severe impact, 50–70 as a moderate impact, and 71– 100 slight impact or no impact (10). The analysis was performed using descriptive statistics. Due to the final conversion of the SWAL-QOL results into categories (ordinal categorical variable), we used the median as a measure of central tendency and the minimum and maximum as a measure of dispersion. Among the issues addressed by the additional instrument, we herein highlight the general health status and self-reported and food consistencies accepted by the volunteer. These variables were analyzed by means of absolute and relative frequencies.

Table 1 shows the distribution of SWAL-QOL domains, according to the median. It was observed that the “communication” and “fear” domains were those with the lowest scores, indicating severe impact on quality of life related to deglutition. The “feeding duration” domain caused moderate impact and the others domains caused discrete impact or no impact. The descriptive analysis (Chart 1) of data revealed that items with higher absolute and relative frequency of responses with scores between 0 and 50 were longer time required to eat (53.3%; “feeding duration” domain), cough to remove the liquid or food out of the mouth when they are standing (40% and 46.7%, respectively, “frequency of symptoms” domain), difficult to understand (46.7%; “communication” domain), and fear choking and having pneumonia (40% and 53.3%, respectively; “fear” domain).

2 (13%) 3 (20%)

Good Satisfatory Very good

10 (67%)

Chart 1. Overall health condition self-reported by patients with total laryngectomy. Quality of life relation to deglutition, Recife, 2011.

1 (7%)

The research was submitted to the Ethics and Human Research committee and approved under the number 67/2010. The volunteers who agreed to participate in the study signed a free consent term, in accordance to Resolution 196/96 of the National Research Ethics Counsel.

Variety of food, including more food difficult difficult to chew Soft food, easy to chew

3 (20%)

RESULTS

Past pasty foods in a blender or food processor

11 (73%)

A sample of 15 volunteers had a mean age of 63 ± 9.3 years and the following profile: male (86.7%), married (53.3%) and uncompleted elementary education (60%). The self-reported condition general health was

Chart 2. Graph of consistency or texture most common last week. Quality of life related to total laryngectomized deglutition, Recife, 2011.

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Table 1. Distribution of variables related to SWAL-QOL domains, according to measures of central tendency and variability. Deglutition quality of life related to total laryngectomy. Recife, 2011. Variable Median Minimum–Maximum Deglutition as a burden 100 0–100 Feeding duration 50 0–100 Desire to eat 75 16.6–100 Symptoms frequency 80.3 37.5–96.4 Food selection 100 50–100 Comunication 37.5 25–37.5 Fear 43.7 25–43.7 Mental health 95 70–95 Social function 95 25–95 Sleep 75 37.5–75 Fatigue 83.3 50–83.3

DISCUSSION In Brazil, a group of researchers published 2 studies in which the SWAL-QOL questionnaire was used in patients after a total laryngectomy in São Paulo; however, unlike the present study, they found only a moderate impact of deglutition on quality of life (10,11). In one of these studies, 12 patients with total laryngectomies answered the questionnaire. In this sample, the domains that resulted in the lowest median values were “communication” and “desire for food,” whose impact was moderate on the quality of life. It is worth noting that the “feeding duration” domain was not considered in this study. In the other work with a sample of the same health service, the lowest median found in the “feeding duration” and “communication” domains, with moderate impact on quality of life (11). It is noticed that the “communication” domain is always present and associated with negative aspects. The permanent loss of laryngeal voice and the difficulties of adapting to alternative communication can support this result (13). The fact that the volunteers of this research are not yet fully adapted to esophageal speech may have influenced the result. In the institution where the collection was made, the esophageal voice was the method of communication rehabilitation, since the other possibilities of more sophisticated vocal rehabilitation (tracheoesophageal and laryngeal electronic prostheses) require costs that are not compatible with the profile of low-income users of this service. We emphasize that the individual variations in relation to culture, beliefs, religions, social, economic,

professional, and family situations (10) can exert a strong influence on the perception that the individuals have of their quality of life. Thus, the differences and similarities between our study and others may possibly be explained by the variable aspects of social determinants, whose importance should be further explored in future research. The SWAL-QOL is a protocol that considers a specific functional domain; however, there are protocols that assess the overall quality of life and include deglutition (3,9). An Australian study (3) investigated the effect of dysphagia on quality of life of 110 patients after total laryngectomy. This study used the World Health Organization Quality of Life-BRIEF (WHOQOL-BRIEF) and the University of Washington QOL (UW-QOL). There was no difference between the findings of the subjects with and without dysphagia; however, total laryngectomy with dysphagia had more functional impairment, reduced social participation, and higher levels of depression and anxiety. The authors conclude that although dysphagia does not directly determine the quality of life after total laryngectomy, it can have a negative impact on functional and psychological wellbeing of the patient. In another study (8) in patients with total laryngectomy with more than 2 years of completion of treatment, the overall quality of life did not differ from that of the general population, but there was adherence to specific scales of the physical domain, which is influenced by age, sex, radiotherapy, and chemotherapy. In the sample of these authors, women reported more difficulties with deglutition, which corroborates the findings of another study (14). Because of our small sample size, we did not compare the results by gender. When considering the patient’s perspective regarding the impact of total laryngectomy on quality of life, a qualitative study (15) received reports of psychological and functional problems, including dysphagia. The authors highlight the high number of difficulties reported even after end of treatment and reinforce the need for maintenance of the monitoring team of multidisciplinary rehabilitation for longer periods after surgery. About this, the literature says that the longer survival is not an accurate reflection of the success of treatment and does not necessarily indicate better quality of life (2). Therefore, there is a need to stimulate a long-term care to these individuals and to promote the application of more reliable instruments that can capture the impression of the subject with respect to their quality of life. For longer-term evaluations, the Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) was

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Table 2. Distribution of the sample of patients with total laryngectomy according to the responses of SWAL-QOL questionnaire (Portas, 2009) with respect to burden, feeding duration, eating desire, symptom frequency, food selection, communication, fear, mental health, social function, sleep, and fatigue domains from quality of life related to deglutition in total laryngectomy patients (Recife 2011). RESPONSES Deglutition as a burden domain Dealing with my deglutition problem is very difficult My deglutition problem is the major disruption in my life Feeding duration domain It takes me longer to eat than others I take much time to eat my meal Eating desire domain Most days, I do not care if I eat or not I’m rarely hungry I don’t have more pleasure in eating Symptoms frequency domain Cough Choking when eating Choking with liquids Present thick saliva or secretion Vomiting Nausea Difficulties in chewing Excessive secretion of saliva Hawking The food stops in the throat The food stops in the mouth Food or drink drip from the mouth Food or drink out through the nose Cough to remove liquid or food out of the mouth when they are stopped Food selection domain Knowing what I can and not can eat is a problem for me It’s hard to find foods I can and like to eat Communication domain People have difficulty understanding me It has been difficult to communicate clearly Fear domain I’m afraid of choking when I eat I worry about having pneumonia I’m afraid of choking on liquids Never know when I’ll choke Mental health domain My deglutition problem depresses me I have to be very careful when I drink or how to bother me I’ve been discouraged with my deglutition problem My deglutition problem frustrates me I become impatient in dealing with my deglutition problem Social function domain I do not go out to eat due to my deglutition problem My deglutition problem becomes difficult to have a social life My job or my leisure activities changed by my deglutition problem Social programs and vacations do not satisfy me because of my deglutition problem My role with family and friends has changed due to my deglutition problem Sleep domain Have trouble sleeping? Is that a problem to keep sleeping? Fatigue domain Do you feel weak? Do you feel tired? Do you feel exhausted?

SCORE 0 n (%)

SCORE 25 n (%)

SCORE 50 n (%)

SCORE 75 n (%)

SCORE 100 n (%)

3 (20%) 1 (6.7%)

-

2 (13.3%)

4 (26.7%)

7 (46.7%) 12 (80%)

8 ( 53.3%) 5 (33.3%)

-

5 (33.3%) 1 (6.7%)

1 (6.7%) -

1 (6.7%) 9 (60%)

3 (20%) 1 (6.7%) 2 (13.3%)

2 (13.3%) 2 (13.3%) 2 (13.3%)

2 (13.3%) 2 (13.3%)

3 (20%) 3 (20%) 1 (6.7%)

7 (46.7%) 7 (46.7%) 8 (53.3%)

1 (6.7%) 3 (20%) 3 (20%) 4 (26.7%) 2 (13.3%) 1 (6.7%) 1 (6.7%) -

3 (20%) 1 (6.7%) 1 (6.7%) 3 (20%) 2 (13.3%) 2 (13.3%) 1 (6.7%) 1 (6.7%) 1 (6.7%) 1 (6.7%) 1 (6.7%)

6 (40%) 1 (6.7%) 4 (26.7%) 2 (13.3%) 1 (6.7%) 3 (20%) 1 (6.7%) 3 (20%)

2 (13.3%) 4 (26.7%) 2 (13.3%) 1 (6.7%) 1 (6.7%) 1 (6.7%) 1 (6.7%) 2 (13.3%) 1 (6.7%) 1 (6.7%)

3 (20%) 9 (60%) 12 (80%) 4 (26.7%) 14 (93.3%) 14 (93.3%) 10 (66.7%) 6 (40%) 10 ( 66.7%) 8 (53.3%) 13 (86.7%) 12 (80%) 10 (66.7%)

7 (46.7%)

-

1 (6.7%)

2 (13.3%)

5 (33.3%)

3 (20%) -

-

1 (6.7%) 1 (6.7%)

3 (20%) 1 (6.7%)

8 (53.3%) 13 (86.7%)

1 (6.7%) 4 (26.7%)

7 (46.7%) 3 (20%)

5 (33.3%) 4 (26.7%)

2 (13.3%)

2 (13.3%) 2 (13.3%)

6 (40%) 8 (53.3%) 5 (33.3%) 5 (33.3%)

1 (6.7%) 1 (6.7%) 1 (6.7%) -

2 (13.3%) 1 (6.7%) -

1 (6.7%) 1 (6.7%) 1 (6.7%) 1 (6.7%)

5 (33.3%) 4 (26.7%) 8 (53.3%) 9 (60%)

1 (6.7%) 2 (13.3%) 1 (6.6%) 2 (13.3%) 2 (13.3%)

1 (6.7%)

2 (13.3%)

2 (13.3%) 3 (20%) 3 (20%) 1 (6.7%) 3 (20%)

9 (60%) 10 (66.7%) 8 (53.3%) 10 (66.7%) 9 (60%)

1 (6.7%) 3 (20%)

3 (20%) 1 (6.7%)

-

-

11 (73.3%) 11 (73.3%)

3 (20%)

-

-

3 (20%)

9 (60%)

2 (13.3%)

-

-

-

13 (86.7%)

2 (13.3%)

1 (6.7%)

-

3 (20%)

9 (60%)

3 (20%) 3 (20%)

1 (6.7%) 2 (13.3%)

1 (6.7%) 3 (20%)

2 (13.3%)

10 (66.7%) 5 (33.3%)

2 (13.3%) 2 (13.3%)

2 (13.3%) 4 (26.7%) 4 (26.7%)

1 (6.7%) 1 (6.7%)

2 (13.3%) 2 (13.3%) 1 (6.7%)

11 (73.3%) 6 (40%) 7 (46.7%)

3 (20%) 2 (13.3%) 1 (6.7%)

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used to assess the degree of dysphagia before and after total laryngectomy in 20 patients (9). It was concluded that the “eating in public” and “normal diet” domains worsened in 50%, even 2 years after surgery. The result reinforces the remarkable social impact that the deglutition difficulty has after total laryngectomy (3), even after a long period after treatment. Moreover, it agrees with the results of our research that revealed a moderate impact on “difficulty eating in public” domain. However, this same work (9), differs from ours with respect to food consistency, but not to other studies using SWAL-QOL. The percentage of subjects with restriction for solids is comparable to that found in a previous study with the same number of individuals (26.3%) (11). In another study with 12 patients, 4 had restriction (10), but these had the lowest scores, which suggests that the consistency of food interferes with quality of life (10). When considering the small number of volunteers, we decided not to make this comparison for believing that the subgroups would be uneven and the result would not be representative of the entire population. Despite the severe and moderate impact found in some domains of SWAL-QOL, no volunteers rated their general health less than satisfactory, and previous studies have also found the same pattern (10,11). This finding can be explained by time to clinical stability at the time of answering the questionnaire. It also reveals that, despite the impact caused by deglutition difficulties, this does not interfere negatively in the context of general health from the perspective of the respondent (10,11). The frequency of deglutition difficulties is greater when surgery is combined with radiotherapy, as observed in the treatment profile of all of our subjects. Researchers recruited 26 patients who underwent only surgery and 95 who underwent surgery combined with radiotherapy. It was found that the deglutition was better in the group whose treatment was surgical alone (14). Unlike our current findings, those of our previous research (2) did not detect a negative impression of the patients in relation to deglutition after treatment. In that study, another specific instrument was used for assessment of dysphagia, the MD Anderson Dysphagia Inventory. This shows that the choice of the questionnaire to be applied must be judicious as well as the interpretation of data by the multidisciplinary team.

“fear” domains and a moderate impact on the “feeding duration” domain. The other domains caused discrete impact or no impact.

THANKS The authors thank the National Council for Technology and Scientific Development (CNPq), which provided financial support through the Notice MCT/CNPq/ Health-CT/MS/SCTIE/DECIT nº 67/2009 - REBRATS.

REFERENCES 1. Genden EM, Ferlito A, Rinaldo A, Silver CE, Fagan JJ, Suárez C et al . Recent changes in the treatment of patients with advanced laryngeal cancer. Head Neck.2008;30(1):103-10. 2. Kazi R, Prasad V, Venkitaraman R, Nutting CM, Clarke P, Rhys-Evans P et al. Questionnaire analysis of the swallowingrelated outcomes following total laryngectomy. Clin Otolaryngol. 2006;31(6):525-30, 3. Maclean J, Cotton S, Perry A. Dysphagia following a total laryngectomy: the effect on quality of life, functioning,and psychological well-being. Dysphagia. 2009;24(3):314-21 4. Schindler A, Favero E, Capaccio P, Albera R, Cavalot AL, Ottaviani F. Supracricoid laryngectomy: age influence on long-term functional results. Laryngoscope. 2009;119(6):1218-25. 5. Ward EC, Bishop B, Frisby J, Stevens M. Swallowing outcomes following total laryngectomy and pharingolaryngectomy. Arch Otolaryngol Head Neck Surg. 2002;128(2):181-6. 6. Maclean J, Cotton S, Perry A. Variation in surgical methods used for total laryngectomy in Australia. 2008; J Laryngol Otol. 122(7):728-32. 7. Zotti P, Lugli D, Vaccher E, Vidotto G, Franchin G, Barzan L. The EORTC quality of life questionnaire-head and neck 35 in Italian laryngectomized patients. European organization for research and treatment of cancer. Qual Life Res. 2000;9(10):1147-53 8.Vilaseca I, Chen AY, Backscheider AG. Long-term quality of life after total laryngectomy. Head Neck.2006;28(4):31320.

CONCLUSION After total laryngectomy, deglutition exerted a severe impact on quality of life in terms of “communication” and

9. Chone CT, Spina AL, Barcellos IH, Servin HH, Crespo NA. A prospective study of long-term dysphagia following total laryngectomy. B-ENT. 2011;7(2):103-9.

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10. Barros APB, Portas JG, Queija DS, Lehn CN, Dedivitis RA. Autopercepção da desvantagem vocal (VHI) e qualidade de vida relacionada à deglutição (SWAL-QOL) de pacientes laringectomizados totais. Rev Bras Cir Cabeça Pescoço. 2007;36(1):32-7. 11. Queija DS, Portas JG, Dedivitis RA, Lehn CN, Barros APB. Deglutição e qualidade de vida após laringectomia e faringolaringectomia total. Braz J Otorhinolaryngol. 2009;75(4):556-64. 12. Portas JG. Validação para a língua portuguesa-brasileira dos questionários: qualidade de vida em disfagia (SWALQOL) e satisfação do paciente e qualidade do cuidade no tratamento da disfagia (SWAL-CARE) [dissertação]. São Paulo: Fundação Antônio Prudente; 2009.

13. Moukarbel RV, Doyle PC, Yoo JH, Franklin JH, Day AMB, Fung K. Voice-related quality of life (V-RQOL) outcomes in laryngectomees. Head Neck. 2011;33(1): 31-6. 14. de Casso C, Slevin NJ, Homer JJ. The impact of radiotherapy on swallowing and speech in patients who undergo total laryngectomy. Otolaryngol Head Neck Surg. 2008;139(6):792-7. 15. Noonan BJ, Hegarty J. The impact of total laryngectomy: the patient’s perspective. Oncol Nurs Forum. 2010;37(3):293-301.

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Int. Arch. Otorhinolaryngol. 2012;16(4):466-475. DOI: 10.7162/S1809-97772012000400007

Original Article

Vestibular schwannoma: 825 cases from a 25-year experience Mariana Hausen Pinna1, Ricardo Ferreira Bento2, Rubens Vuono de Brito Neto3. 1) Specialist ENT. Physician Group Otology HCFMUSP. 2) Full Professor. Head of Clinical Otolaryngology, University of São Paulo School of Medicine. Chief of Otology, HCFMUSP 3) Full Professor, Division of Clinical Otolaryngology, HCFMUSP Institution:

Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo / SP - Brazil Mailing address: Mariana Hausen Pinna - Av. Dr. Enéas de Carvalho Aguiar 255 - Sala 6167 - São Paulo / SP - Brazil – Zip code: 05403-000 - Telephone: (+55 11) 2661-6288 - E-mail: mariana@hausen@gmail.com Article received in April 16, 2012. Article approved in July 31, 2012.

SUMMARY Introduction: Acoustic nerve tumors have been recognized as a clinico-pathologic entity for at least 200 years, and they represent 90% of cerebellopontine angle diseases. Histologically, the tumors are derived from Schwann cells of the myelin sheath, with smaller tumors consisting of elongated palisade cells, while in large tumors, cystic degeneration can be found in the central areas, possibly due to deficient vascularization. We retrospectively reviewed 825 cases of vestibular schwannomas, reported between January 1984 and August 2006, in which the patients underwent surgery to remove the tumor. Objective: To evaluate signs, symptoms, aspects of clinical diagnosis, including the results of audiological and imaging studies, and surgical techniques and complications. Methods: A retrospective chart review. The medical records of all patients undergoing surgical treatment for schwannoma during the period indicated were reviewed. Results and Conclusion: Hearing loss was the first symptom reported in almost all cases, and tumor size was not proportional to the impairment of the auditory threshold. The surgical techniques allowed safe preservation of facial function. In particular, the retrolabyrinthine route proved useful in small tumors, with 50% preservation of hearing. Keywords: neuroma; acoustic; vestibulocochlear nerve diseases; cranial nerve neoplasms.

INTRODUCTION Vestibulocochlear nerve neoplasms have been recognized as a distinct clinical and pathological entity for at least 200 years, and account for approximately 90% of all conditions affecting the cerebellopontine angle. The most appropriate term for these tumors is vestibular schwannoma (1, 2), although the vast majority of physicians refer to them as acoustic neuroma or neurinoma. The first observation of a tumor of the acoustic nerve was made during an autopsy in 1777 by Eduard Sandifort, Professor of Anatomy at Leiden University (3). As the name implies, schwannomas are histologically derived from Schwann cells. Small schwannomas consist of elongated, palisade cells, whereas larger tumors also exhibit central cystic degeneration, possibly due to deficient vascularization. Unlike amputation neuromas, which contain a tangle of nerve fibers, schwannomas contain no such fibers (4). The etiology of vestibular schwannomas is unknown. Cushing (1917) and Revilla (1948) believed trauma was a plausible explanation, as some observations apparently associated occipital trauma with tumors of the cerebellopontine angle (5, 6).

The finding that symptoms are sometimes exacerbated during pregnancy has elicited the hypothesis that hormonal mechanisms may be involved in the genesis or progression of these tumors (3, 7). A hereditary component is reasonably unlikely, except in the unquestionably inherited cases of schwannoma that present as part of the complex of neurofibromatosis type 2. Knowledge of the embryonic development of CN VIII constitutes the foundation of pathogenetic studies that have, on the one hand, provided an understanding of the underlying mechanisms of formation of these nerve tumors and, on the other, shown why of all the cranial nerves, the eighth pair is affected. The most widely accepted hypothesis is the embryonic theory of opposing distal and peripheral fibers that meet at the level of the internal auditory canal to give rise to the vestibulocochlear nerve. In the vast majority of cases, the upper (vestibular) branch of the vestibulocochlear nerve is predisposed to the development of vestibular schwannomas and, in most cases, the tumor arises from the back of the internal auditory canal. Rarely, schwannomas may originate from the cochlear branch of CN VIII (7, 8, 9).

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Figure 1. Tumor grade I. Figure 2. Tumor grade II.

Figure 3. Tumor grade III.

Figure 4. Tumor grade IV.

Several studies have attempted to find an association between mobile phone use and the incidence of vestibular schwannoma. A multicenter European case-control study found no increase in the incidence rate of this tumor, nor did an investigation carried out between 2000 and 2004 in Japan. Therefore, there is currently no evidence confirming that cellular phone use could increase the incidence of vestibular schwannoma (10,11).

Grade III: tumor extending into the posterior fossa, compressing the brainstem, but not shifting it from the midline (Figure 3). Grade IV: tumor extending into the posterior fossa, compressing the brainstem, and shifting it from the midline (Figure 4).

Progress in the diagnosis of vestibular schwannoma has played a significant role in improving treatment outcomes. Early diagnoses are currently due to a spirit of enquiry that is almost exclusive to the field of otology. Vestibular schwannomas are classified into 4 grades: Grade I: exclusively intracanalicular tumor (Figure 1). Grade II: tumor extending into the posterior fossa, with or without an intracanalicular component, without touching the brainstem (Figure 2).

In his 1917 monograph, Cushing (5) provided an outstanding description of the usual sequence of onset and progression of the signs and symptoms of vestibular schwannoma: • Auditory and labyrinthine symptoms. • Occipitofrontal pain, followed by suboccipital discomfort. • Incoordination and instability of cerebellar origin. • Signs of adjacent cranial nerve involvement. • Raised intracranial pressure, with papilledema and its consequences. • Dysarthria, dysphagia, and, finally, cerebellar seizures and respiratory distress.

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In view of the currently available diagnostic and therapeutic armamentarium, this sequence now rarely ever reaches its end. However, it provides an important benchmark for disease staging. In Brazil, the clinical signs, diagnosis, and surgical treatment of vestibular schwannoma have been studied by a number of groups (12-18). Their main findings are described in this introductory section. The main symptom is hearing loss, often associated with tinnitus, due to compression of the cochlear nerve and disturbances in cochlear vascularization. This vascular mechanism explains the possibility of sudden, atypical, fluctuant hearing loss (19), often presenting with audiometry features suggesting peripheral involvement. Other signs and symptoms may also be present, such as vertigo, dizziness, headache, hypoesthesia, and palsies. Clinical presentation is not always proportional to tumor size. Classically, vestibular schwannomas are most often diagnosed around the fifth decade of life. Most authors report a clear female preponderance. Early diagnosis of vestibular schwannoma is essential to disease prognosis. Physicians must be able to recognize suggestive clinical signs, and the index of suspicion should be particularly high in patients just past the age of 40. Vestibular schwannoma must be ruled out in all patients presenting with sensorineural hearing loss, particularly when the hearing loss is asymmetric. Complete removal of vestibular schwannomas is only possible by means of surgery, the only treatment modality that permits resection of the entire tumor with little chance of recurrence. Other therapeutic options include watchful waiting (â&#x20AC;&#x153;wait and scanâ&#x20AC;?), in very small tumors (Class I), very old patients, or those who are poor candidates for surgery and exhibit no major brainstem compression. Stereotactic surgery (20, 21) is indicated in class I or II tumors and in select other cases. This treatment modality provides an attempt at halting tumor growth with a substantial disadvantage of severely jeopardizing the surgical field if future intervention is required. Although rare, facial palsy and hearing loss have been reported as complications. The outcomes of vestibular schwannoma surgery have improved considerably with advances in diagnosis.

In the early 20th century, when only large tumors were diagnosed, the main measure of surgical success was achieving complete or partial tumor resection without causing the death of the patient. At the time, surgical mortality was extraordinarily high. The first successful resection of vestibular schwannoma was performed in 1894 by Charles Ballance, through the suboccipital route (22). As improvements in technique enabled early diagnosis, the main concern of surgeons shifted to preservation of facial nerve function. In 1904, Panse described the translabyrinthine approach to the cerebellopontine angle (23), which was, however, (initially) soon abandoned due to a lack of adequate surgical instruments and to the difficulty of tumor visualization in the pre-microscopic age. After 1920, the translabyrinthine approach appeared destined to oblivion. Only in 1961, after operating with microsurgical instruments and the operating microscope had become routine in otologic surgery, and more effective methods had been made available for diagnosis of these tumors, did House restore the translabyrinthine route to prominence, achieving a mortality rate of 5.4% and 95% preservation of the facial nerve, and completely changing the surgical prognosis of this condition by a dramatic reduction in morbidity and mortality and substantial improvement in quality of facial nerve function (24,25,26). Preservation of facial nerve integrity is now possible in the large majority of cases, and is directly associated with tumor size. More refined surgical techniques, with the advent of more appropriate instruments, intraoperative monitoring of facial and auditory nerve function, and ultrasonic aspirators, have made operative approaches to these tumors much safer. The most significant challenge now is preservation of hearing without detriment to the main goals of surgery, which are low morbidity and mortality, complete tumor resection, and preservation of the facial nerve. Vestibular schwannoma surgery has been the object of numerous publications by otorhinolaryngologists and neurosurgeons, with vigorous debate on routes of access, intraoperative and postoperative complications, residual tumor tissue and tumor recurrence after resection, and preservation of hearing. With some variation, there are 5 broad approaches that are used for resection of vestibular schwannomas, each with its particular pros and cons. These approaches to the internal acoustic canal and cerebellopontine angle can be divided into presigmoid, retrosigmoid, middle fossa, supratemporal, and combined.

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The presigmoid routes are the translabyrinthine approach and the retrolabyrinthine approach. The retrosigmoid routes are the suboccipital approach and the posterior fossa approach. The supratemporal routes are the middle fossa approach and the extended middle fossa approach, and combined approaches are a combination of any of the aforementioned routes. The objective of this article is to report the signs and symptoms exhibited in 825 cases of vestibular schwannoma treated surgically between 1981 and 2006, describing the relevant aspects of clinical, audiometric, and imaging diagnosis; the operative techniques used in this series; and perioperative and postoperative complications, thereby proposing a standardized methodology for diagnosis and treatment.

CASE SERIES AND METHODS A detailed retrospective chart review was conducted of 825 patients diagnosed with vestibular schwannoma who underwent surgery between January 1984 and August 2006. Resection was performed systematically by the same surgeon and team. Most patients had been referred for surgery after a definitive diagnosis had been established by other clinicians at our service or elsewhere. All patients underwent a new history and physical and complete ear, nose, throat, and neurological examination, as well as the following examinations: • Pure tone audiometry • Speech audiometry with single-syllable and spondaic words for determination of the Speech Recognition Index • Auditory brainstem response (ABR) audiometry, when thresholds so permitted • Computed tomography (CT) of the temporal bone • Magnetic resonance imaging (MRI) of the head. The following data, obtained by means of clinical history, were tabulated for the purposes of this study: • Age at time of diagnosis • Sex • Affected side • Chief complaint • Duration of chief complaint • Tumor size • Other signs and symptoms. Inquiries made of patients were regarding the following associated signs and symptoms: hearing loss; continuous or intermittent tinnitus; vertigo; dizziness or

unsteadiness; headache; facial pain or hypoesthesia, including hypoesthesia of Ramsey Hunt’s zone or the external auditory meatus; earache; presence of Hitselberger’s sign; facial palsy; facial spasm; aural fullness; eye pain; signs of intracranial hypertension; and neuralgia.

• • • • • •

Audiometric findings were classified as follows: Pure tone audiometry (for the frequencies 250, 500, 1000, 2000, 4000, and 6000 Hz) Profound hearing loss: >90 dB HL Severe hearing loss: >70 dB HL Moderate hearing loss: 51–70 dB HL Mild hearing loss: 26–50 dB HL Normal hearing: down to 25 dB HL

Tumor size was classified by the grading scheme described in the introduction section, based on MRI findings that were clinically correlated with hearing thresholds, tumor size classification, and speech recognition index. The following surgical approaches were employed throughout our 25-year experience: • Translabyrinthine. • Retrolabyrinthine. • Middle fossa. • Combined posterior fossa and translabyrinthine (24).

RESULTS Of the patients included in the sample, 467 (56.6%) were female and 358 (43.4%) were male. Regarding laterality, 398 (48.2%) tumors were right-sided and 427 (51.8%) were left-sided. The chief complaint was progressive unilateral hearing loss in 656 (79.5%) patients, tinnitus in 67 (8.1%), and sudden hearing loss in 48 (5.8%). Vertigo (5.1%), facial palsy (1%), hemifacial spasm (0.4%), and decreased sensitivity of the internal auditory canal (0.1%) were less frequent complaints (Chart 1). Regarding the duration of the chief complaint at diagnosis, 94 (11.4%) patients had had the symptom for less than 6 months, 170 (20.6%) for 6 months to 1 year, and 561 (68%) for more than 1 year (Chart 2). Patient ages at diagnosis were distributed as follows (Chart 3): 0–20 years: 12 (1.5%) 21–30 years: 55 (6.7%) 31–40 years: 108 (13.1%) 41–50 years: 329 (39.8%) 51–60 years: 216 (26.2%) 61–70 years: 82 (9.9%) 71–80 years: 23 (2.8%).

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Other signs and symptoms found in association with the chief complaint are shown in Chart 4. With respect to hearing loss on the affected side, at the time of surgery, 220 patients (26.7%) had profound hearing loss, 261 (31.6%) had severe hearing loss, 279 (33.8%) had moderate hearing loss, 53 (6.4%) had mild hearing loss, and 12 (1.5%) had normal thresholds.

Progressive unilateral hearing loss Tinnitus Sudden hearing loss Vertigo Facial palsy Hemifacial spasm

The spondee recognition score on the affected side was 100% in 146 patients (17.7%), 70–99% in 212 patients (25.7%), 50–69% in 241 patients (29.2%), 30–49% in 97 patients (11.8%), and <30% in 129 patients. Chart 1.

Electronystagmography was performed in 511 cases. Results were as follows: • Normal: 161 (31.5%) • Ipsilateral hyporeflexia: 97 (19%) • Contralateral hyporeflexia: 67 (13.1%) • Ipsilateral hyperreflexia: 45 (8.8%) • Contralateral hyperreflexia: 65 (12.7%) • Areflexia: 34 (6.5%) • Signs of central involvement: 42 (8.2%). ABR audiometry was not performed due to low hearing thresholds in 333 patients (40.4%). In the remaining patients, it revealed signs of retrocochlear dysfunction in 352 (42.7%) and was within normal limits in 29 (3.5%). There were no data on ABR in the charts of 111 patients (13.4%).

<6 months 6 months– months–1 year >1 year

Tumor size on MRI was consistent with Grade I in 189 cases (22.9%), Grade II in 401 (48.6%), Grade III in 188 (22.8%), and Grade IV in 47 (5.7%), according to the classification scheme described in the introduction section.

Chart 2.

Percentage correlations between tumor size and auditory involvement are shown in Chart 5. Regarding the surgical route of choice, the translabyrinthine approach was employed in 704 patients (85.3%), the retrolabyrinthine in 93 (11.3%), the middle fossa approach in 6 (0.7%), and the combined approach in 22 cases (2.7%). 0–20 years 21– 21 –30 years 31– 31 –40 years 41– 41 –50 years 51– 51 –60 years 61– 61 –70 years 71– 71 –80 years

Complete resection was achieved in 813 cases (98.5%), and planned partial resection in 12 (1.5%). Early postoperative complications (occurring within 1 month of surgery) included CNS fistula in 46 patients (5.5%), intracranial hypertension in 8 (1%), intracranial hemorrhage in 6 (0.9%), cerebellar syndrome in 6 (0.9%), and meningitis in 45 (5.4%). There were 4 deaths (0.5%).

Chart 3.

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Signs of intracranial hypertension Facial spasms Facial palsy Eye pain Ear pain Neuralgia Facial hypoesthesia Facial pain Vertigo Dizziness and/or unsteadiness Aural fullness Intermittent tinnitus Headache Hitselberger's sign Constant tinnitus Hearing loss

Graade IV Gr

Grade III

Profound Severe Moderate

Grade II

Mild Normal

Grade I

0

100

200

300

400

500

600

700

800

0%

900

20%

40%

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Chart 4. Signs and symptoms.

Chart 5. Correlations between tumor size and auditory involvement.

Facial nerve function on the tenth postoperative day (House-Brockmann score) (25) was grade V or VI in 167 patients (20.2%), grade II, III, or IV in 212 (25.7%), and Grade I in 446 (54.1%). At 16-month follow-up, function was normal in 617 patients (74.8%), Grade II in 89 (10.8%), Grade III in 27 (3.3%), Grade IV in 25 (3%), Grade V in 36 (4.4%), and Grade VI in 31 (3.7%).

assessment of the correlation between tumor size and audiometric thresholds and speech discrimination. Analysis of these findings shows that, although larger tumors are generally associated with greater involvement of auditory thresholds, there are cases of small tumors with major auditory involvement and, conversely, large tumors with little effect on auditory function were present in all 3 groups.

In the 93 patients in whom the retrolabyrinthine approach was employed, auditory function at 90-day follow-up (as represented by audiometric thresholds) was unchanged in 45 (48.4%), worse in 7 (7.5%), and had progressed to complete deafness in 41 (44.1%). In patients with preserved hearing, speech discrimination was unchanged in 40 cases (88.9%) and worse in 5 (11.1%). After a minimum 5-year follow-up, there were no signs of recurrence or residual tumor in 813 cases (98.5%). Residual tumor remained in the 12 cases in which partial resection had been planned (1.5%)

Analysis of speech discrimination more clearly demonstrates that involvement of this parameter is not proportional to tumor size. In this series, most patients were diagnosed between the ages of 41 and 60 (66%) years, which is consistent with the international literature. Sixty percent of patients were women, which is also consistent with reports of a female preponderance. Aural fullness is an infrequent symptom. It was not the chief complaint in any of the patients in this series, but was reported in 22.2% of clinical histories. This symptom is often associated with fluctuating hearing loss.

DISCUSSION Auditory Signs and Symptoms According to most authors, progressive, unilateral hearing loss is the initial symptom in approximately 90% of vestibular schwannomas. In our sample, it was the chief complaint in roughly 80% of cases. Hearing loss may present or worsen suddenly, as observed in 6% of cases in our series. According to Sauvaget, 3 to 23% of vestibular schwannomas produce sudden hearing loss, whereas only 2% of cases of sudden hearing loss lead to a diagnosis of schwannoma (19). The degree of hearing loss is not always associated with the anatomical stage of the disease, as shown by our

In older patients, vestibular schwannoma can be mistaken for labyrinthine hydrops or vascular dysfunction, and this can be an important cause of diagnostic delays. Tinnitus, usually high-pitched, was the second most common isolated symptom in our series (8.1%). Continuous or intermittent tinnitus with concomitant hearing loss is present in approximately 90% of cases, and is nearly always unilateral. Vertigo, usually positional, is the presenting symptom in only 5% of patients. As an associated, but not isolated complaint, balance disorder ranging from unsteadiness to frank rotational vertigo is reported by 40% of patients. In

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the literature, reports of balance disorder in vestibular schwannoma vary widely. Some authors maintain it may be the presenting symptom in 15% of cases.

electronystagmography, which showed absolutely no evidence of diagnostic utility in our series.

Headache (40%), facial pain, and earache are also reported, strictly as isolated symptoms. Facial palsies, spasms and dysesthesias, eye pain, and signs of intracranial hypertension are even less frequent, and may reflect advanced-stage or complicated disease.

Clinical symptoms of CN IX, X, XI, or XII dysfunction are exceedingly rare in this disease. Dysphonia and dysphagia (suggesting IX and X involvement) are observed in some cases, and are always indicative of advanced tumor development and inferior extension. None of our patients exhibited these symptoms.

Subjective reports of trigeminal nerve dysfunction are limited to a feeling of thickening of the cheek area, but the entire trigeminal zone may be affected. Trigeminal neuralgia may occur, usually in combination with somewhat diminished facial sensitivity, but it is rare and not characteristic of vestibular schwannoma.

Headache is commonly reported (44% of cases in this series), and is usually caused by large tumors. Later in the disease course, headache may signal intracranial hypertension. As an isolated symptom, it is difficult to assess, as headache has so many other causes and is one of the most commonly reported of all symptoms.

Facial nerve involvement

Cerebellar involvement

A review of the literature shows that, on average preoperative functional involvement of the facial nerve is present in 10% to 30% of vestibular schwannomas. In our series, only 2.2% of patients exhibited such involvement, and the palsy was incomplete, a paresis presenting as barely visible asymmetry of the lower face muscles, flattening of the nasolabial fold evident only during facial movements, and no apparent loss of strength or symmetry during forced movement. Functional exploration of the facial nerve (stimulation, latency measurement, electromyography) might reveal subclinical involvement, but these data were missing for most patients in the present series and were therefore not taken into account.

Cerebellar incoordination is rare and presents essentially as ataxia ipsilateral to the tumor. No cases were found in this series.

Nervus intermedius involvement

General physical examination findings

Changes involving the nervus intermedius (nerve of Wrisberg) may present as an isolated symptom or in combination with taste disturbance(due to increased electrogustometry thresholds in the anterior two-thirds of the tongue) (not observed in our series), reduced tear secretion on Schirmer’s test (not observed in our series), defective nasolacrimal reflex (not elicited in most of our patients), and reduced sensitivity in Ramsey Hunt’s zone. The latter sign was the presenting symptom of vestibular schwannoma in 1 case in our series, occurring in combination with the chief complaint in 9.5% of cases, and was found on physical examination in 48.7% of patients. This is an extremely important finding, as Hitselberger’s sign was positive in nearly 50% of patients in this series, making it a very useful component of the physical examination, in fact, much more useful than many tests often heralded as valuable in diagnosis of vestibular schwannoma, including

In patients with neurofibromatosis type 2, the physical examination may reveal a variety of findings, including neurofibromata throughout the body and café au lait spots. These patients may have bilateral vestibular schwannomas. In our series, 3 patients had bilateral tumors. All were classified as having neurofibromatosis type 2.

All symptoms and signs are represented to varying degrees in the medical literature, due to major country-tocountry variability in study samples, the possibility of more advanced diagnostic modalities in some centers, earlier and more universal access to health care depending on location, varying awareness of medical conditions among the population, and differences in the training of general practitioners and specialists with regard to whether cerebellar schwannoma should always be ruled out in patients with a history of hearing loss.

With respect to audiological testing, pure tone audiometry remains the essential modality. Interest in classical above-threshold (“supraliminal”) tests and Békésy audiometry has waned since the advent of impedance audiometry and evoked potential testing. In a broad review by several authors (Brackmann, Sterkers, Portmann), the mean pure-tone threshold at 500, 1000, 2000, and 4000 Hz was 72 dB, not taking into account disease progression.

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Mean thresholds for each disease stage were as follows: • 61 dB for intracanalicular tumors • 73 dB for stage II tumors • 71 dB for stage III tumors • 74 dB for stage IV tumors. The most commonly encountered audiometric picture is an abrupt decline (audiometric notch or dip) at 4000 Hz, with or without >25 dB hearing loss at frequencies normally used in conversation.

Speech audiometry Assessment of speech discrimination is essential in the diagnostic workup of vestibular schwannoma, and is abnormal in most cases. In our series, 72.6% had a speech recognition index of 50% or higher. The relationship between speech discrimination and tumor size is unclear. Patients with acoustic neurinoma develop a vestibular deficiency syndrome. This deficit occurs gradually and is masked by the adaptive abilities of the vestibular system. Vestibular assessment may include positional maneuvers and caloric testing.

signal suppression. T2 sequences are also useful for assessment of the relationship between the tumor and the internal auditory canal, inner ear, and adjacent cranial nerve pairs. On the basis of these results, our current protocol for diagnosis of cerebellopontine angle masses is as follows: • Clinical history and audiometric evidence of sensorineural hearing loss, particularly when asymmetric: BAEP and contrast-enhanced MRI. If BAEP is prohibitively expensive or might lead to a delay in diagnosis, MRI alone is performed. Once the diagnosis has been established, contrast-enhanced CT of the temporal bone, with particular emphasis on the internal auditory canal, is required for surgical planning. Determination of the spatial relationship between the jugular bulb and the internal auditory canal is especially important. • Physicians should never neglect signs or symptoms indicative of vestibular schwannoma, particularly sensorineural hearing loss (regardless of frequency), unilateral tinnitus, or vestibular hyporeflexia. In patients with these findings, all diagnostic possibilities should be exhausted, as early tumor detection ensures the best possible prognosis with surgical treatment. Treatment

In our series, otoneurological examination was performed in patients who reported balance disorders, but results were inconsistent and did not elicit any clear diagnostic suspicion. Furthermore, the otoneurological examination has been superseded by brainstem auditory evoked potential (BAEP) testing for diagnosis of vestibular schwannoma. In our opinion, electronystagmography as an isolated test should not be used routinely as part of the diagnostic workup when vestibular schwannoma is suspected.

Diagnostic Imaging Imaging tests have become essential for definitive diagnosis, and should always be performed when there is clinical or audiological suspicion of cerebellopontine angle disease. Imaging allows diagnosis of cerebellopontine angle masses and estimations of size and provides information on potential effects on CSF dynamics. MRI is undoubtedly the imaging modality of choice when cerebellopontine angle disease is suspected. Gadolinium contrast-enhanced MRI has nearly 100% reliability, even for small tumors. Schwannomas exhibit intermediate signal intensity on T1 and marked enhancement during the contrast phase. On T2-weighted images, the tumor may not be visible or may present as

In the 825 consecutive cases included in this series, the surgical techniques employed were effective in enabling complete tumor resection, except in 12 patients with bilateral schwannomas due to neurofibromatosis. In these patients, partial resection was planned with the purpose of decompressing the brainstem, which was affected by tumor encroachment, and preserving hearing and facial nerve function as long as possible, as bilateral disease invariably leads to dysfunction as it progresses. Early postoperative complications occurred in 13.3% of cases, and included CNF fistula (5.5%), which was treated with continuous lumbar puncture over 3 days, compression dressings, and treatment of meningitis, which occurred in all cases. In all patients, closure of the fistula was achieved, infection was managed successfully, and surgical outcomes remained unchanged. There were patients with clinical and CT evidence of intracranial hypertension (1%) or intracranial bleeding (0.9%) who underwent reoperation via the retrosigmoid route to good effect. These patients had Grade III tumors; in 2 patients, a combined retrosigmoid and middle fossa approach was employed. The mortality rate in this series was 0.5% (4 deaths). These findings indicate the striking improvements in the prognosis of surgery for vestibular schwannoma in Brazil since as recently as the 1970s.

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In 90% of cases, facial nerve function, which we believe to be the most important factor after complete resection and absence of general complications, was preserved to House-Brackmann Grades I, II, and III, with Grade I (normal) function in 74% of cases, providing evidence of the high effectiveness of current techniques for preservation of the facial nerve. Total palsy occurred in 3.7% of cases, and more severe dysfunction developed in patients with large (Grade III or IV) tumors, who required placement of nerve grafts in the posterior fossa. Facial nerve involvement is most extensive in the early postoperative period and improves over 1 year, which indicates that initial dysfunction merely reflects reversible paresis produced by surgical manipulation of the nerve. One of the most encouraging findings of our study is that auditory function was preserved in 50% of patients who underwent surgery via the retrolabyrinthine approach. We believe this route represents the future of vestibular schwannoma surgery with regard to preservation of hearing.

4. Bento RF, Miniti A, Marone SAM. Tratado de Otologia. São Paulo, EDUSP, 1998. 5. Cushing H. Tumors of the nervus acusticus and the syndrome of cerebellopontine angle, Philadelphia, Saunders, edit., 1917. 6. Revilla AG (1948), apud Dykstra PC (1964). 7. Dykstra PC. The pathology of acoustic neuromas. In: House WF. Monograph- Transtemporal Bone Microsurgical Removal of Acoustic Neuromas. Arch Otolaryngol. 1964;80:751-2. 8. House WF. Transtemporal bone microsurgical removal of acoustic neuromas: report of cases. Arch. Otolaryngol. 1964;80:617-667. 9. Pulec JL, House W, Britton Jr BH, Hitselberger WE. - A system of management of acoustic neuroma based in 364 cases. Trans Am Acad Ophtalmol. Otolaryngol.; 1971;75:4855.

CONCLUSIONS 1) In nearly all cases, asymmetric sensorineural hearing loss is the first symptom of vestibular schwannoma. 2) Tumor size is not proportional to the extent of hearing threshold and speech discrimination involvement. 3) In this sample, magnetic resonance imaging was the modality of choice for definitive diagnosis. 4) The translabyrinthine approach was safe and resulted in few intraoperative or postoperative complications, all of which were managed, and can be used alone or as part of a combined approach to very large tumors. 5) All techniques employed in this series were safe with regard to preservation of facial nerve function. 6) The retrolabyrinthine approach was useful in small tumors, with 50% preserved hearing, and can be recommended in patients with good thresholds and word discrimination.

10. Schoemaker MJ, Swerdlow AJ, Ahlbom A, Auvinen A, Blaasaas K, Cardis E, Christensen HC, Feychting M, Hepworth SJ, Johansen C, Klaeboe L, Lonn S, Mc Kinney PA, Muir K, Raitanen J, Salminen T, Thomsen J, Tynes T. Mobile phone use and risk of acoustic neuroma: results of the interphone case-control study in five North European countries. BR J Cancer. 2005;93(7):842-8. 11. Takebayashi T, Akiba S, Kikuchi Y, Taki M, Wake K, Watanabe S, Yamaguchi N. Mobile phone use and acoustic neuroma risk in Japan. Occup Environ Med. 2006;63 (12):802-7. 12. Tato JM, Venturini N, Ganança M, Anicet A, AntoniCandela F, Linden A. Diagnóstico e tratamento do neurinoma do acústico. Rev Bras Otorrinolaringol. 1970; 36:107-117. 13. Souza OG, Inácio AA, Cabral FG, Carneiro FA, Nunes CA. Neurinoma do Acústico. Rev Bras Otorrinolaringol. 1974;40:157-161.

REFERENCES 1. Woellner RC, Schuknecht HF. Hearing loss from lesions of the cochlear nerve: an experimental and clinical study. Trans Am Acad Ophthalmol Otolaryngol. 1955;59 (2):1479. 2. Stewart TJ, Liland J, Schuknecht HF. Ocult schwannomas of the vestibular nerve . Arch. Otoloryngol. 1975;110(2):9195. 3. Sandifort E. Observationes anatomicae-pathologicae, vd Eryck P, Vygh D, Lugduni Batavorum 1777.

14. Souza OG, Santos SP, Inácio AA, Barbosa VC, Cabral FG. Otoneurocirurgia do meato acústico interno. Rev Bras Otorrinolaringol. 1974;38:200-206. 15. Souza NJA, Guimarães RES, Guimarães HA, Cadar A, Coelho CEC. Neurinoma do Acústico. Rev Bras Otorrinolaringol. 1976;42:35-37. 16. Bento RF, Caropreso CA, Miniti A. A via translabiríntica na cirurgia do neurinoma do acústico. Rev Bras Otorrinolaringol. 1989;55:57-63.

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17. Bento RF, Brito RV, Sanchez TG, Miniti A. The transmastoid retrolabyrinthine approach in vestibular schwannoma surgery. Otolaryngol Head Neck Surg. 2002;127 (5):437-41. 18. Souza OG, Siqueira JM. Conclusões e recomendações da 1a. Conferência Internacional de neuroma do acústico. Rev Bras Otorrinolaringol. 1992;58:257-259. 19. Sauvaget E, Kici S, Kania R, Herman P, Tran Ba Huy, P. Sudden Sensorioneural hearing loss as a revealing symptom of Vestibular Schwanoma. Acta Otolaryngol. 2005;125(6):592-5. 20. Linskey ME, Lunsford LD, Flickinger JC. Radiosurgery for acoustic neuromas: early experience. Neurosurgery 26:736-745, 1990

22. Ballance C (1907), apud House WF. Transtemporal bone microsurgical removal of acoustic neuromas: report of cases. Arch. Otolaryngol. 1964;80:617-667. 23. Panse D (1904), apud House WF. Transtemporal bone microsurgical removal of acoustic neuromas: report of cases. Arch. Otolaryngol. 1964;80:617-667. 24. Hitselberger WE, Pulec JL. Trigeminal nerve (posterior root) retrolabirintine, transtentorial, approach to the brainstein. Otolaryngol Head Neck Surg. 1991;104:130-131. 25. House JW, Brackmann DE. Facial nerve grading system. Otolaryngol. Head Neck Surg. 1985;93:146-147. 26. Yasargil MG. Legacy of microneurosurgery: memoirs, lessons, and axioms. Neurosurgery. 1999;45:1025-91.

21. Flickinger JC, Lunsford LD, Coffey RJ. Radiosurgery for acoustic neurinomas. Cancer. 1991;67:345-353.

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Int. Arch. Otorhinolaryngol. 2012;16(4):476-481. DOI: 10.7162/S1809-97772012000400008

Original Article

Cochlear implants: our experience and literature review Mariane Barreto Brandão Martins1, Francis Vinicius Fontes de Lima1, Ronaldo Carvalho Santos Júnior2, Arlete Cristina Granizo Santos3, Valéria Maria Prado Barreto4, Eduardo Passos Fiel de Jesus3. 1) Doctor. Specializing in Otolaryngology. 2) Doctor of Medicine (Otolaryngology), University of Sao Paulo. Head of the Department of Otorhinolaryngology, University Hospital, Faculty of Medicine, Federal University of Sergipe. 3) Otorhinolaryngologist. Teacher of the Residents of Otorhinolaryngology of the University Hospital of the Faculty of Medicine of the Federal University of Sergipe. 4) Master of Health Sciences, Federal University of Sergipe. Teacher of the Residents of Otorhinolaryngology of the University Hospital of the Faculty of Medicine of the Federal University of Sergipe. Institution:

Universidade Federal de Sergipe. Aracaju / SE – Brazil. Mailing address: Mariane Barreto Brandão Martins - Rua Deputado Antônio Torres, 699 - Condomínio Vila do Sol - Apto. 102A - Bairro: Pereira Lobo. Aracaju / SE - Brazil - Zip code: 49052-050 - Telephone: (+55 79) 9924-4118 / 3222-8388 - E-mail: mari.ane_martins@yahoo.com.br Article received in April 19, 2012. Article approved in July 31, 2012.

SUMMARY Introduction: Cochlear Implants are important for individuals with severe to profound bilateral sensorineural hearing loss. Objective: Evaluate the experience of cochlear implant center of Otorhinolaryngology through the analysis of records of 9 patients who underwent cochlear implant surgery. Methods: This is a retrospective study performed with the patients records. Number 0191.0.107.000-11 ethics committee approval. We evaluated gender, etiology, age at surgery, duration of deafness, classification of deafness, unilateral or bilateral surgery, intraoperative and postoperative neural response and impedance of the electrodes in intraoperative and preoperative tests and found those that counter-indicated surgery. Results: There were 6 pediatric and 3 adult patients. Four male and 5 female. Etiologies: maternal rubella, cytomegalovirus, ototoxicity, meningitis, and sudden deafness. The age at surgery and duration of deafness ranged from 2 – 46 years and 2 – 18 years, respectively. Seven patients were pre-lingual. All had profound bilateral PA. There were 7 bilateral implants. Intraoperative complications: hemorrhage. Complications after surgery: vertigo and internal device failure. In 7 patients the electrodes were implanted through. Telemetry showed satisfactory neural response and impedance. CT and MRI was performed in all patients. We found enlargement of the vestibular aqueduct in a patient and incudomalleolar malformation. Conclusion: The cochlear implant as a form of auditory rehabilitation is well established and spreading to different centers specialized in otoaudiology. Thus, the need for structured services and trained professionals in this type of procedure is clear. Keywords: cochlear implants; hearing loss; hearing loss, sensorineural.

INTRODUCTION

that is improving regularly, as well as with the growing experience of the surgeons.

The hearing deficiency is a pathology that interferes in several aspects of the emotional, psychological, social and intellectual life. So, to solve this problem is of basic importance for the good development of the communication and consequently of whose social inclusion it has.

The present study aims to assess the experience of the Service of Otorhinolaryngology of the University Hospital of the Federal University of Sergipe with patients who have undergone CI surgery.

METHOD Cochlear Implants (CI) are electronic devices that allow hearing rehabilitation of individuals with severe profound bilateral sensorineural hearing lossl1, that did not benefit with the use of individual appliances of resonant enlargement individual2. CIs stimulate electrically the fibers of the hearing nerve, substituting in partial for the function of the cochlea3. Worldwide, more than 120.000 patients were introduced with different types of implants, obtaining better results to each day4. These good results are attributed much to the technology of the appliance,

The study is a retrospective cohort study and it was carried out by means of information obtained through diaries of 9 patients who underwent CI surgery in the Service of Otorhinolaryngology of the University Hospital of the Federal University of Sergipe. The patients were analyzed by gender etiology, age at the time of surgery, duration of deafness, classification of the deafness, type of implant, joined surgery or bilateraly,

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22,25% 22,25%

Rubella Cytpmegalovirus Meningitis

11% Sudden Deafness 22,25%

Ototoxicity

22,25%

Figure 1. Etiology of hearing loss.

intra-operative complications, post-operative complications, impedance and neural answer from the electrodes to the intra-operative telemetry, evaluation audiological powdersimplants, preoperative radiological examinations and radiologic findings that were counter-indicated in the surgery.

RESULTS In our study, 9 patients who underwent CI surgery of implant cochlear, 6 were children and 3 were adults, 4 males and 5 females. The causes are outlined in Figure 1. The time of surgery and the duration of deafness varied with age from 2 to 46 years and from 2 to 18 years, respectively. Seven patients were classified like lingualdaily pay and 2 like lingual-powders. All presented with profound bilateral hearing loss, with the exception of a patient, who presented with profound severe hearing loss on the right. The CI used was the Nucleus Freedom in 8 of 9 patients, being that 5 had the Nucleus 5 speech processor of and 3 others had the Nucleus Freedon speech processor. Only one patient received the implant the implant cochlear of the type Sonata with speech processor Opus 1. In 2 of 9 patients, a straight electrodes bundle was used, since these patients had meningitis as the etiology of the deafness and so had the possibility of an ossified cochlea. A third patient also had a straight electrodes bundle when it was needed to carry out the exchange of the appliance for fault of the internal device. This decision was made considering the possibility of fibrosis and larger difficulty in the passage of the electrodes. In 7 of 9 patients, the implant was carried out bilaterally. As to intra-operative complications, we had hemorrhage in only 1 patient. The complications in the post-operative period are presented in Chart 2. Only 1 patient is presented, who after 2 months of the activation of the implant, faulty in an internal component of the appliance, presented to the realization of another surgical proceeding being necessary, with the

Chart 1. Characteristics of 9 evaluated patients. Characteristics of 9 Evaluated Patients N (%) Age in the IC surgery 2 years 1 (11.1%) 4 years 1 (11.1%) 5 years 2 (22.2%) 6 years 1 (11.1%) 9 years 1 (11.1%) 17 years 1 (11.1%) 20 years 1 (11.1%) 46 years 1 (11.1%) Sex Female 5 (55.5%) Male 4 (44.4%) Time of the hearing loss 1 year (lingual-powders) 1 (11.1%) 2 years (lingual-daily pay) 1 (11.1%) 4 years (lingual-daily pay) 1 (11.1%) 5 years (lingual-daily pay) 2 (22.2%) 6 years (lingual-daily pay) 1 (11.1%) 9 years (lingual-daily pay) 1 (11.1%) 13 years (lingual-powders) 1 (11.1%) 18 years (lingual-daily pay) 1 (11.1%) Time of use of the implant 1 month 4 (44.4%) 5 months 1 (11.1%) 7 months 1 (11.1%) 10 months 1 (11.1%) 20 months 1 (11.1%) 28 months 1 (11.1%) Introduced ear Ear R 1 (11.1%) Ear L 1 (11.1%) Both 7 (77.8%)

Chart 2. Complications surgical-powders of the patients wrapped in the work. Complications Classification of No. % of surgical-powders the complication of cases the total Dizziness Less 1 11.1% Fault of the device Bigger 1 11.1% Total 2 22.2%

Chart 3. Found in examinations of image (TC and RNM). When the CT and RNM found to No. of % of the cases the total Badly formation 1 11.1% Extended vestibular aqueduct 1 11.1% Total 2 22.2%

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Chart 4. Hearing discrimination of the first 5 operated patients. Hearing discrimination IPC: 2 years IPC: 5 years TPS: 2 years TPS: 5 years TI: 10 months TI: 7 months Monosyllabic X Dissyllabic X Syllables without sense Sentences Phonemes Word X

IPC: 9 years TPS: 9 years TI: 5 months -

IPC: 4 years TPS: 4 years TI:20 months X X -

IPC: 20 years TPS: 18 years TI:28 months X X X X

IPC: 9 years TPS: 9 years TI: 5 months X -

IPC: 4 years TPS: 4 years TI:20 months X -

IPC: 20 years TPS: 18 years TI: 28 months X -

-

-

Chart 6. Hearing skills of the first 5 operated patients. Hearing skills IPC: 2 years IPC: 5 years TPS: 2 years TPS: 5 years TI: 10 months TI: 7 months Attention X X Detection X X Location X X Discrimination X Recognition -

IPC: 9 years TPS: 9 years TI: 5 months X X X -

IPC: 4 years TPS: 4 years TI:20 months X X -

IPC: 20 years TPS: 18 years TI: 28 months X X X X -

Chart 7. Sounds of the Ling of the first 5 operated patients. Sounds of the Ling IPC: 2 years IPC: 5 years TPS: 2 years TPS: 5 years TI:10 months TI: 7 months /A/ X X /I/ X /U/ X X /S/ X /M/ X /Ć&#x2019;/ X

IPC: 9 years TPS: 9 years TI: 5 months X -

IPC: 4 years TPS: 4 years TI:20 months X X X X X X

IPC: 20 years TPS: 18 years TI:28 months X X X X X X

Chart 5. Categories of language in the first 5 patients. Categorias Linguagem IPC: 2 years IPC: 5 years TPS: 2 years TPS: 5 years TI:10 months TI: 7 months Not speak X X Emission of isolated words X Emission of simple sentences X Emission of complex sentences Fluent -

exchange of the component. The electrodes were introduced in the complete form in 7 of 9 patients, as soon as 2 had partial unilateral introduction. The telemetry was carried out intra-operatively one to assess the neural answer and the impedance of the introduced electrodes, and we had satisfactory results in both tests. The audiologicals evaluations after implantation are found in charts 4,5,6 and 7, exception of the last 4 patients who did the surgery of

-

implant were still not presenting sufficient time (1 month) for realization of this audiological evaluation, therefore, only the first 5 are shown in the charts. In the preoperative period, all patients underwent imaging examinations including CT and NMR, and in 1 was found enlargement of the vestibular aqueduct being an East, the patient in whom intraoperative hemorrhage occurred; however, they were not considered radiologically to counter-indicate the surgery.

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DISCUSSION In the completed inquiry, we analyzed 9 records of patients who had undergone CI surgery in the period from May 2009 to February 2012 encompassing the age group from 2 to 46 years of age, 4 males and 5 females, which contrasted with other international and national reports of male domininace in the number of implants masculine (5,6,7). This may be due to the low number of the sample overall. The diagnosis of the causes was diversified, 22.2% maternal German measles, 22.2% cytomegalovirus, 22.2% for ototoxicity, 22.2% meningitis, and 11.1% sudden deafness. This result also goes against the findings of other studies, which show etiology unknown as the main cause of sensorioneural deafness (8). The age at the time of surgery varied from 2 to 46 years, being that 6 of 9 patients had age varying from 2 to 9 years, a fact observed in other studies, where the surgery is carried out with greater frequency in children with deafness prelingual (8). Seven of 9 patients were classified as lingual-daily pay. The CIs used were Nucleus Freedom in 8 of 9 patients, and only 1 patient received the Sonata CI. In 2 of 9 patients, a straight electrodes bundle was used, since these patients had meningitis as an etiology of the deafness and so the possibility of a cochlea ossified providing bigger difficulty in the introduction of the bundle of electrodes. A third patient also did that I use the straight electrodes bundle when it needed to carry out the exchange of the appliance for fault of the internal device, this decision was taken thinking about the possibility of fibrosis, also making difficult the passage of the electrodes. In 7 of 9 patients, the implant was carried out bilaterally, which is a worldwide tendency, since it promotes a quicker hearing rehabilitation. The surgical complications can be classified as major when they require a new surgical approach or admission, and in juveniles even when the problem is resolved at the ambulatory level (19). A work carried out in Latin America encompassing 40 CI centers with a sample of 3,768 patients, presented a rate of 5.1% complications surgical-powders, being the spontaneous fault of the system to their principal (larger complication). Other studies of the same nature, had rates of major complications varying from 3 to 13.7% (10-13). In the present study, one patient (12.5 %) presented with complications due to the faulty internal component of the implant unilaterally, a major complication requiring a new surgical approach and another patient (12.5 %) presented with dizziness surgical-powders (minor complication). The patient candidates for the IC undergo an evaluation surgical-daily pay. In this evaluation, the imaging examinations including CT and NMR are carried out with the realization that they are of basic importance while making possible the identification of findings that

would counter-indicate the surgery, assiting in the choice of the ear being introduced, assessing appropriately the anatomy of the area to be explored during the surgery and, inside their limitations, allowing a previsualization of areas of potential complications (3). The conjugated use of the CT and NMR of the result in better agreement of the obtained information and help the surgeon intraoperatively. We performed CT and NMR in all the 9 patients and observed enlargement of the vestibular aqueduct in 1 patient and incudomalleolar malformation in another. These imaging findings were not thought to be of relevance for contra-indication of surgery (3). However, they are important in order that the surgeon has notion of the potential intra-operating problems that can take place. Our patient who had enlargement of the vestibular aqueduct had in an intra-operative gusher, which took the same thing developing dizziness in the post-operative one. The intra-operative telemetry serves to assess the neural answer, obtaining satisfactory results regarding this test. The telemetry of impedances must always be carried out before the neural answer telemetry in order to confirm the appropriate functioning of the receiver and of the stimulation and to check the existence of open circuit or short circuit in the electrodes in cochlears from the measure of the electric resistance of mesmos (14). The objective to the telemetry happening in the intra-operating one is that, depending on the alteration, the surgeon can try to solve the problem before the closure of the cavity, re-positioning the electrodes, or deciding to substitute them if the number of electrodes with impedacias altered is big. The electrodes of the implanted cochlears were introduced in the complete form in 7 of 9 patients, as soon as 2 had partial introduction unilaterally; however, the introduced electrodes had good results to the intra-operating telemetry, equally to that what were introduced in the total form. CI as treatment for hearing deficiency prelingual pay presents countless nuances. It is not simply to introduce surgically the appliance in the patient, and East was driven only by his device electronic (15). The implant cochlear is a process that wraps several stages: evaluation surgicaldaily pay, surgical act, and hearing rehabilitation. This rehabilitation is carried out by the professional of fonoaudiologia, what passes the informations to a medical otorhinolaryngologist of as the hearing development of the patients walks. Some factors influence the good development audiologico, I eat for example, the age in the moment of the surgery, the time of sensory deprivation, the time of use of the implant (16). We value also the hearing skills, the sounds of the ling, the hearing discrimination, and the categories of language at 5 of 9 patients. Four remaining patients carried out the surgery very recently and had not sufficient time to do this evaluation (Charts 4,5,6,7).

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The age in the surgery has been relevant in the results of the cochlear implant. Some studies showed what children introduced before 3 years of age reached quicker results regarding that what were operated in age more tardia (17,18). Up to 6 years of age there is completed the development of the oral language, being that from this age, in averse situations, like the hearing deficiency, progresses do not take place so easily. In our study, where approximately 66.7 % of the patients were below 9 years of age, good results were found regarding the analyzed categories: hearing skills, sounds of the ling, hearing discrimination, and categories of language.

difficulty in the evolution of the therapies when likened to others.

CONCLUSION The cochlear implant is the form of already consolidated hearing rehabilitation and it comes being spread in different specialized centers in otoaudiologia. In this form, there is obvious the necessity of structured and professional services enabled in this type of proceeding.

REFERENCES It is natural that with bigger time of use of the implant and with the maturing inherent in the age, the children present satisfactory performance in tests (19). Some authors think that there is necessary a time of use of the cochlear implant of approximately 2 years for the proof of his benefits in young children. In our study, we already observed good results as for the studied variables, even before completing hmm year of implant, showing this to be a quite efficient treatment. The time of hearing sensory deprivation influences the performance of when daily pay – linguais (20,21) was introduced. We analyze this factor influence and observe good results, showing that the less the deprivation time, better the performance of the patient in the evaluated tests. The patient who was introduced to 20 years of age and who was presenting time of sensory deprivation of 18 years, also had turned out to be satisfactory, what it contradicts what was said previously; however, this patient from always did therapy fonoaudiologica, it had a good lip reading and it was still doing use of appliance of individual resonant enlargement (AASI). Another patient with 17 years did the surgery in spite of presenting sensory deprivation for the past 13 years. The surgery was carried out, in spite of the patient was lingual-powders, since the same thing was presenting a discreet degeneration of the language. Further, we had in our work patient when it was introduced to 46 years of age that had a time of sensory deprivation of 1 year due to sudden deafness (lingual-powders). Meantime, we still have not an evaluation fonoaudiologica of these 2 last patients since the surgery was carried out recently. The children with deafness for cytomegalovírus present a more difficult evolution when compared with deaf children by others causes (22). In spite of the slowness in the progress of the hearing rehabilitation powders-implants, it does not make contra-indication to do the implant in these children. In our work, 2 children took the infection as a cause of the deafness for the cytomegalovírus and really they presented bigger

1. Luxford W, Brackmann D. The history of cochlear implantes. In: Gray R, ed. Cochlear implantes. San Diego: College Hill Press. 1985:10:1100-6. 2. Bevilacqua MC, Moret ALM, Costa Filho AO, Nascimento LT, Banhara MR. Implantes cocleares em crianças portadoras de deficiência auditiva decorrente de meningite. Braz J Otorhinolaryngol. 1994;60(4):1-16. 3. Lima Júnior LRP, Rocha MD, Walsb PV, Antunes CA, Calhau CMDF. Avaliação por imagem nos candidatos ao implante coclear: correlação radiológico-cirúrgica. Braz J Otorhinolaryngol. 2008;74(3):395-400. 4. Lima Júnior LRP, Rodrigues Júnior FA, Calhau CMDF, Calhau ACDF, Palhano CTP. Complicações pós-cirúrgicas em pacientes impantados no Programa de Implante Coclear do Rio Grande do Norte. Braz J Otorhinolaryngol. 2010;76(4):517-21. 5. Nóbrega, M. Deficiência auditiva na infância: a experiência do ambulatório de deficiência auditiva da UNIFESP/EPM. Anais do 170 Encontro Internacional de Audiologia. Bauru; 2002. 6. Reis DC. Saúde auditiva em João Pessoa. [mestrado]. São Paulo (SP): Pontifícia Universidade Católica de São Paulo; 2006. 7. Egeli E, Ciçekci G, Silan F, Oztürk O, Harputluoglu U, Onur A et al. Etiology of deafness at the Yeditepe school for the deaf in Istanbul. Int J Pediatr Otorhinolaryngol. 2003;67(5):467-71. 8. Calháu CMDF, Lima Júnior LRP, Reis AMCS, Capistrano AKB, Lima DVSP, Calháu ACDF et al. Perfil etiológico dos pacientes implantados do Programa de Implante Coclear. Braz J Otorhinolaryngol. 2011; 77(1):13-8. 9. Cohen NL, Hoffman RA. Complications of cochlear implant

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surgery in adults and children. Ann Otol Rhinol Laryngol. 1991; 100:708-11. 10. Dutt SN, Ray J, Hadjihannas E, Cooper H, Donalds I, Proops D. Medical and surgical complications of the second 100 adult cochlear implant patients in Birmingham. J Laryngol Otol. 1996. 11. Hoffman RA, Cohen NL - Complications of cochlear implant surgery. Ann Otol Rhinol Laryngol. 1995;166:420-2. 12. Collins MM, Hawthorne MH, el Hmd K. Cochlear implantation in a district general hospital: problems and complications in the first five years. J Laryngol Otol. 1997;111:325-32. 13. Aschendorff A, Marangos N, Laszig R. Complications and reimplantation. Adv Otorhinolaryngol. 1997;52:167-70. 14. Lai W. An NRT Cookbook: Guidelines for making NRT measurements. 1st ed. Zürich: Cochlear AG; 1999. 15. O’neill, C, O’donoghue GM, Archbold SM, Nikolopoulos TP, Sach T. Variations in gains in auditory performance from pediatric cochlear implantation. Otol Neurotol. 2002; 23(1):44-48.

17. Kirk KI, Miyamoto RT, Lento C L, Ying E, O’neill T, Fears B. Effects of age at implantation in young children. Ann Otol Rhinol Laryngol. 2002;111(5):69-73. 18. Baumgartner WD, Pok SM, Egelierler B, Franz P, Gstoettner W, Hamzavi J. The role of age in pediatric cochlear implantation. Int J Pediatr Otorhinolaryngol. 2002;62(3):22328. 19. Miyamoto RT, Houston DM, Kirk KI, Perdew AE, Svirsky MA. Language development in deaf infants following cochlear implantation. Acta Otolaryngol. 2003;123(2):24144. 20. Nicholas JG, Geers AE. Will they catch up? The role of age at cochlear implantation in the spoken language development of children with severe to profound hearing loss. J Speech Lang Hear Res. 2007;50(4):1048-62. 21. Flipsen P Jr, Colvard LG. Intelligibility of conversational speech produced by children with cochlear implants. J Commun Disord. 2006;39(2):93-108. 22. Ramirez IJM, Nikolopoulos TP. Cochlear Implantation in children deafened by cytomegalovirus: Speech perception and speech intelligibility outcomes. Otology & Neurotology. 2004;25(4):479-82.

16. Richter B, Eibele S, Laszig R, Löhle E. Receptive and expressive language skills of 106 children with a minimum of 2 years’experience in hearing with a cochlear implant. Int J Pediatr Otorhinolaryngol. 2002; 64(2):111-25.

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Int. Arch. Otorhinolaryngol. 2012;16(4):482-491. DOI: 10.7162/S1809-97772012000400009

Original Article

Limits on quality of life in communication after total laryngectomy Adriana Di Donato Chaves1, Leandro de Araújo Pernambuco2, Patrícia Maria Mendes Balata3, Veridiana da Silva Santos4, Leilane Maria de Lima5, Síntia Ribeiro de Souza6, Hilton Justino da Silva7. 1) 2) 3) 4) 5) 6) 7)

Doctor in course in Linguistics. Federal University of Paraíba - (Assistant Professor in Speech Therapy). Doctor in course in Public Health Federal University of Rio Grande do Norte - (Assistant Professor in Speech Therapy). Doctor in course in Neuropsychiatry and Behavioral Sciences Federal University of Pernambuco - (Speech Therapy). Master in Biometrics -Federal Rural University of Pernambuco - (Assistant Professor in Statistics). Speech Therapy. Federal University of Pernambuco - (Speech Therapy). Specialized Center in Speech Therapy - Redentor College - (Speech Therapy). PhD in Nutrition -. Federal University of Pernambuco - (Adjunct Professor 2).

Institution:

Universidade Federal de Pernambuco. Recife / PE – Brazil. Mailing address: Adriana Di Donato - Universidade Federal de Pernambuco/ Departamento de Fonoaudiologia - Rua Arthur de Sá, s/n - Cidade Universitária – Recife / PE - Brazil - Zip code: 50740-520 – Telephone: (+55 81) 2126-8927 - E-mail: adrianadidonato1@gmail.com MCT/CNPq/CT-Saúde/MS/SCTIE/DECIT nº 67/2009 - REBRATS Article received in April 24, 2012. Article approved in August 10, 2012.

SUMMARY Introduction: Among people affected by cancer, the impairment of quality of life of people affected by cancer can cause have devastating effects. The self-image of patients after post-laryngectomyzed patients may be find themselves compromised, affecting the quality of life in this population. Objective: To characterize quality of life in related to communication in people who have undergone went total laryngectomy surgery. Methods: This is an observational study, with a cross-sectional and descriptive series. Design of series study. The sample were comprised 15 patients interviewed the period from January to February of 2011. We used the Quality Protocol for Life Communication in Post-laryngectomy adapted from Bertocello (2004); which this questionnaire contains 55 questions. The protocol was organized from the nature of using responses classified as positive and negative aspects, proposals in with respect to five 5 communication domains: family relationships, social relationships, personal analysis; morphofunctional aspect, and use of writing. To promote and guarantee the autonomy of the respondents, was examiners made use of used assistive technology with the Visual Response Scale. Results: The responses that total laryngectomy compromises the quality of life in communication amounted to 463 occurrences (65.7%), and that who responses suggesting good quality of life were represented with amounted to 242 occurrences (34.3%), from a total of 705 occurrencesresponses. From Among the five 5 Communication domains, four 4 had percentages of above 63% for occurrences of negative content for impact on communication. Appearance Morphofunctional appearance gave the had the highest percentage of negative content, amounting to 77.3% of cases. Conclusions: The results showed important limitations of a personal and social nature due to poor communication with their peers. Thus, there is a need for multidisciplinary interventions that aim to minimize the entrapment of negative impact on these people communication among these patients. Keywords: quality of life; laryngectomy; communication; protocols.

INTRODUCTION For the year 2012, in Brazil, it is an expected 6,110 new cases of laryngeal cancer are expected, with an estimated risk of 6 cases per 100 000 individuals. The Laryngeal cancer is the sixth most frequent in the Northeast region (4/100 000). ), seventh in the South region (9/100 000) and North regions (2/100 000), occupies the seventh position; eighth in the Southeast region (8/100 000), eighth, and ninth in the Midwest region (5/100 000), the ninth (1) position. The Therapeutic procedures indicated for patients suffering from laryngeal cancer in advanced stages is the

total laryngectomy. Despite his statement efforts to be very careful, that is, and operate only when it has there is a high degree of infiltration and involvement (stages III and IV) (2-4), changes in chewing, deglutition, breathing, and speech (5) presents serious complications as in the patient’s life, particularly in interaction with their peers. The selfimage of laryngectomiyzed patients may be find themselves compromised, further affecting the quality of life in this population (6-7), and may also result in pain, postural changes, difficulty in performing daily tasks, and sleep disorders (2,8-12). The Communication is put effected into the society through various codes used by men individuals to express their views ,and to represent things, beings, and ideas;,

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and among them these codes, the most important is the language. Many authors describe the impact of communication and adaptation after laryngectomy in surviving patients with survival(13-17). The ability to communicate has a very strong association with improved quality of life (13-17). However, other studies do not have point to report the existence of a correlation between quality of life and speech (18). While there is no consensus on the concept of quality of life, three 3 fundamental aspects related to its construct nature were obtained through the work of a group of scholars from different cultures. They are (1) subjectivity, (2) multidimensionality, and (3) presence of positive dimensions (e.g.: mobility) and negative (e.g.: pain). The development of these elements led to the definition of quality of life as “”an individual’s perception of their position in life in the context of (the) culture and value system in which they live and in relation to their goals, expectations, standards and concerns”,” defined by the WHOQOL GROUP (19). The impairment of quality of life of people affected by cancer can cause devastating damage to entire families., This is especially true when the head of the family who is the provider of the only source of income gets sick, being the provider of the only source of income, as well as when one 1 parent is affected by the disease and children come to exercise have to care activities of the family, failing to take live their lives within according to the standards expected for their age (1). To this end, we applied the Protocol for the Evaluation of Communication Satisfaction of Patients after Total Laryngectomy adapted from Bertoncello (20) (Table 1), a validated instrument that measures the degree of satisfaction of the patient with his/her’s communication after total laryngectomy, and presents objective questions that facilitate the participant’s response. In order to post scenario, Communication difficulties permeate family, professional, and social relationships of a family, professional and social, uniquely affecting uniquely the quality of life of these subject’s patients (20). This article aims to evaluate the satisfaction of communication and its relationship to quality of life in patients after total laryngectomyzed.

METHOD This is an observational study, with a cross-sectional descriptive. Design of series study. This study is part of the research entitled “”Quality of life and its relations with the use of diagnostic technologies in human

communication disorders in rural workers who underwent total laryngectomy,” ,” Call MCT/CNPq/Health-CT/MS/ SCTIE/DECIT nº. 67/2009 - REBRATS, with approval by the Ethics Committee in Research of Pernambuco Society for Fighting Cancer/Cancer Hospital of Pernambuco, nº. 67/2010. We adopted the following profile of volunteers to participate in the study: (a) Inclusion criteria were as follows: an aged between 40 and 75 years; both sexes; who underwent surgery for total laryngectomy with or without neck dissection; at least 45 days; adjuvant radiotherapy; being serviced at the Speech Pathology (SEFON) Department of Head and Neck (DCCP) from the present hospital; and signature on the Instrument of Consent (TCLE).; (b) Exclusion criteria criteria were as follows: previous head and neck surgery; hold another type of laryngectomy, or tracheotomy prior to total laryngectomy; alternative route of feeding way prior to total laryngectomy or present at the time of application of the protocol, ; patients who underwent history of postoperative complications (pharyngocutaneous phystula, dehiscence, and tissue necrosis); previous frame of difficulty in understanding simple commands or neurological/neuromuscular/neurodegenerative disease, ; and individuals who refuse to participate on in the study. Data were collected and applied on a chip containing participant personal data items relating name, age, gender (male/female), schooling, and occupational status functional (active and retired). On the basis of the schooling, topic the participants were organized into four 4 groups: (illiterate; 1 to 4 years of schooling; 5 to 8 years of schooling; and 9 to 11 years of schooling). Here goes for clarification regarding the adoption of the schooling classification criteria. From the Federal Resolution no. 4 of 07.13.2010 (21), which stablisheds the National General Curriculum Guidelines for Basic Education, and made 9 years of primary education it became compulsory primary education with nine years. However, we chose to keep the schooling calculations given on eight years of compulsory education, considering that the our research sample was composed of adults and elderly, who would have been schooled so when the previous regime statute still in force with eight years of schooling was still in force. All patients were in had adapted of an esophageal speech process, since because the service of this hospital does not offer the traqueosophagic or electronic larynx prosthesis. The research population belonged to lowincome groups and generally therefore also has had no own spare resources for acquiring them prostheses on their own. Subsequently, we applied the Protocol for the

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Table 1. Functional assessment of communication with patients after total laryngectomy. Adapted from Bertoncello (2004). Issues

1. 2. 3. 4. 5.

Commu- Not at nication all true domains score n (%)

Before surgery my way of speaking was easy to understand My way of speaking interferes with my work My way of speaking interferes in the relationship with my family My way of speaking interferes with the interaction with others I stopped attending parties (social gatherings) because of embarrassment caused by my manner of speaking 6. When I go out I choose less crowded streets to not find known people 7. My friends stopped coming to my house because of my difficulty speaking 8. I do not answer people when they ring my doorbell 9. I do not answer the phone due to my way of talking 10. My way of speaking requires a greater respiratory effort 11. My way of speaking requires greater effort 12. My way of speaking requires greater motivation 13. Talk me pain 14. Talking causes me pain 15. I have to make effort to talk 16. Some people have trouble in understanding me 17. Most of people have trouble in understanding me 18. It seems that people are bothered with my way of talking 19. My way of speaking embarrasses me 20. I get annoyed when people ask me to repeat what I said 21. My speech is the same after surgery 22. I have difficulty in speaking some words 23. I can be understood in a telephone conversation 24. Only my familyFamily can understand me 25. Only one person in the family understands me and she always helps me to explain my speech to the others 26. There are some people in my family that do not talk to me because they do not understand my speech 27. My family has no patience with me because of my speech 28. People finish the conversation with me when they do not understand what I say 29. People pretend that they understood what I said 30. Only my friends can understand me 31. I need someone to explain (translate) my speech because other people do not understand me 32. I cannot be understood by anyone 33. I cannot be understood by anyone so I use the writing 34. My speech is always understood 35. My speech most of the time is comprehensive, there is a need for repetition 36. My speech is usually understandable, but does not require theface to face contact 37. My speech is usually understandable, but it is not necessary to write some words for people to fully understand me 38. My speech is difficult to be understood 39. I get annoyed when people do not understand my speech 40. My speech is never understood, I have to use written communication 41. I find it difficult to produce certain types of sounds

Somewhat true score n (%)

RS RS RF RS

2 (13.3%) NA 3 (20%) 3 (20%)

3 (20%) NA 1 (6.7%) -

RS

6 (40%)

AP

9 (60%)

More true score n (%)

Very true score n (%)

Very much true score n (%)

Total

1 (6.7%) 1 (6.7%) 8 (53.3%) 2 (13.3%) NA 1 (6.6%) 3 (20%) 3 (20%) 5 (33.3%) 4 (26.7%) 4 (26.7%) 4 (26.7%)

15 3 15 15

-

1 (6.7%)

1 (6.7%)

7 (46.7%)

15

1 (6.7%)

-

-

5 (33.3%)

15

3 (20%) 3 (20%) 1 (6.7%) 4 (26.7%) 1 (6.7%) 2 (13.3%) 3 (20%) 3 (20%) 2 (13.3%) 2 (13.3%)

2 (13.3%) 1 (6.7%) 4 (26.7%) 4 (26.7%) 4 (26.7%) 1 (6.7%) 3 (20%) 1 (6.7%) 2 (13.3%) 5 (33.3%) 2 (13.3%) 2 (13.3%) 3 (20%) 3 (20%) 3 (20%) 4 (26.7%)

3 (20%) 8 (53.3%) 12 (80%) 11 (73.3%) 11 (73.3%) 7 (46.7%) 3 (20%) 3 (20%) 8 (53.3%) 9 (60%) 9 (60%) 3 (20%) 3 (20%) 2 (13.3%) 2 (13.3%) 10(66.7%) 4 (26.7%)

15 15 15 15 15 15 15 14 15 15 15 15 13 15 15 15 15 15

3 (20%)

4 (26.7%)

3 (20%)

15

2 (13.3%) 2 (13.3%) 3 (20%)

9 (60%) 3 (20%)

15 15

AP AP AP AM AP AP AM AM AM RS RS RS AP AP AM AM RS RF

6 (40%) 1 (6.7%) 5 (33.3%) 1 (6.7%) 3 (20%) 1 (6.7%) 9 ( 60%) 1 (6.7%) 4 (26.7%) 2 (13.3%) 3 (20%) 1 (6.7%) 1 (6.7%) 1 (6.7%) 5 (33.3%) 2 (13.3%) 5 (33.3%) 7 (46.7%) 1 (6.7%) 12 (80%) 1 (6.7%) 1 (6.7%) 1 (6.7%) 9 (60%) 3 (20%) 3 (20%) 2 (13.3%)

RF

5 (33.3%)

-

RF RF

2 (13.3%) 9 (60%)

-

RS AP RS

4 (26.7%) 1 (6.7%) 9 (60%)

1 (6.7%) -

AP AP EU AP

3 (20%) 10 (66.7%) 1 (6.7%) 6 (40%) 3 (20%) 1 (6.7%) 5(33.3%)

4 (26.7%) 1 (6.7%) 6 (40%) 3 (20%) 3 (30%) 7 ( 46.7%) 3 (20%) 2 (13.3%) 1 (6.7%) 3 (20%) 3 (20%) 6 (40%)

15 15 15

1 (6.7%) 8 (53.3%) 1 (6.7%) 3 (20%) 3 (20%) 2 (13.3%) 1 (6.7%)

15 15 15 15

2 (13.3%) 7 (46.7%) 5 (33.3%)

15

AP

1 (6.7%)

-

AP

8 (53.3%)

1 (6.7%)

3 (20%)

AM AP AP

6 (40%) 2 (13.3%) 4 (26.7%)

-

3 (20%) 3 (20%) 6 (40%)

5 (33.3%) 1 (6.7%) 3 (20%) 7 (46.7%) 2 (13.3%) 3 (20%)

15 15 15

AM AM

9 (60%) 1 (6.7%)

1 (6.7%) -

2 (13.3%) 1 (6.7%)

1 (6.7%) 2 (13.3%) 3 (20%) 10 (66.7%)

15 15

-

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3 (20%)

15


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Cont. Table 1. Functional assessment of communication with patients after total laryngectomy. Adapted from Bertoncello (2004). Issues Commu- Not at Somewhat More Very Very much Total nication all true true true true true domains score score score score score n (%) n (%) n (%) n (%) n (%) 42. I can sing AM 10 (66.7%) 2(13.3%) 2 (13.3%) 1 (6.7%) 15 43. I can change my tone of voice AM 9 (60%) 3 (20%) 2 (13.3%) 1 (6.7%) 15 44. I am able to hold long conversations with people AP 4 (26.7%) 3 (20%) 2 (13.3%) 1 (6.7%) 5 (33.3%) 15 45. I find it difficult to maintain long conversations with people AP 5 (33.3%) 1 (6.7%) 4 (26.7%) 5 (33.3%) 15 46. My communication got worse after surgery AP 2 (13.3%) 1 (6.7%) 3 (20%) 9 (60%) 15 47. My communication improved after surgery AP 9 (60%) 3 (20%) 2 (13.3%) 1 (6.7%) 15 48. After surgery I stopped expressing my ideas because of the difficulty of talking AM 2 (13.3%) 1 (6.7%) 3 (20%) 9 (60%) 15 49. I can speak to family members on the phone RF 12 (80%) 1 (6.7%) 2 (13.3%) 15 50. I can talk to friends on the phone RF 12 (80%) 1 (6.7%) 2 (13.3%) 15 51. I can talk to strangers on the phone RS 12 (80%) 1 (6.7%) 2 (13.3%) 15 52. I can normally use my voice to communicate in social situations RS 6 (40%) 2 (13.3%) 1 (6.7%) 6 (40%) 15 53. I can normally use my voice to communicate at work RS NA NA 2 (13.3%) 1 (6.6%) NA 3 54. People realize that I speak differently AP 1 (6.7%) 14 (93.3%) 15 55. When I speak people look at me differently AP 3 (20%) 2 (13.3%) 2 (13.3%) 8 (53.3%) 15

Evaluation of Communication Satisfaction of Patients after Total Laryngectomy adapted from Bertoncello (20) (Table 1). The adapted instrument for this study consists of fifty five55 specific items for functional communication evaluation with highly satisfactory reliability indices. Has Each has 5five possible answers: (1) not at all true, (2) somewhat true, (3) more true, (4) very true, and (5) very much true. For analysis purposes, we chose to organize the 55 questions from the Bertoncello protocol (20) in five 5 communication domains (Table 2): (1) Family Relationship, (2) Social Relationship, (3) Staff Analysis, (4) Morphofunctional Appearance, and (5) Writing Use. The original numbering of the Protocol was maintained. The protocol used has the peculiarity to of providing responses that may indicate positive and negative characteristics traits from the five 5 possible answers. To optimize the responses, analysis in each domain was rated on positive and negative aspects. All participants were treated in the SEFON of the hospital, a reference institution center for oncology treatment in the North and Northeast of Brazil. In SEFON, the patients receive speech therapy before and after surgery to and orientation and rehabilitation of chewing, deglutition, and voice functions. Fifteen individuals postwho underwent laryngectomy participated voluntarily at in this study., The study population included two 2 females women (13.3%) and thirteen 13 males men (86.6%), aged between 47 and 73 years with a mean age

of 62.8 years. The collected surveys were performed from January to February 2011. Considering the profile for research participants who were illiterate or poorly schooling, we chose to read the protocol by the researcher, where and the participant would only choose one answer for each question presented; giving also the patients the option of reading the protocol by themselves. To obtain more reliable answers produced by the participant, and considering that the public profile of the research presents difficulties in speech production due to laryngectomy, we designed a feature assistive technology: the Visual Response Scale. Depending on The Technical Assistance Committee, at the ATAâ&#x20AC;&#x2122;s Seventh Meeting of the Committee on Technical Assistance, Special Secretariat for Human Rights (22) stated as follows: Assistive technology is an area of knowledge, of interdisciplinary character, which includes products, resources, methodologies, strategies, practices, and services that aim to promote the functionality, related to the activity and participation of people with disabilities, incapacities or reduced mobility, seeking autonomy independence, quality of life and social inclusion. (BRAZIL, 2007). The instrument contained in staggered columns with a single color (blue), where each column had a lighter tone subsequent number of responses related to the protocol. The participant indicates the desired response,

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Table 2. Functional assessment of communication in patients post-after total -laryngectomy. Adapted from Bertoncello (2004): positive and negative aspects. Communication Domain Matter Relating Positive Aspect (+) Negative Aspect (-) Family Relationship (RF) 49, 50 3, 24, 25, 26, 27 Social Relationship (RS) 1, 23, 28, 51-â&#x20AC;&#x201C;53 2, 4, 5, 16, 17,18, 30, Self Analysis (AP) 34, 35, 36, 47 6, 7, 8, 9, 11, 12, 19, 20, 29, 31, 32, 38, 39, 44, 45, 46, 54, 55 Morphofunctional aspects (AM) 21, 41, 42, 43 10, 13, 14, 15, 22, 48 Writing Use (UE) 37 33, 40

Table 3. Profile of research of participants research. Name Gender Age Schooling Male Female Illiterate 1 to 4 years 5 to 8 years 9 to 11 years PAC 1 1 68 1 PAC 2 1 65 1 PAC 3 1 57 1 PAC 4 1 61 1 PAC 5 1 56 1 PAC 6 1 86 1 PAC 7 1 58 1 PAC 8 1 70 1 PAC 9 1 63 1 PAC 10 1 70 1 PAC 11 1 57 1 PAC 12 1 58 1 PAC 13 1 47 1 PAC 14 1 57 1 PAC 15 1 73 1 * TOTAL 13 2 62,8 3 11 1 0 (%) (86,7) (13,3) (20%) (73,3%) (6,7%) OBS: *These data refer to the mean age of participants.

Active 1 1

1

3 (20%)

12 (80%)

relating the column size and color depth to the order of their responses. Please note that appeal was presented to the participant, however, used only with the concurrence of the same. All caregivers were instructed to wait for the response of the participant, allowing the subject patient himself to answer autonomously themselves.

among the participants, 86.7% are were male and 13.3% were female, with a mean age of 62.8 years. There is was prevalence of low schooling, totaling (93.3%), considering the illiterate subjects and from those with 1 to 4 years of schooling. Of the respondents, 3 (20%) are in were working activity and 12 (80%) are were retired.

The average time of the protocol application was forty 40 minutes. The analysis was performed using descriptive statistics, using a simple frequency and average due to the qualitative profile of the study.

Of the possible 825 events, 798 were recorded. The questions no. 2 and no. 53 were related to the work, thus twelve participants did not answer. One participant did not answer the question no. 14, and two non answered question no. 19.

RESULTS

The responses collected from the fifteen 15 participants are were organized from three perspectives (Table 4): (a) the five types of responses (Not at all true, Little True, More True, Very True, and Very Much True), (b) the Communication Domain (Family Relationship, Social

The scenario presented in building the profile of participants can be seen in Table 3, relating gender, age, schooling, and job function. Contains the following data

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Table 4. Results of the answers as to Communication Domain in its positive and negative aspects. Communication Domain NPV PV MV BV + + + + Family Relationship 24 22 3 3 1 10 1 16 Social Relationship 29 29 7 3 5 19 6 17 Self Analysise 19 70 9 10 11 34 11 36 Morphofunctional aspect 31 19 6 5 8 4 18 Writing use 6 15 4 3 2 5 4 Total 109 155 22 25 20 73 27 91

MTV + 4 16 10 4 1 35

24 40 118 54 5 241

Total 105 171 328 149 45 798

Subtitles: NPV, – not at all true; PV, – a little true; MV, – true; BV, – very true; MTV, – very much true. (+) Positive aspect, (“) Negative aspect.

Table 5. General framework reflecting good and poor quality of life (QOL) from the responses obtained in 705 instances of positive and negative aspects. Communication Domain Responses Thatreflect Responses Thatreflect Total Good Qv Bad Poor Qv occurrences (AN)NPV/PV (AP)BV/MTV (AP) NPV/PV (AN)BV/MTV Family Relationship 25 (25,8%) 5 (5,2%) 27 (27,8%) 40 (41,2%) 97 (100%) Social Relationship 32 (21,7%) 22 (15%) 36 (24,5%) 57 (38,8%) 147 (100%) Self Analysise 80 (28,3%) 21 (7,4%) 28 (9,9%) 154 (54,4) 283 (100%) Morphofunctional aspect 24 (17%) 8 (5,7%) 37 (26,2%) 72 (51,1%) 141 (100%) Writing use 19 (47,5%) 6 (15%) 6 (15%) 9 (22,5%) 40 (100%) Total 180 (25,4%) 62 (8,8%) 134 (18,9%) 332 (46,9%) 708 (100%) General Total 242 (34,2%) 466 (65,8%) Subtitles: QOL, – quality of life; AN, – negative aspect; AP, – positive aspect; NPV, – not at all true; PV, – a little true; BV, – very true; MTV, – very much true.

Relationship, Personnel Analysis, Appearance Morphofunctional Appearance, and Writing Use), and (c) the positive and negative aspects of each domains.

Morphofunctional item, and 40 occurrences for the Writing Use Item.

The overall picture (Table 5) reflects the responses of participants considering which would point to a good communication quality of life and which would point to a poor quality of life in communication, from the number of occurrences in each of the Communication domains, categorizing them into two groups: the more negative responses, like, “not at all true “ (NPV) and “somewhat true” (PV); and, the most positive, like, “very true” (BV) and “very much true” (MTV). Ninety-three responses such as “very much true” (MV) had a total of 93 occurrences and were discarded for this analysis to position themselves in a intermediary categorization proposed by the protocol Bertoncello (2004), aiming for greater objectivity. Thus, instances of the analysis are added to 705 responses were analyzed.

The results of each items of Communication Domains in relation to responses that point to indicate a good quality of life in communication (BGQVC) and those that who suggest poor quality of life in communication (MPQVC) were as follows: Family relationship item: - BQVC GQVC, with 30 occurrences (31.9%) and MQVC PQVC, with 64 occurrences (68.1%); Social Relationship item: - BGQVC, with 54 occurrences (36.7%) and MPQVC, with 93 occurrences (63.3%); Staff Analysis item: - BGQVC, with 101 occurrences (35.7%) and MPQVC, with 182 (64.3%); Morphofunctional Appearance item: - BGQVC, with 32 occurrences (22.7%) and MPQVC, with 109 (77.3%); Writing Use Item: - BQVCGQVC, with 25 occurrences (62.5%) and MQVCPQVC, with 15 (37.5%). Computed responses suggest show that our findings is of BQVCGQVC of have 242 occurrences (34.3%) and those that suggest of MQVCPQVC, have 463 occurrences (65.7%).

Of the 705 events (Table 5) present at the end of the protocol application adapted from Bertoncello (20), there were 97 cases for the Family Relationship domain, 147 to for the Social Relationship domain, 283 instances for the Personal Analysis item, 141 cases for the Appearance

DISCUSSION The protocol adopted (20) consists of direct questions

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and easily understood by participants;, however, we analyzed the need for greater autonomy in the production of responses by subjects. Although not shown, it is common to caregivers or companions of people after who have undergone total laryngectomy generally take for them the word of speak for the patients, by because of the own nature of the communication disorder. In While analyzing the profiles of respondents (Table 3), even considering the relatively small sample size (fifteen 15 members), total laryngectomy there were was more frequent in males (86.7%) than in females (13.3%). This finding agrees with the literature on laryngeal cancer, which occurrs predominantly in males, as well as does the age of the study sample, which shows variation between 50 and 70 years (3,23-24). According to the INCA in 2012 (1), it is not recommended to estimate the cancer in women in 2012 is not recommended due to its low magnitude incidence. The schooling of the sample was characterized as low (93.3%), adding to consider the illiterate (20%) and those who attended between 1 and 4 years of formal education (73.3%). This is a common fact finding among low-income people in the Brazilian reality. Only one 1 participant reported having schooling between 5 and 8 years (6.7%) and none between 9 and 11 years. The profile of laryngectomized participants with a low schooling level of this research sample was also found in other studies (20,25-26). Thus, the schooling of the participants could interfere in the production provision of answers as this type of activity, because these participants are not familiar with the questionnaire is not very familiar in their daily lives. However, a questionnaires answered by the patients themselves as is a resource commonly used tool for assessing the quality of life (24). When we proposed the use of an assistive technology with the Visual Response Scale was used, we observed that this instrument helped to safety in facilitated the responses of participants who opted for it. Sometimes, the verbal response was associated with the use of the instrument, reflecting the need to of the respondentâ&#x20AC;&#x2122;s to ensure understanding of by the evaluator, since it was someone outside of their immediate communication. This behavior suggests the uncertainty of the respondents in the use of verbal communication in new situations, on the part of respondents. However, it should not fail to consider the artificiality of communication involved in the use of a questionnaire implementation of as an instrument of evaluation should also be considered. Even if the evaluator seeks to perform

the activity with the greatest possible comfort for the participant, the circumstances of impartiality can not be disregarded. Importantly, to point out that all volunteers have demonstrated desire and devotion in the active participation of in the research. Of the three subjects patients who that met the functional occupancy (20%), all are were male and are aged between 58 and 68 years. The total number of retirees consisteds of twelve subjects participants (80%) with aged between 47 and 73 years;, seven men and two women (60%) have had a lower age for retirement, age being a total of 60%. Thus, it is anticipated since the time of retirement is due to the onset of cancer. Of respondents who were working, all claimed that their voice can could be understood, even partially, in question 53. In the discussion in relation to regarding gender, the two women in the study have had undergone schooling between 1 and 4 years, are were retired, and their responses indicated greater impairment in communication, corroborating the findings by Gomes (17). For developing a closer look, the Table 5 shows the occurrences on the Communications domains organized into two groups for the two responses that the said dispute, or type responses Not at all true (NPV) and little true (PV) and two 2 more to confirm the saying, and they very true (BV) and very much true (MTV). The intermediate response More True (MV) was discarded to had provide balance in relation to nature of the responses. With this table, we seek to sharpen the look at more clearly outline the relationship that formed between the quality of responses and their relationship to the quality of life of this research population. Writing use is presented as an alternative communication method, used but not necessarily desired, as soon as there is the implication of failure case of verbal communication failed. In question 37, which talks about discussed not using writing as a means to make himself oneself understood, a balanced was a result of the response was obtained, where with six subjects said they disagreeing, six agreeing, with said and three opting for an intermediate response, More True (MV). These results, an apparently positive writing use item, reflected in 62.5%, still must be balanced, taking into account the low schooling level, so either do not make use of writing, or they use it of restricted mode. The Family Relationship item was the second of more negative (69%) item, after the morphofunctional aspect item (77.3%), according to protocol data. Patients may have had some difficulties while answering issues related to the Family Relationship item may have had

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some degree of difficulty to be answered, since family members often play the role of accompanying the patient. Still, the high rate of responses that indicate difficulties of family interaction can be illustrated by the question 03, which states that the respondent’s way of speaking interferes with family relationships; where eight subjects (53.3%) confirmed the said with the two more affirmative responses and three did so with an intermediate responses, totaling eleven replies indicating full or partial agreement (73.3%). This is a group composed consisted of 80% of retirees, so the family life becomes more intense and in view of the participants, the communication aspect is strongly marked in a negative way. Although the profile of the study population to provided users of esophageal speech, Bertoncello (2004, p.86) describes research, as in Carr et al [2000], where the subjects, even varying the type of oral rehabilitation, present commitments in relation to quality of life in communication. The morphofunctional aspect stands out for its highest incidence in relation to others. Some data that follow illustrate and may serve as a tipping point for both the speech therapist, as and for related areas. It can be seen that 66.7% of patients responded positively to the items of discomfort and greater effort (question 15 and 16);. Although not being the majority, 33.3% of patients had pain when speaking, because it and this could be controlled. There was a greater negative impact on all questions relating to the act of singing (question 42, - 80%), change the in voice tone (question 43, to 86.6%), and send producing some speech sounds (question 22, - 80%). Faced with this panorama this wide variety of conditions, it may be possible to suggest treated by multidisciplinary interventions that will minimize it. Talking on the phone was characterized as an indicative outline of the difficulties presented in the communication interaction of people post-who had undergone laryngectomyzed, with family, friends, or strangers (80% of respondents as “”very true” “ for each group). In Brazil, more than fixed telephony, mobile telephony is more prevalent than fixed telephon Brazil is among the technologies available today, getting to have with more lines of cell phone lines, than the number of people in over twenty Brazilian states (27). While talking on the phone is an activity common to most of the Brazilians, for patients post-who have undergone laryngectomy people this activity involves great difficulty practice presents itself as an element of great disorder. Regarding the Social Relationship domain, the question 17 portrays the negative impact on dealing with the others, where fourteen (93.3%, adding to MTV and BV)

of respondents said that most people have difficulty in understanding them. In this study, the following limits can be highlighted as relevant to communication quality of life in patients surviving after laryngectomy survival: great difficulty in verbal interaction with family, friends, and strangers; friends move away become distant; the phone is a feature that worsens the communicative situation; annoyance when it is not understood; physical discomfort when speaking; and finally, failure to express their ideas. For people who have left are able still to express their ideas, participation in this study may had have represented a listening moment. Professionals and families to reflect on this data, can show how they are emotional and social interaction committed, and the urgency of changes in a difficult reality experienced by this group. Perhaps, the participation of post-laryngectomy patients has provided its own subject reflection on condition to a right of communication.

CONCLUSION The adapted Protocol Assessment of Communication Satisfaction of Patients after Total Laryngectomy (21) was relevant to the objective of this research objectives, allowing it to have providing an overview of the communication quality of life of those who have undergone went total laryngectomy and presenting, as a consequence , changes in your previous standards of communicative functioning. The Visual Response Scale, such provided as assistive technology, proved to be a facilitator, contributing to an inclusive stance against the persons subjected to undergoing total laryngectomy. The role of speech therapy interventions pervades these areas of speech communication. From Among the techniques used, all have favorable and unfavorable aspects. Taking into account various factors, however, none of them allowed a satisfactory level of excellence. It will consider wish the individual, since there is need to develop new learning and skills to be involved by the same, which require flexibility and adaptation, and they can not always reach them (28). Concern about the quality of life refers to a movement in the human and biological sciences in appreciating broader parameters that controls symptoms, decreased mortality, and increased life expectancy (25). Quality of life can be a very subjective concept, but subjectivity can not be an impediment to be for enhanced techniques, since this could lead to stagnation of this type of research (28,29).

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Language permeates all these domains that make constitute the quality of life, and through it the human relations are established through language (26). After laryngectomy, Where once there was a guy person with fluent and independent discourse, is to present a scenario of experience linguistic isolation and silence; imposed on himself in the person also faces of negative attitudes, subjective or explicit, their from social peers. Social relations from a non-standard communication results in changes in the behavior of some patients. The norm centrism imposed by the different models of truth, implies paradigms breaking in the context of their own health professionals. Therefore, the stigma of normality reported by Larrosa and Skliar (30) expelled discursive spaces of various groups, among them laryngectomyzed people.

5. Furia CLB. Reabilitação fonoaudiológica nas ressecções de boca e faringe. In: Carrara de Angelis E, Furia CLB, Mourão LF, Kowalski LP. A atuação fonoaudiológica no câncer de cabeça e pescoço. São Paulo: Lovise, 2000. p. 209-19

Knowledge with more properly the questions about of these changes that bring them in produce social limitations, could be a force arm the people submitted to individuals who have undergone total laryngectomy, compared to deal with managers of public politics, allowing more focused on promoting health communication actions.

8. Miller EH, Quinn AI. Dental considerations in the management of head and neck cancer patients. Otolaryngol Clin North Am. 2006;39(2):319-29.

The expansion of this sector of studies favors the demystification of a non-standard human communication, from a multiprophessional intervention, promoting rehabilitation, recovery, or even resetting establishment of new goals near to this for post-laryngectomyzed, with quality of life.

6. Amar A, Rapoport A, Franzi AS, Bisordi C, Lehn CN. Qualidade de vida e prognóstico nos carcinomas epidermóides de cabeça e pescoço. Rev Bras de Otorrinolaringol. 2002;68(3):parte 1. 7. Katz MR, Irish JC, Devins GM, Rodin GM, Gullane PJ. Psychosocial adjustment in head and neck cancer: the impact of disfigurement, gender and social support. Head and Neck, Feb. 2003.

9. Sawada NO, Dias AM, Zago MMF. O efeito da radioterapia sobre a qualidade de vida dos pacientes com câncer de cabeça e pescoço. Rev Bras de Cancerol. 2006;52(4):32329. 10. Mozzini CB, Schuster RC, Mozzini AR. O esvaziamento cervical e o papel da fisioterapia na sua reabilitação. Rev Bras de Cancerol. 2007;53(1):55-61. 11. Salomão CHD, Melo AS, Carvalho EC. Incertezas do paciente a ser submetido à cirurgia de laringectomia total. Rev Enferm UFPE. 2008;2(1):55-60.

THANKS To REBRANTS/CNPq, the Electromyography Laboratory of the Graduate Program in Pathology, UFPE, and the Cancer Hospital of Pernambuco.

12. Barrichello E. Distúrbios no padrão do sono em pacientes submetidos à cirurgia oncológica. São Paulo, 2008, p. 114 (Tese de Doutorado - Escola de Enfermagem de Ribeirão Preto. Universidade de São Paulo).

REFERENCES 1. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA) /Ministério da Saúde (MS). Estimativa 2012: incidência de câncer no Brasil– Rio de Janeiro: Inca, 2011.

13. Biazevic MG, Antunes JL, Togni J, Carvalho MB. Immediate impact of a primary surgery on health-related quality of life of hospitalized patients with oral and oropharyngeal cancer. J. Oral Maxilofac. Surg. 2008;66(7):1343-50.

2. Hannickel S, Zago MMF, Barbeira CBS, Sawada NO. O comportamento dos laringectomizados frente à imagem corporal. Rev Bras de Cancerol. 2002;48(3):333-39.

14. Barros BPA, Angelis CE, Lourenço CTM et al. Qualidade de vida, depressão e hipertireoidismo após laringectomia total. Rev Bras Cir Cabeça Pescoço. 2006;35(1):26-31.

3. Silva LSL, Pinto MH, Zago MMF. Assistência de enfermagem ao laringectomizado no período pós-operatório. Rev Bras de Cancerol. 2002;48(2):213-11.

15. Barros BPA, Portas, GJ Queija SD. Implicações da traqueostomia na comunicação e na deglutição. Rev Bras Cir Cabeça Pescoço. 2009;8(3):202-207.

4. Freitas TA, Lynch CS, Silva HMM. Câncer de laringe e fonoaudiologia. Rev Lato & Sensu, Belém. 2003;4(1):35.

16. Akduman D, Karaman M, Uslu C et al. Larynnx câncer treatment results: survive and quality of life assessment. Kulak Burun Boagaz Ihtis Derg. 2010;20(1):25-32.

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17. Gomes TABF, Rodrigues FM. Qualidade de vida do laringectomizado traqueostomizado. Rev Bras Cir de Cabeça e Pescoço. 2010;39(3):199-205. 18. Paula FC, Gama RR. Avaliação de qualidade de vida em laringectomizados totais. Rev Bras Cir de Cabeça e Pescoço. 2009;38(3):177-182. 19. Fleck MPA. Versão em português dos instrumentos de avaliação de qualidade de vida (WHOQOL) 1998 - Divisão de Saúde Mental Grupo WHOQOL- OMS. Psiquiatria. UFRGS. Disponível em: <http://www.ufrgs.br/psiq/whoqol1. html#top> Acesso em: 24 nov. 2009 20. Bertoncello KCG. Qualidade de Vida e a Satisfação da Comunicação do Comunicação do Paciente após a Laringectomia Total: construção e validação de um instrumento de medida. São Paulo, 2004, p. 226 (Tese de Doutorado - Escola de Enfermagem Geral de Ribeirão Preto/ USP).

Estudos Experimentais - Animais e Humanos (RIEE). 2010;2(4):126-134. 25. Moreno AB, Lopes CS. Avaliação da qualidade de vida em pacientes laringectomizados: uma revisão sistemática. Caderno de Saúde Pública, Rio de Janeiro. 2002;18(1):8192. 26. Carmo RD, Camargo Z, Nemr K. Relação entre qualidade de vida e auto-percepção da qualidade vocal de pacientes laringectomizados totais: estudo piloto. Rev CEFAC, São Paulo. 2006;8(4):518-28. 27. Brasil. Em 20 estados e no DF há mais telefones celulares do que habitantes. Disponível em: <http:// www.brasil.gov.br/noticias/arquivos/ 2011/10/19/em-20estados-e-no-df-ha-mais-telefones-celulares-do-quehabitantes> Acesso em: 26/01/2012.

21. Brasil. Conselho Nacional de Educação/ Ministério da Educação. Resolução Nº 1, de 14 de janeiro de 2010.

28. Gonçalvez, MI, Behlau, MS. Laringectomia Total: perspectivas de reabilitação vocal. In: Lopes Filho, OC. Tratado de Fonoaudiologia. São Paulo: Roca, 1997, p.10651077.

22. Brasil. Comitê de Ajudas Técnicas, na ATA da VII Reunião do Comitê de Ajudas Técnicas, da Coordenadoria Nacional Para Integração Da Pessoa Portadora De Deficiência, Secretaria Especial dos Direitos Humanos. Brasília. 13 e 14 de 2007.

29. Oliveira IB, Costa CC, Chagas JFS, Rochetti ECG, Oliveira LO. Comunicação oral de laringectomizados com prótese traqueoesofágica: análise comparativa pré e pós-treino. PróFono Revista de Atualização Científica, Barueri (SP). 2005;17(2):165-174.

23. Wunsgh VF. The epidemiology of laryngeal cancer in Brazil. São Paulo Medical Journal. 2004;122(5):188-94.

30. Larrosa J, Skliar C (Eds.). Habitantes de Babel: políticas e poéticas da diferença. Belo Horizonte: Autêntica Editora, 2001.

24. Maciel CTV, Leite ICG, Soares TV. Câncer de laringe: um olhar sobre a qualidade de vida. Revista Interdisciplinar de

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Int. Arch. Otorhinolaryngol. 2012;16(4):492-496. DOI: 10.7162/S1809-97772012000400010

Original Article

Respiratory muscle strength in asthmatic children Alessandra Maria Farias Cavalcante Marcelino1, Daniele Andrade da Cunha2, Renata Andrade da Cunha3, Hilton Justino da Silva4. 1) 2) 3) 4)

Master. Professor. PhD. Professor. Master. Student. PhD. Professor.

Institution:

Universidade Federal de Pernambuco - Pós-graduação em Patologia Recife / PE – Brazil. Mailing address: Hilton Justino da Silva - Rua São Salvador, 105 Apto. 1002 - Espinheiro - Recife / PE - Brazil - Zip code: 52020-200 - Telephone: (+55 81) 2126-8927 - E-mail: hdfono@yahoo.com.br Edital Universal CNPq 15/2007. Article received in May 25, 2012. Article approved in July 31, 2012.

SUMMARY Introduction: Changes in the respiratory system of asthmatics are also due to the mechanical disadvantage caused by the increased airway resistance. Objective: The study aims to evaluate the respiratory muscle strength and nutritional status of asthmatic children. Method: This is a prospective descriptive and transversal study with 50 children aged 7 to 12 years, who were placed into 2 groups, asthmatic and non-asthmatic. Respiratory muscle strength was evaluated on the basis of maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP). The nutritional status was evaluated by measuring the anthropometric data, including height, weight, and body mass index (BMI). The findings were subjected to analysis of variance, chi-square, and Student’s t test, and p-values<0.05 was considered statistically significant. Results: In our comparisons, we observed statistically significantly lower values for age, weight, and height in asthmatic patients: 8.52 ± 1.49 years, 30.62 ± 7.66 kg, and 129.85 ± 10.24 cm, respectively, vs. non-asthmatic children(9.79 ± 1.51 years, 39.92 ± 16.57 kg, and 139.04 ± 11.62 cm, respectively). There was no significant increase in MIP and MEP between the groups: MIP was -84.96 ± 27.52 cmH2O for the asthmatic group and -88.56 ± 26.50 cmH2O for the non-asthmatic group, and MEP was 64.48 ± 19.23 cmH2O for asthmatic children and +66.72 ± 16.56 cmH2O for non-asthmatics. Conclusion: There was no statistically significant difference between groups, but we observed that MIP and MEP were slightly higher in the non-asthmatic group than in the asthmatic group. Keywords: asthma; muscle strength; respiratory muscles.

INTRODUCTION Asthma usually begins early (1) and is considered the most common disease in children. It can lead to impaired psychomotor, social, educational, and emotional development (2). There are classic symptoms such as shortness of breath, coughing, and wheezing (2,3), and daily the use of medication should be recommended for all children with moderate to severe asthma, according to guidelines(4). In general, the medical treatment is administrations of corticosteroids, which may incur the risk of developing steroid-induced myopathy when used for long periods and in high quantities. This myopathy occurs in the peripheral muscles, but its impact on respiratory muscle it is not clear yet (5,6,7). There are also changes in the respiratory system of asthmatics due to the mechanical disadvantage caused by increased airway resistance (8). Such changes may be

responsible for a decrease in respiratory muscle efficiency. One of them is the hyperinflation, which flattens the diaphragm, thereby shortening the inspiratory muscle (8.9). Several studies suggest that hyperinflation negatively affects the efficiency of respiratory muscles in asthmatic adults (8,9,10). This study is important because its objective is to evaluate the respiratory muscle strength in asthmatic children, whereas most studies on pathophysiology and treatment of the disease evolution have until now been performed only in adults (11).

METHOD This is a descriptive cross-sectional and individualized study that was developed in the pediatric allergology ambulatory and/or general pediatric clinic of the Hospital das Clínicas, linked to the Universidade Federal of Pernambuco (UFPE), between August 2008 and July 2009.

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The study population included 2 groups: a group of asthmatic children, including 25 children with diagnosis of asthma per the handbook of pediatric ambulatory allergology, who had asthma as the main complaint, and the other group of 25 non-asthmatic children. Their ages were between 7 and 12 years. This age group was selected because this is considered a transition period in the development of the respiratory system and marks the end of pubertal growth and structural changes in the peripheral lung (12). Children who had neurological neurologic impairment, crisis of asthma at the time of evaluation, serious cardiopathies, orthodontic devices, craniofacial abnormalities, and hypertrophy of tonsil and/or adenoids and those whose guardians did not consent were excluded from this study. In both groups, respiratory muscle strength was evaluated by measuring the maximal inspiratory pressure(MIP) and maximal expiratory pressure (MEP) produced in the mouth during the maximum effort against occluded airway during inspiration and exhalation, respectively, using a portable manuvacuometer (Medical Commercial, Brazil). The children were asked to make a maximal inspiration from the residual volume for the measurement of MIP with the occluded valve. To determine MEP, a maximal exhalation from total lung capacity was performedto register the peak pressure against the valve (13). Each child performed the procedure, at the most, 5 times, resulting in at least 3 acceptable maneuvers (with no leaks during at least 2 seconds of each maneuver). Then, the highest pressure values in cmH2O were compared between the groups. To assess this measure, the children were seated with their nose occluded with a nose clip for inspiration, and exhalation was performed only at the mouth, with the mouthpiece connected to the manuvacuometer. To evaluate the nutritional status of children in this sample, the distribution of percentiles of body mass index (BMI) was analyzed according to age and sex, obtained using the equation BMI = weight (kg)/height (m2). Weight was recorded using a properly calibrated balance Filizzola® with sensitivity of 1kg with each child wearing as little clothing as possible, requiring the registration of the weight in kilograms and grams. Height was measured with the child in a standing position, barefoot, with feet parallel and together; a tape-measure and a square, which was firmly supported on the head were used for measuring the height. A descriptive analysis was performed to explain the results. The measured variables are presented in tables and include descriptive measures such as minimum, maximum,

average, and standard deviation. The Kolmogorov–Smirnov test was applied test the assumption of normality of the variables involved in the study. For the analysis of quantitative variables between asthmatic and non-asthmatic groups, the Student’s t test was used, and to analyze the qualitative variables, a chi-square test was used. All the conclusions are based on the significance level of 5%. The children’s’ guardians received clarification about the objectives of this research and were informed that this study was approved by the research ethics committee of the Universidade Federal de Pernambuco; they were requested to sign an assent free and clarified term allowing the child’s participation in the study. This work was approved by the ethics committee in research of Universidade Federal de Pernambuco (224/2006).

RESULTS The sample in this study consisted of 50 children distributed into 2 groups, the asthmatic and non-asthmatic groups. Table 1 shows the distribution of children evaluated by gender in the asthmatic and non-asthmatic groups. In the asthmatic group, 52% children were male and 48% were female, and in the non-asthmatic group, 32% were male and 68%were female. Although there were more male children in the asthmatic group, this difference was not significant, so the groups were distributed evenly by gender. Table 2 shows the distribution of the data for age, weight, height, and BMI in the asthmatic and non-asthmatic groups. The average of age of children in the asthmatic group was 8.52 ± 1.49 years and in the non-asthmatic group it was 9.79 years ± 1.51 years(p = 0.004). The asthmatic group had a mean weight of 30.62 ± 7.66kg and the non-asthmatic group had mean weight of 39.92 ± 16.57kg (p = 0.016). Average height was 129.85 ± 10.24cm in the asthmatic children and 139.04 ± 11.62cm in the nonasthmatic children (p = 0.005). The average BMI was 17.94

Table 1. Distribution of children evaluated for gender in asthmatic and non-asthmatic groups. Gender Asthmatic Non-asthmatic p-value N % N % Male 13 52 8 32 Female 12 48 17 68 0.252 N- number of children in the group %- percentage corresponding to the number of children in the group Statistical test, chi-square

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Table 2. Distribution of children by age, weight, height, and BMI in asthmatic and non-asthmatic groups. N Minimum Maximum Average Standard Deviation p-value Age (years) Asthmatic 25 7.02 11.98 8.52 1.49 Non-asthmatic 25 6.27 11.90 9.79 1.51 0.004 Weight (kg) Asthmatic 25 18.30 49.80 30.62 7.66 Non-asthmatic 25 17.70 84.50 39.92 16.57 0.016 Height (cm) Asthmatic 25 108 149 129.85 10.24 Non-asthmatic 25 118 162 139.04 11.62 0.005 BMI Asthmatic 25 14.34 24.52 17.94 2.94 Non-asthmatic 25 12.09 33.03 20.08 6.26 0.133 N, number of children in the group Statistical test, Student’s t Table 3. Distribution of inspiratory and peak expiratory pressures in asthmatic and non-asthmatic groups. N Minimum Maximum Average Standard Deviation p-value MIP (cmH2O) Asthmatic 25 32 120 84.96 27.57 Non-asthmatic 25 30 120 88.56 26.50 0.640 MEP (cmH2O) Asthmatic 25 32 104 64.48 19.23 Non-asthmatic 25 44 100 66.72 16.56 0.661 MIP, maximum inspiratory pressure MEP, maximum expiratory pressure Statistical test, Student’s t

± 2.94kg/m2in the asthmatic group and 20.08 ± 6.26kg/ m2in the non-asthmatic group(p = 0.133). Thus, the nonasthmatic children had greater age, weight, and height, but no significant differences were found in BMI. Table 3 shows the distribution of children evaluated for mean inspiratory and peak expiratory pressures in the asthmatic and non-asthmatic groups. The average MIP in the asthmatic group was 84.96 ± 27.57cmH2O and in the non-asthmatic group was 88.56 ± 26.50cmH2O (p = 0.640). The average MEP was 64.48 ± 19.23cmH2O in the asthmatic group and 66.72 ± 16.56cmH2Oin the nonasthmatic group (p = 0.661). It was observed that although the non-asthmatic group showed greater maximal inspiratory and expiratory pressures, there was no statistically significant difference between the groups for MIP and MEP.

DISCUSSION Cohen et al. (14) in 1940, observed that the

association between asthma and growth inhibition manifested initially as weight loss and if the symptoms persisted, as compromised height and bone maturity. This growth retardation may be associated with early onset asthma, time and severity of the disease, thoracic deformities, hypoxemia, chronic anorexia, corticosteroid use, and socioeconomic status. However, more recent studies concerned with the increase in obesity in the general population have established a relation with asthma; thus, obesity also increases the probability of developing asthma. In this study, statistically significant values for lower height and weightwerefoundin the asthmatic group compared to the non-asthmatic group, corroborating the work of Cohen et al., without a corresponding change in BMI. All children in the asthmatic group had been taking corticosteroids for a long period of time, but the treatment of asthma as well as the socioeconomic level was low in both groups, which could be correlated with the region where the study was conducted. Thus, the prolonged use

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of steroids or low socioeconomic status may have led to growth retardation, without association with obesity. We also observed a slight decrease in respiratory muscle strength in asthmatic children compared to nonasthmatic children, but this difference was not statistically significant. It has been proposed by several authors that asthma leads to decreased overall muscle strength especially of the respiratory muscles(6) because of hyperinflation by air trapping that occurs as a consequence to bronchoconstriction(15,16,17) and continuous use and high doses of corticosteroids(5,6,7) for the treatment and control of asthma. According to Weiner et al., hyperinflation leads to respiratory muscle weakness because it interferes at the insertion of the muscles responsible for the biomechanics of breathing, leading to flattening of the diaphragm and mechanical disadvantage. Corticosteroids in high doses lead to steroid-induced myopathy (5). However, some studies have been establish a relation between long-term corticosteroid treatment even at low doses and decreased muscle strength (6,7,11).

framework, not verifying a mechanical disadvantage that would lead to decreased muscle strength. In contrast, studies in adults have shown that the changes in the biomechanics of the thorax are permanent, and the time of exposure to the effects of prolonged use of corticosteroids is higher. Thus, the respiratory muscle weakness becomes more evident (5,6,15,16,17). Dividing the asthmatic group according to asthma severity would relate the decrease in respiratory muscle strength with asthma in patients with severe asthma. In moderate asthma, where the disease could lead to faster development of mechanical disadvantage, lower MIP and MEP were observed compared to the non-asthmatic group and a sub-group with mild asthmawould be expected. Overall, there is a scarcity of articles in the literature relating to respiratory muscle strength in asthmatic children. Many studies were performed on adults but there are few studies describing and standardizing respiratory muscle strength in children.

CONCLUSION In this study, we could not determine the degree of hyperinflation because the children in prepubertal age are still developing their respiratory framework. They do not show structural changes expected with permanent changes imposed by time, such as imprisonment entrapment of air and increased airway resistance. All had used corticosteroids for long time. In a literature research for related articles, we found no studies evaluating the impact of asthma and the biomechanical changes in children leading to a decrease in respiratory muscle strength. Only 2articles that evaluate muscle strength in asthmatic children were found. Nickerson et al. evaluated the effects of inspiratory muscle training in asthmatic children and compared the MIP values with the values predicted, concluding that children with asthma had reduced respiratory muscle strength and with training, these values were increased. Lands L et al. examined the MIP and nutritional status in children with asthma, cystic fibrosis, and changes in nutritional status and concluded that only the group with cystic fibrosis had decreased MIP, and that this reduction was related to hyperinflation. Cystic fibrosis has a rapid developmental course and is often more severe than asthma. It is possible that changes in respiratory function, such as hyperinflation will progress more quickly in this group of patients. Furthermore, since this research sample also dealt with children, who, as noted, are still in the process of developing their respiratory

This research proposes further studies monitoring the dosage and duration of corticosteroid use for comparing asthmatic children who are non-users or short-term users of corticosteroids with long-term users. According to the severity of asthma, it is important to have studies relating corticosteroid use with respiratory muscle strength. Studies concerning nutritional status may be more reliable with skinfold measurements, Z-Score, and questionnaires about the childâ&#x20AC;&#x2122;s feeding and may help determine the associations between respiratory muscle strength, nutritional status, and use of corticosteroids. We suggest that similar samples be allocated in others institutions, making this a multicenter study with no influence of the socioeconomic realities of a particular region, thereby providing a greater chance of increasing the validity of the sample. Moreover, the children in the non-asthmatic groups could be found in schools, daycare centers and other local area without links with hospitals and, thus, unrelated to disease.

REFERENCES 1. Asher MI, Keil U, Anderson HR, Beasley R, Crane J, Martinez F et al. International Study of Asthma and Allergies in Childhood (ISAAC): rationale and methods. Eur Respir J. 1995;8:483-91. 2. Pianosi PT, Davis HS. Determinants of physical fitness in

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children with asthma. Pediatrics 2004;113 (3 Pt 1):e225229. 3. Juniper EF, Guyatt GH, Feeny DH, Ferrie PJ, Griffith LE, Townsend M. Measuring quality of life in children with asthma. Quality of Life Research. 1996;5:35-46. 4. National Asthma Education Program: Expert Panel Report II. Guidelines for the Diagnosis and Management of Asthma. Bethesda, MDUS Department of Health and Human Services; 1997. NIH Publication No. 97-4051 5. Decramer M, Lacquet LM, Fagard R, Rogiers P. Corticosteroids contribute to muscle weakness in chronic airflow obstruction. Am J Respir Crit Care Med. 1994;150:11– 16. 6. Bowyer SL, Lamothe MP, Hollister JR: Steroid myopathy: Incidence and detection in a population with asthma. J Allergy Clin Immunol. 1985;76:234–242. 7. Akkoca O, Mungan D, Karabiyikoglu G, Misirligil Z. Inhaled and systemic corticosteroid therapies: Do they contribute to inspiratory muscle Weakness in asthma? Respiration. 1999;66:332-337. 8. Weiner S, Suo J, Fernandez E, Cherniack RM. The effect of hyperinflation on respiratory muscle strength and efficiency in healthy subjects and patients with asthma. Am Rev Respir Dis. 1990;141:1501–1505.

10. Lavietes MH, Grocela JA, Maniatis T, Potulski F, Ritter AB, Sunderam G. Inspiratory Muscle Strength in Asthma. Chest. 1988;93(5):1043-1048. 11. Bisgaard H. Long-acting β2—agonists in management of childhood asthma: a critical review of the literature. Pediatric Pulmonology. 2000;29:221-34. 12. Merkus PJ, Ten Have-Opbroek AA, Quanjer PH. Human lung growth: a review. Pediatr Pulmonol. 1996;21(6):38397. 13. ATS/ERS. Statement on respiratory muscle test. Am J Resp Crit Care Med. 2002;166:518-624. 14. Cohen MB, Weller RR, Cohen S. Antropometry in children. Progress in allergic children as shown by increments in height, weight and maturity. Am J Dis Child. 1940;60:1058-66. 15. Weiner P, Berar-Yanay N, Davidovich A, Magadle R, Weiner M. Specific inspiratory muscle training in patients with mild asthma with high consumption of inhaled beta(2)agonists. Chest. 2000;117(3):722-7. 16. Gorini M, Iandelli I, Misuri G, Bertoli F, Filippelli M, Mancini M, et al. Chest wall hyperinflation during acute bronchoconstriction in asthma. Am J Respir Crit Care Med. 1999;160(3):808-16. 17. Laghi F, Tobin MJ. Disorders of the respiratory muscles. Am J Respir Crit Care Med. 2003;168(1):10-48.

9. Weiner P, Azgad Y, Ganam R, Weiner M. Inspiratory muscle training in patients with bronchial asthma. Chest. 1992;102:1357–1361.

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Int. Arch. Otorhinolaryngol. 2012;16(4):497-501. DOI: 10.7162/S1809-97772012000400011

Original Article

Electronic data collection for the analysis of surgical maneuvers on patients submitted to rhinoplasty Cezar Berger1, Renato Freitas2, Osvaldo Malafaia3, José Simão de Paula Pinto4, Marcos Mocellin5, Evaldo Macedo6, Marina Serrato Coelho Fagundes7. 1) Master. Volunteer Teacher in the ENT Department of HC-UFPR and Doctor and Medical Advisor for the Fellowship Program at IPO. 2) Associate Professor and Head of the Plastic Surgery Service of the Federal University of Parana. Associate Professor and Head of the Plastic Surgery Service of the Federal University of Parana. 3) Doctor. Professor of Surgery at UFPR, Coordinator of the Graduate Program in the Principles of Surgery of the HUEC, and Professor at the Evangelical School of Paraná. 4) Doctor. Adjunct Professor at the Federal University of Parana and Coordinator of the Master of Science, Management and Information Technology. 5) Doctor. Head of the Department of Otorhinolaryngology, HC-UFPR. 6) Doctor. Coordinator of the NEP IPO and Professor at the Department of Otorhinolaryngology, HC-UFPR. 7) Graduate Student. ENT doctor. Institution:

Hospital Instituto de Otorrinolaringologia do HC-UFPR. Curitba / PR - Brazil. Mailing address: - Marina Serrato Coelho Fagundes - Av. Republica Argentina 2069 - Curitiba / PR - Brazil - Zip code: 80620-010 - Telephone: (+55 41) 3074-7482 E-mail: ma.serrato@hotmail.com Article received in February 1st,2012. Article approved in August 26, 2012 .

SUMMARY Introduction: In the health field, computerization has become increasingly necessary in professional practice, since it facilitates data recovery and assists in the development of research with greater scientific rigor. Objective: the present work aimed to develop, apply, and validate specific electronic protocols for patients referred for rhinoplasty. Methods: The prospective research had 3 stages: (1) preparation of theoretical data bases; (2) creation of a master protocol using Integrated System of Electronic Protocol (SINPE©); and (3) elaboration, application, and validation of a specific protocol for the nose and sinuses regarding rhinoplasty. Results: After the preparation of the master protocol, which dealt with the entire field of otorhinolaryngology, we idealized a specific protocol containing all matters related to the patient. In particular, the aesthetic and functional nasal complaints referred for surgical treatment (i.e., rhinoplasty) were organized into 6 main hierarchical categories: anamnesis, physical examination, complementary exams, diagnosis, treatment, and outcome. This protocol utilized these categories and their sub-items: finality; access; surgical maneuvers on the nasal dorsum, tip, and base; clinical evolution after 3, 6, and 12 months; revisional surgery; and quantitative and qualitative evaluations. Conclusion: The developed electronic-specific protocol is feasible and important for information registration from patients referred to rhinoplasty. Keywords: rhinoplasty; medical informatics; database.

INTRODUCTION Computerization is becoming increasingly necessary to professional practice in several fields, including the health area, because it eases the recovery of stored data. Further, it is being used to promote the production of research with a high degree of scientific rigor. The development of data bases with systematically organized information permits the use of computerization in scientific work and thereby results in more reliable conclusions. Therefore, the improvement of data collection via computerization is indisputably important.

National Institute of Industrial Property (INPI) under the number 00051543 (1). The system enables the development of research in the otorhinolaryngology and facial plastic surgery fields with greater readiness and versatility in data collection, allowing the immediate sharing of information within the scientific community. The present study integrates the line of research named “Computerized Protocols” from the post-graduation program at the Surgical Clinic of the Division of Health Sciences at Federal University of Parana.

METHOD The Integrated System of Electronic Protocol (SINPE©, intellectual property of Professor Osvaldo Malafaia) was created in 1999 and has been registered with the

For developing a theoretical database, all necessary information in the field of otorhinolaryngology and facial

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plastic surgery was gathered from text books and published periodicals (22). Once the information was compiled, an electronic database was created using the Microsoft Word and Microsoft Excel programs. Afterwards, the generated files were converted to text format archives to enable their incorporation into SINPE©. We created a master protocol containing 20,109 items. The structure incorporates practical sorting and is constituted of anamnesis, general physical examinations, complementary exams, and clinical treatment. For each area, as determined from the physical exam, the information is specific and encompasses the diagnosis, surgical treatment, complications, and follow-up. A specific protocol termed “Rhinoplasty” was created from 954 items. Two different manager protocols were developed to organize data in the software: (1) a master protocol that works as a receptacle for information related to otorhinolaryngologic diseases but in a non-selective manner and (2) a specific protocol that selects, covers, and groups exclusive information from determined fields of practice.

RESULTS After concluding the elaboration and review of the master protocol (20,209 items), which encompassed the greater field of otorhinolaryngology, we hierarchized an idealization of the specific protocol (954 items) containing the entire subject related to patients with aesthetic and functional nasal complaints referred to surgical treatment (i.e., rhinoplasty) into 6 main categories related to research: anamnesis, physical examination, complementary exams, diagnosis, treatments, and outcome. For the present research, we used the categories of treatment and outcome (main roots) and their sub-items, as listed below. 1. Finality 2. Accesses 3. Surgical maneuvers on the nasal dorsum 4. Surgical maneuvers on the nasal tip 5. Surgical maneuvers on the base of the nose 6. Clinical evolution—3 months 7. Clinical evolution—6 months 8. Clinical evolution—12 months 9. Revision surgeries 10. Qualitative evaluation (satisfaction) 11. Quantitative evaluation (measures of the nose)

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the option to initiate or simulate data collection or initiate a search. Using the option “Patients,” the user can identify or insert a patient in the program, or even consult preexisting data. By selecting “Doctors,” the user is allowed to insert, modify, or exclude a particular professional. In the item “Parameters,” one can verify users, access permissions, subscribe to new institutions, and view a unit’s fields and fees. Finally, help options are available under the item “Help: protocols system help; how to make security copies; how to restore a security copy; how to send a copy to the central database; and data regarding the program.” By clicking on the icon “+” beside the word root, one can open it to show the content of the master protocol. The icon “+” next to the root of a folder or an archive indicates that the folder or archive is closed (i.e., the content is not exposed). Clicking on the icon “+” will convert it into “X,” exposing the content to be used. Along the horizontal column above this icon are shown 5 options in the master protocol: clicking on the blank box beside “View in alphabetic order” will result in the folder contents being shown in alphabetic order. By clicking on “Expand,” the folder content is selected and entirely exposed. Conversely, clicking on the option “Reduce” will close the folder. Clicking on the option “Father” will create a new father item. The option “$” can be used to modify numerical value data, such as fees, procedures codes, and medications. In addition, 3 options are available in the right vertical column: the magnifying glass icon is utilized to perform a search within the entire master protocol and is aimed at finding specific information; by clicking the up and down arrows, the user can alter the position of an item inside the folder. At the bottom of the screen, 5 options can be found in the master protocol: “Add sibling,” “Add son,” “Remove,” “Refresh,” and “Visualize in HTML.” All options can only be used after opening the root, when the master protocol content is exposed. To close the master protocol and return to the computerized protocol operation, just click on the option “Close” positioned at the right side of the bottom of the screen. The screen in Figure 1 shows the content corresponding to the master protocol with the opened root. The folders contain clinical data from several otorhinolaryngological pathologies.

1.1 The creation of the master protocol Clicking on “Protocols” will display the protocol options (master or specific). Clicking on “Data” will present

When the root is opened, it is possible to list the functions of the options shown at the bottom horizontal line. Clicking on “Remove,” the user can exclude a folder or archive selected by using the mouse. To alter the characteristics of a selected folder or archive, such as the orthography, just use the option “Alter” by clicking over it with the mouse. After concluding the desired alteration, the user confirms the text and again includes the folder or archive selected by clicking on the option “Refresh.” For

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creating and including a new folder or archive of features similar to the ones for the selected item, the user must use the option “Add sibling.” When the archive or folder is a branch of the selected item, the option to be used is “Add son.” The “Visualize in HTML” option permits the transposition of data from the protocol to a Word archive spreadsheet. As explained previously, the option “Close” at the bottom right corner enables the user to close the master protocol.

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Watts defines 3 important aspects in the computerization in the medical field: requests for increased productivity, diminished costs, and an improvement in the quality of the service (26). In the 1990s, a series of computerizing systems emerged in the health field for the monitoring of the health

Since 6 activity fields (ear; face; nose and paranasal sinus; oral cavity; pharynx; and larynx) are present in all the specific protocols, only the folders corresponding to “Clinical condition” and “Physical exam” were determined as general. The remaining folders were applied exclusively in the specific protocol of the activity field.

1.2 Creation of the specific protocol Using the option “Specific registered protocols,” the user can create a specific protocol for new areas from the master protocol. Afterwards, a new screen will appear with the options “Insert,” “Exclude,” “Alter,” “Cancel,” and “Save.” Two boards are presented on this screen (Figure 2). The board on the left, with the previously opened root, shows all the folders of the master protocol. The board on the right presents spaces for the specific protocol items. Using both arrows between the boards, the user can transpose data from the master protocol to the specific protocol, selecting them on the board on the left and clicking on the arrow pointing to the right. In the reverse way, clicking on the arrow pointing to the left, the selected item on the board on the right will be transposed to the board on the left. To print or save the specific protocol in HTML format, just click on the existing options at the bottom right line. To save the alterations and close the screen, return to the figure 9 screen, just click on the option “Close.” When the user follows these steps, all items necessary for data collection in the research will be in the specific protocol (Figure 3).

Figure 1. Screen editing master protocol in which the root “Otolaryngology” has been opened.

Figure 2. Placing items in a specific protocol.

DISCUSSION Shortliffe (23) defines medical informatics as a field of study in which informatics resources can be applied to the management and utilization of biomedical information. Shortliffe and Blois (24) cite the first application of informatics as the gathering of epidemiological data for the U.S. census. This method was applied in epidemiology from 1920 to 1930. The first reports on the computerization of medical records are from 1970 by the Mayo Clinic (25).

Figure 3. A specific protocol (rhinoplasty) concluded.

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care process and increased the quality of assistance to the patient, since these systems assisted in the diagnosis process and therapy prescription. This capacity can be implemented due to intelligent systems, which permit the inclusion of clinical reminders for assistance follow-up, warnings about drugs interaction, alerts in dubious treatments, and deviations from clinical protocols (27). Electronic protocols, in which questionnaires are filled using the computer, can be used as tools for prospective data collection. These protocols are effective because they enable the inclusion of systematized data through software that permits posterior manipulation by crossing data to generate quality scientific information.

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CONCLUSION Applied in a simple and systematic way, the developed electronic specific protocol (SINPE) is a viable method for registering information on patients with an indication for rhinoplasty.

REFERENCES 1. Malafaia O, Borsato EP, Pinto JSP. Manual do usuário do SINPE©. Curitiba: UFPR, 2003.

Quality clinical studies are fundamental to continued scientific development. They allow secure access to new information with a consequent improvement of knowledge, goal planning, disclosure of procedure evaluations, and professional conduct.

2. Adamson PA, Galli S. Rhinoplasty Approache: Current State of the Art. Arch Facial Plast Surg. 2005;7(1):32-7.

SINPE© permits the user to create, modify, and add necessary information into master and specific protocols. This type of collected data storage allows the research to inform all parameters of the research (28). Furthermore, the possibility of interconnecting computers and institutions expands the collection and storage of data, which will be of fundamental importance in the development of computerized and multicenter databases in improving reliability.

4. Bracaglia R, Fortunato R, Gentilesch S. Secondary Rhinoplasty, Aesthetic Plast Surg. 2005;29(4):230-9.

The creation of a protocol specific to rhinoplasty emerged from the requirement for standardized and reliable information collection and led to the elaboration of descriptive and analytical studies in the field of nasal aesthetics, in which the subjectivity of the evaluations of surgical maneuvers and indications is preponderant.

7. Gunter J. Dallas rhinoplasty – Nasal Surgery by the masters. Quality Medical Publishing. 2006.p.70-92.

At large medical centers in Europe and the United States, the computerization of patient data has enabled these difficulties to be resolved and has led to a steady increase in the inclusion of such studies in journals that avoid the subjective nature of data collection (27). This protocol contains the option of direct filling. This feature enables the researcher to avoid the subjectivity that is characteristic of information collection and that complicates the interpretation of the results in high quality journals. A collector can fill in the initial information on the patient, such as name, age, gender, and insurance. However, a doctor must perform the collection of information related to the medical area, which was encompassed in this study in performed surgical maneuvers, and data related to satisfaction and interpretation of nose measures.

3. Alsarraf R, Larrabee WF JR. Outcomes research in facial plastic surgery [editorial]. Arch Facial Plast Surg. 2001;3:7.

5. Corrado A, Bloom J, Becker D. Domal Stabilization Suture in Tip Rhinoplasty. Arch Facial Plast Surg. 2009;11(3):1947. 6. Gruber, R, Weintraub, J, pomerantz, J.Sutura Techniques for Nasal Tip. Aesthetic Surg J. 2008;28:92-100.

8. Guyuron B, Behmand R.Nasal tip sutures part II: the interplays. Plast Reconst Surg. 2003;12(8):1146-9. 9. Leach JL, Athré.Four suture tip rhinoplasty: A powerful tool for controlling tip dynamics. Otol Head Neck Surg. 2006;135:227-31. 10. Loe S, Rowe-Jones J. Suture techniques in nasal tip sculpture: Current Concepts. J Laryngol Otol. 2007;121:810. 11. Luce EA. Outcome studies and practice guidelines in plastic surgery [editorial]. Plast Reconstr Surg. 1999;104:118790. 12. Maniglia AJ, Maniglia JJ, Maniglia JV. Rinoplastia Estética Funcional e Reconstrutora. São Paulo: Revinter, 2002. p.12950. 13. Mckieinan DC. Patient Benefits from Functional and Cosmetics Rhinoplasty. Clin. Otolaryngol. 2001;26:50-2.

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500


Electronic data collection for the analysis of surgical maneuvers on patients submitted to rhinoplasty.

Berger et al.

14. Mocellin M, Pasinato R, Berger CAS, et al. Estreitamento da Base Nasal no Nariz Caucasiano através da Técnica de Cerclagem. Arq. Int. Otorrinolaringol. 2010;14(2):199-205.

22. Toriumi D, Becker DG. Rhinoplasty Dissection Manual. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 3757.

15. Patrocínio JA. Manobras cirúrgicas realizadas nas rinoplastiasde um serviço de residência médica em otorrinolaringologia. Braz J Otorhinolaryngol. 2006;72:43942.

23. Shortliffe EH. The science of biomedical computing. Med Inform. 1984;9:185-93.

16. Perkins S, Patel A.Endonasal Suture Techniques in Tip Rhinoplasty. Facial Plast. Surg. Clin. North Am. 2009;17(1):4154. 17. Rees TD, Krupp S, Wood-Smith D. Secondary rhinoplasty. Plast Reconstr Surg. 1970;46(4):332-40. 18. Rohrich RJ, Adams WP. The Boxy Nasal Tip: Classification and Management Based on Alar Cartilage Suturing Techniques. Plast Reconst Surg. 2001;1849:107. 19. Sheen JH. Rhinoplasty: personal evolution and milestones. Plast Reconstr Surg. 2002;105:1820-2000. 20. Tebbetts JB. Discussion: nasal tip sutures part I: the evolution. Plast Reconst Surg. 2003;12(8):1146-9.

24. Shortliffe EH. Medical Informatics: An Emerging Discipline with Academic and Institutional Perspectives, Journal of the American Medical Association. 2006;263(8):1114-20. 25. Grimson J. Delivering the eletronic healthcare Record for the 21st century. Int J Med Inf. 2001;64:111-27. 26. Blum DKA. A History of Medical Informatics. New York, ACM Press, 1990. 27. Lima JHF. Implantação e validação do sistema integrado de protocolos eletrônicos (SINPE©) sobre as doenças do aparelho digestivo no Hospital de Clínicas da UFPR. Curitiba, 2008. 84f. Tese (Doutorado em Clínica Cirúrgica) – Setor de Ciências da Saúde, Universidade Federal do Paraná. 28. Frisby AJ. The internet and medical education. Del Me. Jrl., 1996;68(12):602-5.

21. Tardy M, Brown RJ. Surgical anatomy of the nose. New York: Raven Press; 1990.p.113-58.

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Int. Arch. Otorhinolaryngol. 2012;16(4):502-508. DOI: 10.7162/S1809-97772012000400012

Original Article

Pharyngeal swallowing phase and chronic cough Daniela Rejane Constantino Drozdz1, Cintia Conceição Costa2, Paulo Roberto de Oliveira Jesus3, Mateus Silva Trindade4, Guilherme Weiss5, Abdias Baptista M. Neto6, Ana Maria T. da Silva7, Renata Mancopes8. 1) Speech Language Pathologist, Specialist in Oral Motricity approach with hospital. Master student of the Post-graduation Program in Human Communication Disorders, Federal University of Santa Maria (UFSM), Santa Maria, Rio Grande do Sul. 2) Speech Language Pathologist post-graduation. Master student of the Post-graduation Program in Human Communication Disorders, Federal University of Santa Maria Santa Maria (UFSM), Santa Maria, Rio Grande do Sul, Brazil. 3) Radiologist Doctor. Chief of the Radiology service of the Academic Hospital of Santa Maria (HUSM), Santa Maria, Rio Grande do Sul, Brazil. 4) Radiology Technician. 5) Physical Specialist in Radiology Diagnostic by the ABFM. Physical specialist in radiology diagnostic by the ABFM. 6) Pulmonologist Doctor. 7) Speech Language Pathologist (SLP); Associate Professor of the Phonoaudiology Department of the Federal University of Santa Maria (UFSM), Santa Maria, Rio Grande do Sul, Brazil, PhD. 8) Speech Language Pathologist (SLP), Adjunct Professor of the Post-Graduation Program in Human Communication Disorders, Santa Maria (UFSM), Santa Maria, Rio Grande do Sul, Brazil, PhD. Institution:

Universidade Federal de Santa Maria. Santa Maria / RS – Brazil. Mailing address: Daniela Rejane Constantino Drozdz - Avenida Fernando Ferrari, 1220 – Apto. 302 - Santa Maria / RS – Brazil - Zip code: 97050-801 - E-mail: danidrozdz@hotmail.com Article received in June 30, 2012. Article approved in August 26, 2012.

SUMMARY Introduction: The act of swallowing depends on a complex and dynamic process which uses common structures to the act of breathing; respiratory problems can cause swallowing difficulties. Aim: To assess the swallowing pharyngeal phase in patients with chronic cough. Method: Retrospective study with 15 patients of both genders, patients with chronic cough and risk factors for aspiration defined by the pneumologic diagnosis. The patients were submitted to anamnesis on complaints related to swallowing, chewing and breathing, or related to food and to videofluoroscopic examination. Results: It was observed that 33.3% had normal and functional swallowing, being the last one of most prevalence. The mild dysphagia was observed in 20% of the patients, the mild to moderate dysphagia in 6.7% of them. In relation to the Rosenbek scale, 73.3% of patients presented degree 1, 6.7% presented degrees 2 and 3, and 13.3% presented degree 8. The most found pathology was the chronic cough with 40%, followed by asthma with 20%; 69.2% of patients presented stasis and of these, five used protection maneuvers, of these, seven were effective and only three were used in the presence of stasis. The most used maneuver was the multiple swallowing, being effective in 100%. Conclusion: There are peculiarities in the patients’ swallowing with chronic cough that, although not presenting complaints relating to swallowing, it presents an important aspiration risk due to the presence of changes in breathing pattern that can intervene in the coordination between breathing and swallowing, which is essential to protect the lower airway. Keywords: deglutition disorders; fluoroscopy; methods; cough.

INTRODUCTION The act of swallowing is a vital function to human beings, although it seems simple, it is a highly complex and dynamic process, which structures and systems involved are common to the act of breathing, being of extremely importance for the nutrition of the organism as a whole (1,2). During swallowing, the food will be transported from the mouth to the stomach, without occurring during this process, the entry of substances into the airway, for this, it is required for the individual to have a precise coordination, especially between the oral and pharyngeal phases (2). In general, swallowing can be divided into four phases: preparatory phase, oral phase, pharyngeal phase

and oesophageal phase (3). The pharyngeal phase is sorted as the main pharyngeal during swallowing, as there is involvement of the oral cavity part, of the masticatory muscles and of the intrinsic and extrinsic muscles of the larynx (4). In some cases, the physiological process of swallowing can be adjusted either by mechanical causes, such as neurological causes, characterizing thus the clinical picture of dysphagia (5). The patient with a clinical picture of dysphagia may present several changes in the act of swallowing, including: inability to handle food; trouble for keeping the food in the mouth, difficulty controlling the saliva, coughing before, during and after swallowing, recurrent pneumonias; weight

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loss without definite reason, choking and suffocation, among other changes (1,2,6). At presenting clinical evidences for the diagnosis of dysphagia, the patient must be referred to an objective instrument assessment. This may be the videofluoroscopy (VFL) which is a radiological method that allows the evaluation of all phases of swallowing dynamically and it is considered the gold standard for diagnosis and treatment of oropharyngeal dysphagia (7,8). During the performance of this examination, it is observed the presence of aspirations which may be asymptomatic (9), demonstrating thus the need for an evaluation of swallowing dysfunction in such patients (10). Moreover, the indication of this test aims to determine the effectiveness of the rehabilitation strategies and to provide a pre- and post-therapy visual feedback (11). Aspiration is defined as the inhalation of an oropharyngeal or gastric content into the larynx and into the lower respiratory tract (10). This material (bacteria, stomach acid, food particles and foreign bodies) can cause to an individual, a lung disease and its severity depends on the suctioned amount. Among the most common forms of aspiration lung disease, there are found: bronchiectasis, abscesses and interstitial fibrosis (12). It is observed in this case, the interest of the pulmonologists and Speech Language Pathologists in the complications arising from dysphagia (4), as patients with chronic lung disease present changes in the coordination of the respiratory cycle with the swallowing, and this disruption may increase the risk of aspiration in patients on the advanced stage of the disease, thus contributing to exacerbations (13). It is common in these patients the presence of chronic cough, which is characterized by the presence of cough for more than three weeks. It is believed that it is often related to the post nasal drip, to asthma, to the gastroesophageal reflux, to chronic bronchitis and to bronchiectasis (14). Clinical and research evidences demonstrate that by using systematic programs of screening, diagnosis and dysphagia treatment, there is a significant reduction in the rates of aspiration pneumonia (15). Thus the speech pathology intervention in hospitals enables an early evaluation and a differential diagnosis in cases of dysphagia, aiming to prevent, avoid and/or minimize the clinical complications of the patient (16). The speech pathology assessment, therefore, must

consider the patient’s overall clinical status and the presence of lung disorders associated with complaints of swallowing or presence of chronic cough, which will allow the proper formulation of diagnostic hypotheses about aspiration risk in these cases. The objective of this study is to analyze the pharyngeal phase of swallowing in patients with chronic cough.

METHOD This is a retrospective, cross-sectional, population study and of quantitative character. The same was done at a University Hospital of Rio Grande do Sul, during the period from September 2011 to February 2012. The sample comprised 15 patients with an average age of 67.1 years, of both genders, patients with chronic cough (> 8 weeks of duration) and with risk factors for aspiration, defined by the pneumologic diagnosis as patients with chronic cough and/or respiratory symptoms. They were referred by the teams of pulmonology and speech pathology. All subjects received instructions about the objectives, justification and methodology of the proposed study and signed a Free and Informed Consent Form. The patients were subjected to anamnesis, to obtain information about complaints in relation to swallowing, chewing, breathing, and related to the feeding moment. It was performed the videofluoroscopy (VFL) examination using the videofluoroscopy protocol usual of the service, which includes the analysis of food intake contrasted in the liquid, nectar, honey pudding and solid consistencies. For liquid consistency, it was added water to the liquid barium (Bariogel®), in a proportion of one to one (15 ml water to 15 ml of barium); in nectar, there were used 30 ml of liquid barium, for the honey it was used 15ml of water and 15ml of barium and one 3ml tablespoon of thickener (Thick and up®), for the pudding, it was used 15ml of water, 15 ml of barium and 5ml of thickener and for the solid, it was used bread soaked with barium (17). When performing the VFL, individuals remained seated and the capturing of pictures was made in the lateral-lateral position, fluoroscopic image focus previously defined by the lips, superiorly by the hard palate, then by the posterior pharyngeal wall and inferiorly by the bifurcation of the airway and oesophagus (at the height of the 7th cervical vertebra). Initially, there were offered the liquid and nectar consistencies in the 5ml spoon and in free sips

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respectively then were offered the honey and pudding consistencies in the 5 ml spoon and finally the solid consistency with the ingestion of bread. All examinations were performed by two Speech Language Pathologists, and a radiology technician. The images of videofluoroscopy were obtained using a Siemens equipment, Axiom Iconos R200 model, being captured and recorded by the ZScan6 Gastro software - Version: 6.1.2.11, installed on the Itautec Infoway computer, Windows 7, Intel Pentium P6200, which resulted in an average exposure of 0.14 mR /frame. For purposes of this study, there were analyzed: gender, degree of dysphagia, the presence/absence of penetration and/or laryngeal aspiration, the presence/ absence of stasis, the use of therapeutic maneuvers, types of used maneuvers and their effectiveness. The data used in this study are part of a project previously approved by the Ethics Committee in Research of the Federal University of Santa Maria - CEP/UFSM under the protocol number 23081.013174/2011-46.

RESULTS In order to meet the objectives proposed in this study, there were considered several statistical techniques of the chi-square and the Speerman correlation. Initially, it was performed a descriptive analysis of all the variables in order to obtain the profile of patients attended in the service. For nominal variables, it was performed the chisquare test, which verified the relationship of these variables with the diagnosis; now for the ordinal variables, it was used the Spearman correlation test. It was adopted a significance level of 5% (0.05). The related data were processed and analyzed in electronic form from the construction of a database (Excel 2007) and of an analysis specific program to meet the research objectives, the Statistical Package software for Social Science 15.0 (SPSS). Out of the 15 patients that participated of the survey, the average age was of 67.1 years, 53.3% were women and 46.7% were men. The profiles of the patients according to the variables of the pharyngeal phase are shown in Tables 1, 2 and 3 below: The dysphagia can be classified into seven degrees (18). Concerning the degree of dysphagia in this sample, it was observed that 33.3% had degree 7 (normal

swallowing) and degree 6 (functional swallowing), being the last one of the most prevalence. The degree 5 (mild dysphagia) was observed in 20% of the patients, being found 6.7% in the degrees 4 (mild to moderate dysphagia) and 3 (moderate dysphagia) respectively. There were not found patients in the degrees 2 and 1 (moderate to severe dysphagia and severe dysphagia) (Table 1). As regards to the analysis of laryngeal penetration and aspiration (19), it was observed that most of the patients (73.3%) had degree 1 (no entry of contrast in the airway), while 6.7% had the degrees 2 (contrast enters above the vocal folds, without residue) and 3 (contrast remains above the vocal folds with residue). The degree eight (contrast passes to the glottis is no response from the patient) was found 13.3% of patients (Table 2). The most commonly found pathology of pneumologic origin during the visits was chronic cough

Table 1. Dysphagia degree*. Dysphagia degree Patients 7 5 6 5 5 3 4 1 3 1 Total 15

(%) 33,3 33,3 20,0 6,7 6,7 100

*Classification according to O´NEIL et al, 199918.

Table 2. Rosenbeck scale*. Rosenbeck scale Patients 1 11 2 1 3 1 8 2 Total 15

(%) 73,3 6,7 6,7 13,3 100

* Rosenbeck scale et al,199618.

Table 3. Description of lung disorders that were found in the assessed patients. Pathologies Patients (%) ASTHMA 3 20,0 Chronic cough 6 40,0 Emphysema 1 6,7 Pulmonary fibrosis 1 6,7 Pneumonia 1 6,7 Bronchiectasis 2 13,3 COPD 1 6,7 Total 15 100

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with 40%, followed by the asthma with 20%. Apart from these, other pathologies amounted 46.8% of the sample and included: pulmonary emphysema, pulmonary fibrosis, pneumonia, bronchiectasis and COPD (Table 3). In Table 4, it is presented the presence of stasis during swallowing and it is observed the use, type and effectiveness of the maneuvers for this variable. Out of the fifteen patients, nine (60%) showed stasis and of these, five used protection maneuvers. Concerning these maneuvers: seven were effective, but only three were used in the presence of the stasis. Among these maneuvers, the most used was the multiple swallowing, being effective in 100% of the cases. In Table 5, it is observed the correlation between the variables: degree of dysphagia, Rosenbeck scale (19), presence of penetration or aspiration. There was significant negative correlation between the Rosenbeck scale (18) and the degree of dysphagia. This is explained by the relationship of inversion between the adopted classes. That is, the worse the degree of dysphagia (18) the lower will be the number on that scale and in the classification of the degree of penetration/ aspiration (19); the worse the penetration/aspiration the greater will be the number on this scale. In addition, in this sample, it was possible to verify that there was a significant negative correlation between the degree of dysphagia and the presence of penetration and aspiration, showing that the smaller the degree of dysphagia, the higher is the presence of penetration and aspiration. In Table 6 it is observed that there was no correlation between the variables: stasis, Rosenbeck scale (19), and presence of penetration or aspiration.

DISCUSSION

Table 4. Statistical analysis of the stasis presence in relation to the: use of maneuvers, effective maneuver, type of maneuver and gender. Variables Stasis p-value Presence Absence N (%) N (%) Use of Maneuver 0,667 Yes 5 (55,6) 4 (44,4) No 4 (66,7) 2 (33,3) Effective Maneuver Yes 3 (42,9) 4 (57,1) 0,091 No 3 (100,0) 0 (0,0) Type of Maneuver Multiple swallowing 3 (50,0) 3 (50,0) 0,290 Reflex cough 2 (100) 0 (0,0) Head backwards 0 (0,0) 1 (100,0) Multiple swallowing +Cough 1 (100,0) 0 (0,0) Gender Female 4 (50,0) 4 (50,0) 0,398 Male 5 (71,4) 2 (28,6) * Statistically significant values Chi-square test.

Table 5. Variables correlation: dysphagia degree, Rosenbeck scale, presence of penetration or aspiration. Analysed variables n Spearman p* Dysphagia degree and Rosenbeck 15 -0,777067 0,000653* Dysphagia degree and penetration presence 15 -0,763359 0,000928* Dysphagia degree and aspiration presence 15 -0,614741 0,014739* *Statistically significant values Spearman correlation test.

Table 6. Variables correlation: penetration and aspiration. Analysed variables n Stasis and Rosenbeck 15 Stasis and penetration presence 15 Stasis and aspiration presence 15

stasis, Rosenbeck scale, Spearman 0,485786 0,492366 0,320256

p* 0,066380 0,062252 0,244539

*Statistically significant values Spearman correlation test.

In cases of patients with chronic cough, the doctor must through their clinical judgment to identify patients who are at risk of aspiration and direct them to a swallowing assessment, and also for the VFL examination (20), since the presented evidences demonstrate difficulties in swallowing and aspiration risk in this sample. Regarding gender, a study (21) investigated asymptomatic men and women through the VFL and can observe that the differences found in swallowing could be more related to the anatomy than to a dysfunction, as the physiological system can perform its function with certain

variability. Another research (22) also said that studies that equate swallowing of men and women do not indicate differences in the measures that rely on preferred mode of the sensory stimuli, such as the start site of the pharyngeal phase. This can be observed in this sample, since there was no significant difference between the genders in the analyzed data.

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Although patients have not shown clinical signs of dysphagia, history of recurrent pneumonia became an issue to be investigated in view of that, this may be an indicator of symptoms of dysphagia related to oesophageal and pharyngeal phase of swallowing (23) in this sample. With the use of videofluoroscopy as a method of instrumental assessment of dysphagia, it was possible to visualize the anatomy, physiology and the swallowing process, being also possible through this information to determine which therapeutic procedures can also be effective in relation to the found problem (24) as the effectiveness of the maneuver of multiple swallowing in these cases. Regarding the presence of dysphagia, 20% of patients presented mild dysphagia and others (13.4%) presented mild to moderate and moderate dysphagia. It is important to highlight that changes in breathing pattern, presented by patients with chronic cough may alter the coordination between breathing and swallowing, being that this change will affect the essential timing for the protection of the inferior airway (25), which can be crucial in dysphagia disease. The analysis of presence of penetrations and laryngeal aspirations (19) revealed the presence of 1 degree in most evaluated patients which will establish the relationship with the degree of dysphagia (18), since the closer to the normality is the swallowing, the absent or lower will be the degree of found aspiration/penetration. However, two patients present eight degree (19), demonstrating the presence of silent aspiration. The presence of silent aspiration may be linked to the reduction of respiratory strength and of the ability to clean the airway, thus compromising the protection of the same (26). Eating and breathing are acts that are closely integrated, so it is essential to focus on the patient’s swallowing, especially on those that present pulmonary diseases (27). Among the lung disorders found in this study, the chronic cough was more prevalent in relation to other pathologies. It can be sort the chronic cough as the first symptom for the diagnosis of COPD (chronic obstructive pulmonary disease) (23), so this should be considered a symptom and its cause must be investigated before the treatment establishment (28).

A recent study (22) showed that the quantification of the oral or pharyngeal stasis (defined as a residue in the oral cavity, in the pharynx during swallowing) in the videofluoroscopic assessment is limited to a subjective character. Although the tests of association and correlation of the stasis variable did not present significance, it is important to note that the literature (30) shows that there is still no consensus on the form of analysis, definition and stasis degree, which can diversify according to each researcher. Another study (31) concluded that the risk of aspiration increases proportionally with the amount of stasis. Moreover, there is no agreement between the ways of measuring this variable, either subjectively or objectively. Thus, the fact of not presenting significance in the analyses in relation to stasis, it does not rule out the importance of this investigation, but reinforces the need to continue with investigations of this variable in the process of swallowing. The correlation analysis between the presence/ absence of stasis, the type of maneuvers used and their effectiveness, become essential for prognosis and for the definition of the speech therapy to be performed. It is noteworthy that by subjecting the patient to radiation in the examination of VFL, as well as by understanding the dynamics of swallowing, it is essential for the Speech Language Pathologist to try therapeutic maneuvers to seek greater efficiency and accuracy in treating patients with risk of aspiration. Despite not presenting statistical significance, the maneuver of multiple swallowing seems to be the most appropriate and effective in these cases.

CONCLUSION The analysis of the swallowing pharyngeal phase in patients with chronic cough reveals that there are peculiarities in the swallowing functioning of this population, despite not presenting complaints relating to swallowing, it presents important aspiration risk due to the presence of changes in breathing pattern that can intervene in the coordination between breathing and swallowing, which is essential for the protection of the lower airway. However, there are recommended studies with larger samples that allow more inferences on this issue.

REFERENCES The previous diagnosis of lung disorders is important and requires interdisciplinary care. Notably in this study, it is perceived the relationship between the lung disease and the aspiration risk, attested by the findings found during the VFL (29).

1. Prodomo LPV, Angelis Ec, Barros ANP. Avaliação clínica fonoaudiológica das disfagias. In: Jotz GP, Angelis EC, Barros APB. Tratado da deglutição e disfagia: no adulto e na criança. Rio de Janeiro: Revinter, 2010. cap 6. p. 61-67.

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506


Pharyngeal swallowing phase and chronic cough.

Drozdz et al.

2. Marchesan IQ. O que se considera normal na deglutição. In: Jacobi JS, Levy DS, Silva LMC. Disfagia avaliação e tratamento. Rio de Janeiro: Revinter, 2003. cap 1. p.318. 3. Andrade CRF. Processamento motor- Padrão de organização da mastigação e deglutição. In: Andrade CRF, Limongi SCO. Disfagia prática baseada em evidências. São Paulo: Sarvier, 2012. cap.3. p. 24-31. 4. Jotz GP, Dornelles S. Fisiologia da deglutição. In: Jotz GP, Angelis EC, Barros APB. Tratado da deglutição e disfagia: no adulto e na criança. Rio de Janeiro: Revinter, 2010. cap. 2. p.16-20.

15.Andrade CRF. Prática Baseada em Evidência na Disfagia. In: Andrade CRF, Limongi SCO. Disfagia Prática Baseada em Evidências. São Paulo: Sarvier, 2012. cap. 1. p. 3-6. 16. Cardoso MCAF, Fontoura EG. Valor da auscuta cervical em pacientes acometidos por disfagia neurogênica. Arq. Int. Otorrinolaringol. 2009; 13 (4): 431-9. 17. Furkim, AM. Silva, RG. Programas de Reabilitação em Disfagia Neurogênica. In: Furkim, AM, Santini, CS. Disfagias Orofaríngeas. São Paulo: Pró – Fono; 1999. 18. O´Neil KH, Purdy M, Falk J, Gallo L. The dysphagia outcome and severity scale.Dysphagia. 1999; 14: 139-145.

5. Gonçalves MIR, César SR. Disfagias neurogênicas: Avaliação. In: Ortiz, KZ. (Org). Distúrbios neurológicos adquiridos. Barueri – SP: Manole, 2010. c. 14. p. 278-301.

19. Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996; 11: 938.

6. Silva RG. Disfagia orofaríngea pós acidente vascular encefálico. In: FERREIRA, LP et al. Tratado de Fonoaudiologia. São Paulo: Roca, 2004. cap.5. p. 354-355.

20. Paintal HS, Kuschner WG. Aspiration syndromes: 10 clinical pearls every physician should know. International Journal of Clinical Practice. 2007; 61 (5): 846-852.

7. Souza BBA et al. Nutrição e disfagia: Guia para profissionais. Curitiba – PR: Nutroclínica, 2003. cap.5. p. 17-22.

21. Dantas RO, Cassiani RA, Santos CM, Gonzaga GC, Alves LMT, Mazin SC. Effect of gender on swallow event duration assessed by videofluoroscopy. Dysphagia. 2009; 24:2804.

8. Swanson PB, Carrau RL, Murry T. Avaliação da deglutição com fibroendoscópio – FEES. In: Jotz GP, Angelis EC, Barros APB. Tratado da deglutição e disfagia. Rio de Janeiro: Revinter, 2010. cap. 9. p. 76-81. 9. Miller CD, Rebuck JA, Ahern JW, Rogers FB. Daily evaluation of macroaspiration in the critically Ill post-trauma patient. Current Surgery. 2005; 62 (5): 504-508. 10. Marik PE. Primary Care: Aspiration pneumonitis and aspiration pneumonia. The New England Journal of Medicine. 2001; 334 (9): 665-671. 11. Lopes FO. Tratado de Fonaudiologia. São Paulo: Tecmedd, 2005. 2ed. 12. Fleming CM, Shepard JO, Mark EJ. Case 15-2003: A 47year-old man with waxing and waning pulmonary nodules five years after treatment for testicular seminoma. The New England Journal of Medicine.2003. 348 (20): 2019-2027. 13.Gross RD, Atwood Jr CW, Ross SB, Olszewski JW, Eichhorn KA. The coordination of breathing and swallowing in chronic obstructive pulmonary Disease. Am J Respir Crit Care Med. 2009; 179 (7): 559-65. 14.Palombini BC et al. Recentes progressos no diagnóstico diferencial da tosse crônica. Rev Bras Clín Ter. 1997; 23(2):402.

22. Prodomo LPV. Caracterização videofluoroscópica da fase faríngea da deglutição [ tese de doutorado]. São Paulo (SP): Fundação Antonio Prudente; 2010. 23. Chaves RD, Carvalho CRF, Cukier A, Stelmach R, Andrade CRF. Indicadores de disfagia na doença pulmonar obstrutiva crônica. In: : Andrade CRF, Limongi SCO. Disfagia Prática Baseada em Evidências. São Paulo: Sarvier, 2012. cap.13. p. 151-166. 24. Kolb G, Bröker M. State of the art in aspiration assessment and the idea of a new non invasive predictive test for the risk of aspiration in stroke. The Journal of Nutrition, Health & Aging©. 2009; 13 (5): 429-433. 25. Kijima M, Isono S, Nishino T. Coordination of swallowing and phases of respiration during added respiratory loads in awake subjects. American Journal of Respiratory and Critical Care Medicine. 1999; 159: 1989-1902. 26. Coelho CA. 1987 apud Chaves RD, Carvalho CRF, Cukier A, Stelmach R, Andrade CRF. Sintomas indicativos de disfagia em portadores de DPOC. J Bras Pneumol. 2011; 37(2):176183. 27. Silva LMC, Jacobi JS. Disfagia orofaríngea e sua importância na pneumologia. In: Jacobi JS, Levy DS, Silva LMC. Disfagia

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avaliação e tratamento. Rio de Janeiro: Revinter, 2003. cap. 12. p. 163-180. 28. Person OC, Cerchiari DP, Zanini RVR, Santos RO, Rapoport PB. Cisto de base de língua como causa de tosse crônica. Arq Med ABC. 2005; 31 (1): 35-7. 29. Langmore SE, et al. Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia. 1998; 13 (2): 6981.

30. Dyer JC, Leslie P, Drinnan MJ. Objective computer-based assessment of valleculae residue—is it useful? Dysphagia. 2008; 23 (1): 7-15. 31. Eisenhuber E, et al. Videofluoroscopic assessment of patients with dysphagia: Pharyngeal retention is a predictive factor for aspiration. AJR Am J Roentgenol. 2002; 178 (2): 393-8.

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Int. Arch. Otorhinolaryngol. 2012;16(4):509-514. DOI: 10.7162/S1809-97772012000400013

Original Article

Prevalence of noise-induced hearing loss in drivers Andréa Cintra Lopes1, Vanessa Guioto Otowiz2, Patrícia Monteiro de Barros Lopes3, José Roberto Pereira Lauris4, Cibele Carméllo Santos5. 1) PhD. Associate Professor, Department of Speech Pathology, Faculty of Dentistry of Bauru, FOB-USP. 2) Audiologist for Hearing and Communication Institute. Speech therapist. 3) Degree in Speech Pathology. Speech Therapist - Director of SEAI-Specialized Industrial Audiology. 4) Doctor. Associate Professor, Department of Pediatric Dentistry, Orthodontics and Public Health, FOB-USP. 5) Speech. Master in Sciences Graduate Program in Applied Dental Sciences - Area Speech Pathology, Faculty of Dentistry of Bauru - FOB-USP. Institution:

Department of Speech Pathology. University of Dentistry of Bauru. University of São Paulo. Bauru / SP - Brazil. Mailing address: Andrea Lopes Cintra - Department of Speech Pathology, Faculty of Dentistry of Bauru - University of São Paulo - Dr. Octavio Al Pinheiro Brisolla, 9-75 - Vila Universidade - Bauru / SP - Brazil - Zip code 17043-101 - PO Box: 73 - Telephone: (+55 14) 3235-8000 ext: 8532 - Email: aclopes@usp.br Article received October 14, 2009. Article approved on April 27, 2011.

SUMMARY Introduction: Work-related hearing loss is one of the most common occupational illness progresses over the years of noise exposure associated with the work environment, may cause damage to undertake physical activity, the individual’s physiological and mental besides causing hearing damage irreversible interfering with communication and quality of life. With high prevalence of male evaluates which is the second leading cause of hearing loss. Since there is no medical treatment for this type of hearing loss, it is evident the importance of preventive and conferences aimed at preserving hearing and health as a whole. Objective: To assess the prevalence of hearing loss in audiometry admission of drivers. Methods: Retrospective study. By 76 charts of professional drivers in leased transport companies. We analyzed data from specific interview and pure tone audiometry. Results: The prevalence of abnormal tests was 22.36% with the lowest thresholds for tritonal average of 3,000, 4,000 and 6,000 Hz. The higher the age, the higher thresholds. Conclusion: This study has highlighted the occurrence of hearing in the absence of complaints. Considering that PAIR is preventable, justifies the importance of coordinated and multidisciplinary involving not only health teams and safety, but also the institutions involved in preserving the health of workers, as the team SESMET, unions or prosecutors. Keywords: noise; pure tone audiometry; hearing loss.

INTRODUCTION Hearing loss related to work has been the subject of studies in the field of public health in terms of hearing disorders that affect communication and quality of life of workers. It is an occupational disease of high prevalence. In Brazil, noise induced hearing loss (PAIR) is one of the major health problems of workers (1) and ranks second among the most frequent diseases of the hearing aid (2). This occupational disease was defined as a gradual decrease in hearing acuity resulting from continuous exposure to high sound pressure levels, causing injury to the inner and outer hair cells of the organ of Corti. It is characterized by sensorineural hearing loss, irreversible, almost always bilateral and symmetrical, not exceeding 40 dB (NA) at low frequencies and 75 dB (NA) at high frequencies, manifesting itself first in 6000 Hz, 4000 Hz and / or 3000Hz, extending up to frequencies of 8000 Hz, 2000 Hz, 1000 Hz, 500 Hz, 250 Hz and is irreversible character and progressive

evolution, but preventable (3). Also described as a cumulative and insidious disease that progress over the years of noise exposure associated with the work environment. His initial signs show the onset of hearing thresholds in one or more frequency range between 30006000 Hz (4). Occupational noise may also contribute to accidents in the workplace; it increases communication difficulties (5), maintenance of attention, concentration and memory (6), in addition to stress and excessive fatigue (7). Although work-related hearing loss has reached major proportions in the industrial environment, the estimates of prevalence of this disease in different segments of the working classes, are basically made by some epidemiological studies, once again, that in most cases, does not cause incapacity for work, according to the Ministry of Social Security, in 1998, difficulties in determining this aspect notification of this hazard to worker health (8).

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A survey of the literature to ascertain the existence of similar work undertaken with the approach proposed in this study. To this end the research was performed in the Cochrane Portal Virtual Health Library (VHL), Medline, Lilacs and SciELO, using the following keywords: hearing loss, driver / hearing loss, and drivers. The study period was from 1997 to 2009. This search identified 37 articles. Excluding repeated studies and those not related directly or indirectly to the subject of this project were obtained from a total of 9 studies listed in Table 1.

Picture 1. Number of citations found in search sources on the studies related to hearing loss in drivers. Descriptors Source Search Cochrane Medline Lilacs SicElo Hearing loss and drivers 7 20 4 0 Hearing loss and driver 0 0 2 4

The studies related to hearing loss in drivers, as well as the prevalence of PA and main symptoms are presented in Table 2.

was used to an analysis of variance and Tukey test. In all statistical tests we adopted a significance level of 5% (p <0.05).

Whereas the effects of work-related Hearing Loss (PAIR, acoustic trauma and hearing loss caused by exposure to chemicals) may impair the quality of life since they affect work and social relations with the disease is evident importance of preventive and collective aimed at preserving hearing and overall health. Thus, this study has the main objective to assess the prevalence of hearing loss in audiometry admission of drivers. These data that will be used to implement educational measures and / or preventive in this population.

RESULTS Regarding the characterization of the study population, this study was composed only by male workers, ranging from age 19 to 54 years, with 63.16% of the sample had between 19 and 35 years, 21.05% were aged between 36 to 45 years and 15.79% aged 46-54 years. In the interview specifies, it can be seen that the presence of tinnitus were reported by one subject (1.32%). No other symptoms were identified impaired or nonoccupational information.

METHOD The prevalence of altered audiometry was 22.36%. This is a retrospective study, which examined the medical records of 76 audiometries admission of leased drivers in transport companies after having received the approval of the Research Ethics Committee, as Case No. 147/2009. We excluded records of drivers who had hearing loss with undetermined etiology, aged 55 years or who were deemed unfit for the role. Interview data were observed specific and pure tone audiometry, performed by the audiometer Interacoustics Midimate 622 model. Audiometry was performed in a soundproof booth and auditory rest of 14 hours. Previously audiometry was performed visual inspection of the external auditory canal to verify the possibility for the realization of pure tone audiometry.

While investigating, through Friedaman test if there was any more often affected, there were no significant results. Chart 1 shows the mean thresholds for all frequencies studied, considering the average tritonal (500Hz, 1kHz and 2kHz) and (3 kHz, 4 kHz and 6 kHz) for both ears through the paired t test, in which the frequencies of 500KHz, 1kHz, 2kHz and 3kHz average of tritonal, 4kHz and 6kHz both ears studied showed statistically significant result. In the right and left ears, the average tritonal 500Hz, 1kHz and 2kHz, obtained was 11.67 dB, while the average tritonal 3kHz, 4kHz and 6kHz for the right ear was 10.83 dB while the left ear was 13 33 dB. Thus, there are increased thresholds for high frequencies.

Statistical method The values observed in the studied variables were stored in Microsoft Excel. We used descriptive statistics by mean, median, minimum and maximum values. To analyze the comparison between right ear and left ear test was used t-test. We used the Pearson correlation coefficient to assess the correlation between the age of the individuals surveyed and hearing thresholds. To compare the three age groups

Regarding the age groups studied, the highest prevalence was obtained from changes observed in the older age groups. Table 1, using the Test of Pearson Correlation Coefficient presents data averages tritonal correlation with the age groups. To compare the three age groups was used to an analysis of variance and Tukey test when they were

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Picture 2. Studies related hearing loss in drivers. Authors/Year Objective Cordeiro, Lima-Filho e Associated between Birth / 1994 induced hearing loss by noise and cumulative time of work Martins e cols / 2001

Investigate the hearing

Corrêa Filho et al / 2002

To estimate the prevalence hearing loss of and noise-induced hypertension in urban bus drivers Investigate hearing

Cepinho, Corrêa, Bernardi / 2003 Freitas e Nakamura / 2004

Silva e Mendes / 2005

Siviero et al / 2005

Silva, Gomes, Zaher / 2006 Lopes, Russo, Fiorini / 2007

Janghorbani, Sheikhi, Pourabdian / 2009

Lopes et al.

Casuistry 278 drivers: 147 drivers 131collectors of vehicles collective of the city of Campinas - SP 174 participants (140 bus drivers e 34 collectors) 108 drivers of Campinas - SP

111 drivers from GI bus 57 GII truck drivers To study the incidence of 104 drivers from induced hearing loss two companies by noise in drivers mass transport from bus with the engine from checking the front Campinas - SP audiological profile of this population Quantify exposure 141 drivers of of bus drivers Bus - group exposed the body vibration and control group, whole and noise, and being 74 (52,5%) of analyze the possible group with a driver association between in the company These two factors not exceeding three years of risk for PAIR 67(47,5%) with five years or more To study the prevalence 50 drivers from hearing loss audiometric and the bus, with time characteristics on drivers of exposure to City Bus noise over Maringá - Paraná five years Audiological profile 28 drivers from ambulance drivers Studying the hearing 75 drivers and its relationship to Truck with time life quality in drivers of trucks Estimating the Random sample of prevalende and the 4300 drivers that factores risks drives over long distances

Age Without information

Prevalence of DA Without information

18 to 60 years old Average of 38.64 years

37% group of drivers (34%) group of collectors (3%) 32.7% of the total examined

35 to 43 years old

4,5% GI and 11,5% GII

21 to 63 19% of years old, audiometries with average from 37,5 years

Without information

Without information

46% in the group considered as above and 24% no defined as unexposed

28% of audiograms suggesting PAINSPE

Until 63 yeras

50% presented PAIR

27 to 61 years profession varying 5 a 40 years Greater than or equal to 20 years

28,6%

Prvalence of bilateral PAIR was of 18,1%, bigger in right ear 6,5% do than the left ear

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intensity (dB)

z

e z

1K H

4K H

z,

z,

0 2 4 6 8 10 12 14 16 18

3K H

50 0H

25 0H z 50 0H z 1k H z 2k H z 3k H z 4k H z 6k H z 8k H z

z

e

Frequence (Hz)

Table 1. Correlation between age groups and the average tritonal. Correlation R P 500Hz, 1kHz e 2kHz OD 0,2641 0,021* 500Hz, 1kHz e 2kHz OE 0,1945 0,092 3kHz, 4kHz e 6kHz OD 0,2459 0,032* 3kHz, 4kHz e 6kHz OE 0,3026 0,008* * Statistically significant correlation (p<0,05)

6K H

2K H

z

Prevalence of noise-induced hearing loss in drivers.

LE Average RE Average

Graphic 1. Shows the comparison between the average hearing thresholds of right and left ears done all frequencies studied and compare the average of hearing thresholds of mid frequencies (500Hz, 1kHz and 2kHz) and high (3 kHz, 4 kHz and 6 kHz) for both ears.

Table 2. Mean and standard deviation of hearing thresholds in the different age groups. Age group Ear

19 a 35 36 a 45 46 a 54

Right

19 a 35 36 a 45 46 a 54

Left

250Hz

500Hz

1KHz

2kHz

3 kHz

4kHz

Aver. SD Aver. SD Aver. SD Aver. SD Aver. SD 14.63 4.77 13.65 4.58 9.58 6.09 7.71 7.07 8.75 7.96 12.19 7.74 12.19 7.74 9.69 6.45 9.69 6.94 11.25 10.80 15.42 3.96 16.25 4.83 12.92 5.82 12.50 10.55 16.25 11.51 13.85 5.95 14.17 4.58 13.75 6.71 13.44 7.74 15.83 4.69 15.83 4.83

4.83 5.32 6.08

6kHz

Aver. SD Aver. SD 12.08 11.62 9.89 11.46 10.94 9.87 9.71 11.25 20.00 10.22 7.53 13.75

8kHz

frequencies averages

high frequencies

Aver. SD Aver. SD 9.27 8.87 10.31 4.68 12.50 9.83 10.52 5.70 10.83 10.19 13.89 5.43

Aver. SD 11.22 8.77 10.77 8.26 18.61 8.25

6.09 9.17 5.86 10.42 8.30 12.81 11.98 15.10 11.32 8.65 9.49 11.60 3.95 12.78 9.44 6.45 10.31 6.70 14.06 8.61 18.13 7.72 15.63 9.98 11.88 9.46 11.67 5.34 15.94 8.12 5.82 10.42 6.56 17.08 12.70 23.75 12.45 18.33 10.52 13.75 10.25 13.33 4.08 19.72 8.81

created three groups with Group I consists of workers aged 19-35 years, group II of 36 to 45 years and group III 46-54 years. Table 2 shows the mean and standard deviation of hearing thresholds in these age groups.

psychologists, nurses, speech therapists, as well as management teams.

DISCUSSION

Traffic noise is a major cause of noise pollution, especially in large centers. Several studies have described the compromises health in drivers, since the performance of professional drivers is of great responsibility, are responsible for the care and safety of the vehicle, lives under its responsibility, valuable and toxic loads, defective signaling pathways in addition to their own health care, these added responsibilities, this profession is characterized by daily challenges that the driver is forced to confront in their working day. Besides these aspects, excessive noise, heat it gives off from inside the cab, the conformation of the chair, not always anatomically correct, and remaining in the same position in front of the steering wheel, these professionals require intense physical and mental activity.

The health care worker is a will that intertwines workers and researchers creating a scenario interdisciplinary and multidisciplinary, as it is discussed by various knowledge areas such as workplace safety professionals, physicians,

In this study, the age of the study population ranged from 19 to 54 years, with 63.16% aged 19 to 35 years, as well as other studies show consisting of young workers (9, 10, 11, 12, 13). Another fact is the prevalence

From the results presented in Table 2 it was noted that the frequencies of 3 kHz, and the average tritonal 3kHz, 4kHz and 6kHz in the right ear and left ear 3kHz significant difference between the age group 19-35 years and 46 to 54 years, so those frequencies in the lower age group had better hearing thresholds than the group aged 46-54 years. The frequency of 6 kHz in the right ear with the group aged 36 to 45 showed better thresholds statistically significant compared to groups aged between 46 and 54 years.

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of males, justified in terms of the professional category studied, since this also obtained in all studies cited in the literature. Another data obtained from medical records analyzed was that there was only one information from tinnitus (1.32%), information obtained in a participant 54 years of age who had normal audiogram, bilaterally. Tinnitus is a common complaint and is present in 4% of the sample of the work of Araujo (2002) (14) and 2.75% in the work of LOPES and NELLI (2008) (15). We believe that in this study there was no association of altered thresholds and tinnitus probably by way of collecting information. Considering the results obtained in this study, an alarming factor, though expected, was the prevalence of abnormal audiograms, since PAIR ranks second among the most frequent diseases of the hearing. In this study, the prevalence of abnormal tests was 22.36%, this figure is equivalent to other studies. In studies HANGER and BARBOSA-BRANCO (2004) (3) had a prevalence of 48% in workers exposed to noise, LOPES and NELLI (2009) (15) the prevalence was 24.75%, this professional category, previous studies showed a prevalence ranging from 4.5% to 46% (16,12,9,10,11,17,18 and 13). Although the literature indicates a high prevalence of abnormal tests in subjects exposed to occupational noise, 100% of the records analyzed reported no abuse hearing, given that observed in previous studies (19). The comparative analysis between the mean tritonal 500, 1kHz and 2kHz and 3kHz, 4kHz and 6kHz, as can be seen in Table 1, demonstrates worse thresholds for high frequencies, meeting with literature data (20, 21, 14 and 15). In analyzing whether age influenced the participants studied in auditory thresholds, as shown in Table 2 the age influenced the audiometric findings, the higher the age, the higher thresholds, as well as the findings of LOPES, RUSSO and FIORINI, 2007 (12) and LOPES and NELLI, 2009 (15). By analyzing the results of audiometry admission of these workers and assuming 100% of them did not complain hearing, and the prevalence of abnormal tests was high it is essential that the audiometric assessment should not only indicate the annual prevalence of hearing impairment, but rather by midst deploy a Prevention Program hearing Loss (PPPA), which primarily promotes actions to prevent the onset or worsening of hearing loss, as well as the extra-auditory effects caused by exposure to loud noise or other risk agents to audition for professional drivers. Once you for good job performance, the driver

should enjoy good health, working hours and conditions appropriate. Finally, there is the need for greater investment in research capable of providing subsidies to create viable strategies for prevention and intervention in this population.

CONCLUSION This study has highlighted the occurrence of hearing loss suggestive of work-related hearing loss in the absence of hearing complaints. Considering that PAIR is preventable, justifies the importance of coordinated and multidisciplinary involving not only health teams and safety, but also the institutions involved in preserving the health of workers, as the team SESMET, unions or prosecutors.

REFERENCES 1. Gabas G. Listen well and protect yourself. Rev Protection. 2007, 181:54-61. 2. Atti JL, Correa AG, Stefani F, Vaccaro S. Noise Induced Hearing Loss. Rev Cient AMECS. 2000, 9(2):40-4. 3. Hanger MRHC, Barbosa-Branco A. Auditory effects resulting from occupational noise exposure in workers at quarries in the Federal District. Rev Brazilian Med Assoc. São Paulo. 2004, 50(4):396-9. 4. Gatto C, Lerman RA, Teixeira, TM, Magni C, Morata TC. The analysis of the conduct of doctors before workers with hearing loss. Rev. Communication Disorders. São Paulo. 2005, 17(1):101-14. 5. Hétu R, Quoc HT. Psychoacoustic performance in workers with PAIR. In: Axelson A, Bordigrevink H, Hamernik RP, Hellstrom P, Henderson D, Salvi RJ, editors. Scientific basis of noise-induced hearing loss. New York: Thieme; 1996. p. 264-85. 6. Silva GLL, Gomes MVSG, Zaher VL. Audiological profile of ambulance drivers from two hospitals in the city of São Paulo, Brazil. Arq Int Otolaryngol. 2006, 10(2):132-140. 7. Ferreira Jr M. Noise-induced hearing loss. In: Ferreira Jr Ed. Worker Health. São Paulo: Rocca; 2000, p.265-85. 8. Ministry of Social Security. Technical Standard for Review of Disability – PAIR, 05 of August 1998. Approves Technical Standard on sensorineural hearing loss by continuous exposure to high sound pressure levels. Service Order INSS/ DSS no. 608, Brasília - DF; 1998.

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9. Martins AL, Alvarenga KF, Bevilacqua MC, Costa Filho AO. Hearing loss in bus drivers and conductors. Rev Bras Otolaryngol. 2001, 67(4):467-73. 10. Corrêa Filho HR, Costa LS, Hoehne EL, Pérez MAG, Nascimento LCR, Moura EC. Noise-induced hearing loss and hypertension in bus drivers. Rev Public Health. 2002, 36(6):693-701. 11. Freitas RGF, NAKAMURA HY. Noise Induced Hearing Loss in Bus Drivers with Motor Front. Health Rev Piracicaba. 2003, 5(10):13-19.

truck and bus drivers from Sao Paulo. Rev Cefac. 2003, 5(2):181-6. 17. Silva LF; Mendes R. Combined exposure to noise and vibration and its effects on the hearing of workers. Rev Public Health. 2005, 39(1):9-17. 18. Siviero AB; Fernandes MJ, Lima JAC; Santoni CB, Bernadi APA. Prevalence of hearing loss among drivers of public transport buses in the city of Maringá, PR. Rev Cefac. 2005, 7(3):376-81.

12. Lopes G, Russo ICP e Fiorini AC. Study of hearing and quality of life in truck drivers. Rev CEFAC. 2007, 9(4):532-42.

19. Amorin RB, Lopes AC, Santos KTP, Melo ADP, Lauris JRP. Changes in Occupational Hearing Exposure Musicians. Arq Intern Otolaryngol. 2008, 12(3):377-83.

13. Janghorbani M, Sheikhi A, Pourabdian S. The prevalence and correlates of hearing loss in drivers in isfahan, iran. Archives of Iranian medicine. 2009, 12(2):128-34.

20. Kós AOA, Kós MI. Etiologies of hearing loss and auditory characteristics. In: Frota, Silava. Fundamentals in Speech. Rio de Janeiro: Ed. Guanabara Koogan, 1998.

14. Araujo SA. Noise-induced hearing loss among workers of metallurgical. Rev Bras Otolaryngol. 2002, 68(1):47-52.

21. Ruggieri M, Cattan S, Giardini LDL, Oliveira KAS. Noiseinduced hearing loss in 472 workers from the region of ABC. Arq Méd ABC. 1991, 14(1):19-23.

15. Lopes AC, Nelli MP, Lauris JRP, Amorin RB, MeloADP. Terms of hearing health at work: investigation of auditory effects in workers exposed to occupational noise. Arq Int Otolaryngol. 2009, 13(1):49-54. 16. Cepinho PC, Correa A, Bernardi APA. Hearing loss in

References which are cited only in table 2 Cordeiro R, Clemente APG, Diniz CS, Dias A. Occupational noise exposure as a risk factor for workplace accidents. Rev Public Health. 2005, 39(3):461-6.

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Int. Arch. Otorhinolaryngol. 2012;16(4):515-522. DOI: 10.7162/S1809-97772012000400014

Review Article

Evoked otoacoustic emissions in workers exposed to noise: A review Patrícia Arruda de Souza Alcarás1, Débora Lüders1, Denise Maria Vaz Romano França1, Regina Maria Klas2, Adriana Bender Moreira de Lacerda3, Cláudia Giglio de Oliveira Gonçalves3. 1) Master. Fonoaudiology - Teacher. 2) Master. Fonoaudiology. 3) Doctor. Fonoaudiology - Teacher. Institution:

Trabalho realizado no Programa de Mestrado e Doutorado em Distúrbios da Comunicação Humana, Universidade Tuiuti do Paraná - UTP. Curitiba / PR - Brazil. Mailing address: Patrícia Arruda de Souza Alcarás – Rua Manoel Eugênio, 529 - Cidade Universitária - Presidente Prudente / SP – Brazil - Zip code: 19050-300 – E-mail: patricialcaras@hotmail.com Article received in March 2, 2012. Article approved in May 27, 2012.

SUMMARY Introduction: The otoacoustic emissions test is an essential tool in the evaluation of auditory function, since it allows the early detection of cochlear damage of occupational origin. Objective: To present a review of the literature and analyze the effectiveness of the clinical application of the otoacoustic emissions test in workers exposed to noise. Methods: A bibliographical search covering a period of 10 years was performed in the Virtual Health Library including published articles in national and international journals indexed in the internationally recognized databases for the health sciences, LILACS, SCIELO, and MEDLINE, using the terms “otoacoustic emissions” and “occupational exposure.” The type of published article (national/international), the type and intensity of the stimulus most commonly used for the evoked otoacoustic emissions, the gender and age of the subjects, and the conclusions from the retrospective studies were all taken into consideration. Results and Conclusions: A total of 19 articles were analyzed, 7 national and 12 international, covering subjects from 17 to 77 years of age, mostly men. The type of stimulus most commonly used for the evoked otoacoustic emissions was the distortion method (12). Through this review, we have concluded that testing of evoked otoacoustic emissions in workers exposed to noise is an important tool in the early diagnosis of noise-induced cochlear hearing disorders. Keywords: occupational health; hearing; electrophysiology; noise effects; occupational exposure.

INTRODUCTION Hearing is crucial in the communication process, and any change in auditory perception can lead to problems in communication and socialization of human beings with their peers (1,2). Exposure to loud noise is an occupational health risk factor, causing general, and auditory disturbances (3,4). In the auditory system, noise will affect mainly the outer hair cells in the cochlea. Current knowledge of the physiology of hearing aids, particularly in the functioning of the cochlea, allows for insight regarding studies of noise-induced hearing loss (NIHL). It has been reported (5) that noise can affect cochlear function through 7 possible mechanisms: 1. by

direct mechanical injury, 2. by excess glutamate in the synapses of inner hair cells, 3. by over-stimulation of Nmethyl-D-aspartame receptors that would lead to the release of nitric oxide, 4. by free radicals of oxygen atoms, 5. by a reduction of magnesium that would alter intracellular activity, 6. by an increase of intracellular calcium, and 7. by protein damage. NIHL is irreversible and progressive sensorineural cochlear damage. In the early stages of NIHL, the individual may have tinnitus and a fleeting feeling of auditory plenitude, but the hearing loss cannot be identified in an audiogram. However, with continued exposure to loud noise over several years, there will be hearing loss that can be described in an audiogram, initiating then a permanent decline in hearing (6). It has also been reported (7) that cell damage by noise can be described in 3 stages, in accordance with exposure time:

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1. onset, the death of hair cells with formation of scabs, which is not distinguishable by conventional audiometry; 2. after several years of exposure, damage in the first third of the cochlea, or 10 mm from the cochlear base, which is a more sensitive area owing to metabolic, vascular, and anatomical factors, with detectable changes in audiometric pure tone thresholds of 3–6 kHz; 3. after decades of exposure, injuries of a more extensive range in the cochlea, affecting the mid and low frequencies.

because its subject of research was animals exposed to broadband noise.

REVIEW After selection and full analysis of the publications, each article was classified according to whether it was nationally or internationally published, and the articles were indexed by 5 categories: database, article title, author, year, and country of publication.

Legally, the evaluation of patients with NIHL occurs through the use of audiometric tests (8). Currently, other objective tests are recommended for early diagnosis of NIHL, as in the case of evoked otoacoustic emissions (EOAE) (9,10,11,12).

Next, we analyzed the criteria used by the authors of each article, taking into account the following variables: number of participants, age (given by the variance or mean age), and gender.

EOAE testing was introduced at the end of the 1970s (13), and reduction in the amplitude of EOAE intensity response in patients with NIHL compared to the unexposed group was demonstrated.

Finally, analyses were made of the parameters used in the investigation of the EOAE tests, classifying them by stimulus intensity and type of test: transient evoked, distortion product, or both.

Recent research shows that the EOAE test has become an essential tool in the evaluation of auditory function because it allows early detection of cochlear damage resulting from occupational noise (14).

Chart 1 presents the studies classified according to their origin (national/international), database, title, author, year, and country of publication.

The aim of this study was to analyze the recent scientific literature on the clinical application EOAE tests in workers exposed to noise.

Table 1 presents the criteria of the research, taking into account the age (given by the variance or mean age), gender, and number of subjects. Table 2 shows the analysis of parameters used to investigate the OAEs according to the type of test: transient evoked (TEOAE), distortion product (DPOAE)(11; 57.89%), or both (8, 42.11%), and the intensity of the stimulus.

METHODS The universe of analysis chosen for the literature review included scientific publications in national and international journals that were indexed in 3 internationally recognized databases for the health sciences: LILACS, SciELO, and Medline. A search was performed in the Virtual Health Library, covering a period of 10 years, using the terms “otoacoustic emissions” and “occupational exposure.” A survey of the publications was initially performed by reading abstracts in the BIREME virtual library (www.bireme.br), and when the abstract served the interests of this study, the full text of the article was requested for analysis. The indexed periodicals surveyed in the databases included for this review were national and international scientific publications published in Portuguese or English between 2000 and 2010. There were 19 papers selected for analysis, 7 national and 12 international. Only 1 study was excluded

RESULTS The goal of this review was to analyze the scientific literature on the clinical application of EOAE tests for workers exposed to noise. In referring to the origin of publications, there were more articles found in international journals than in national journals (Chart 1). The results the analysis suggest that EOAE testing is a valuable tool for occupational health research and early diagnosis of NIHL in various professions. The occupational categories included were: musicians (15,16,17), fishermen (18), farmers (12), construction workers (19,20), military personnel (21), textile industry workers (22), workers in various industrial activities (23,24,25,26,27), university employees exposed

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Chart 1. Analysis of scientific articles regarding otoacoustic emissions in workers exposed to occupational noise based on database, article title, author, and year/country. T Database Article Title Author Year/Country National 1 LILACS Estudo da audição de músicos de rock and roll Maia and Russo (16) 2008/Brasil 2 LILACS Exposição ao ruído ocupacional: alteração no exame de emissões Marques and Costa (4) 2006/Brasil otoacústicas 3 LILACS Emissões otoacústicas - produto de distorção em indivíduos Alvarenga et al. (23) 2003/Brasil expostos ao chumbo e ao ruído 4 LILACS Avaliação Audiológica e de emissões otoacústicas em indivíduos Guida et al. (12) 2009/Brasil expostos a ruído e praguicida 5 LILACS Alterações auditivas da exposição ocupacional em músicos Amorin et al. (15) 2008/Brasil 6 LILACS Emissões otoacústicas – Produto de distorção: Estudo de diferentes Fiorini and Parrado-Moran (22) 2005/Brasil relações de níveis sonoros no teste em indivíduos com e sem perdas auditivas 7 LILACS Aplicações clínicas das emissões otoacústicas: produto de distorção Parrado-Moran and Fiorini (31) 2003/Brasil em indivíduos com perda auditiva induzida por ruído ocupacional International 8 Medline Audiological findings among workers from Brazilian small-scale Paini et al. (18) 2009/USA fisheries 9 Medline Audiological findings in workers exposed to styrene alone or in concert with noise Johnson et al. (24) 2006/England 10 Medline Distortion product otoacoustic emissions in an industrial setting Korres et al. (25) 2009/England 11 Medline Effect of exposure to a mixture of solvents and noise on hearing and Prasher et al. (28) 2005/England balance in aircraft maintenance workers 12 Medline Effectiveness of hearing protector devices in impulse noise verified Bockstael et al. (21) 2008/USA with transiently evoked and distortion product otoacoustic emissions 13 Medline Low-level otoacoustic emissions may predict susceptibility to noise- Lapsley Miller et al. (29) 2006/USA induced hearing loss 14 Medline Music exposure and audiological findings in Brazilian disc jockeys Santos et al. (17) 2007/USA 15 Medline Otoacoustic emission sensitivity to low levels of noise-induced Sisto et al. (26) 2007/USA hearing loss 16 Medline Predictions of hearing threshold levels and Distortion product Seixas et al. (19) 2004/England otoacoustic emissions among noise exposed young adults 17 Medline Prospective noise induced changes to hearing among construction Seixas et al. (20) 2005/ England industry apprentices 18 Medline Susceptibility to tinnitus revealed at 2 kHz range by bilateral lower Job, Raynal, and 2007/ DPOAEs in normal hearing subjects with noise exposure Kossowski (30) Switzerland 19 Medline The evaluation of noise-induced hearing loss with distortion Balatsouras (27) 2004/Poland product otoacoustic emissions Legend: DPOAE: distortion product otoacoustic emissions

to occupational noise (4), carpenters (4), aviation employees (28), mariners (29), aviators (30), and workers exposed to noise (31) (Table 1). Regarding the combined exposure to noise and environmental contaminants (solvents, asphyxiants, metals, and pesticides) (31), it was noted that there is controversy

on this subject. While some authors offered significant evidence of effects on EOAE results in workers exposed simultaneously to noise and chemicals compared to workers exposed only to noise (12,24,28), other authors did not agree (23). For all studies (Table 1), the total number of

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Table 1. Analysis of criteria used in the studies according to the number of participants, age group, and gender Article Database Title Number Age Group of Subjects 1 LILACS Estudo da audição de músicos de rock and roll 23 21–38 2

LILACS

3

LILACS

4

LILACS

5

LILACS

6

LILACS

7

LILACS

8 9

Medline Medline

10

Medline

11

Medline

12

Medline

13

Medline

Exposição ao ruído ocupacional: alteração no exame de emissões otoacústicas Emissões otoacústicas - produto de distorção em indivíduos expostos ao chumbo e ao ruído Avaliação Audiológica e de emissões otoacústicas em indivíduos expostos a ruído e praguicida Alterações auditivas da exposição ocupacional em músicos

74

Not specified

66

34–40

51

24–57

30

18–37

Emissões otoacústicas – Produto de distorção: Estudo de diferentes relações de níveis sonoros no teste em indivíduos com e sem perdas auditivas

G1 = 80 14–46 G2 = 89 20–60

Aplicações clínicas das emissões otoacústicas: produto de distroção em indivíduos com perda auditiva induzida por ruído ocupacional Audiological findings among workers from Brazilian small-scale fisheries Audiological findings in workers exposed to styrene alone or in concert with noise Distortion product otoacoustic emissions in an industrial setting

89

20 – 60

141 313

18–77 20–65

139

24–54

Effect of exposure to a mixture of solvents and noise on hearing and balance in aircraft maintenance workers

G1=174 G1=47.4 avg.

Effectiveness of hearing protector devices in impulse noise verified with transiently evoked and distortion product otoacoustic emissions Low-level otoacoustic emissions may predict susceptibility to noise-induced hearing loss

G2=153G2=53.3 avg. G3=13 G3=49.6 avg. G4=39 G4=47.6 avg. 55 19–48 G1=33818–46 G2=28 20–53

14 15

Medline Medline

16

Medline

Music exposure and audiological findings in Brazilian disc jockeys (DJs) 30 Otoacoustic emission sensitivity to low levels of noise-induced hearing loss 217

17–39 18–35

Predictors of hearing threshold levels and distortion product 436 17–57 otoacoustic emissions among noise exposed young adults 17 Medline Prospective noise induced changes to hearing among construction 328 27.5 avg. industry apprentices 316 25–35 18 Medline Susceptibility to tinnitus revealed at 2 kHz range by bilateral lower DPOAEs in normal hearing subjects with noise exposure 19 Medline The evaluation of noise-induced hearing loss with distortion 34 29–54 product otoacoustic emissions Legend: M, male; F, female; G 1, 2, 3, 4, groups; avg., average; DPOAEs, distortion product otoacoustic emissions.

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Gender 19 M 4F 74 M Not specified 51 M. 27 M 3F 66 M 14 F 66 M 4F 64 M. 4F 141 M. 278 M 35 F 86 M 53 F Not specified

55 M 35 F 303 M 8F 20 M 30 M Not specified 367 M 69 F 272 M 56 F 306 M 10 F 22 M 12 F


Evoked otoacoustic emissions in workers exposed to noise: A review.

Alcarás et al.

Table 2. Analysis of scientific articles in relation to the research parameters used. Article Database Author Year/Country Type of OAE Stimulus Intensity 1 LILACS Maia and Russo (16) 2008/Brazil TEOAE 80 dB SPL DPOAE L1 = 65 dB SPL, L2 = 55 dB SPL 2 LILACS Marques and Costa (4) 2006/Brazil DPOAE L1 and L2 intensity not specified 3 LILACS Alvarenga et al. (23) 2003/Brazil DPOAE L1 = 70 dB, L2 = 70 dB 4 LILACS Guida et al. (12) 2009/Brazil DPOAE L1 = 65 dB SPL, L2 = 55 dB SPL 5 LILACS Amorin et al. (15) 2008/Brazil TEOAE 79–83 dB SPL DPOAE L1 = 65 dB SPL, L2 = 55 dB SPL 6 LILACS Fiorini and Parrado-Moran (22) 2005/Brazil DPOAE L1 and L2 = 70 dB SPL; L1=65 dB SPL, L2=55 dB SPL 7 LILACS Parrado-Moran and Fiorini (31) 2003/Brazil DPOAE L1=65 dB SPL, L2=55 dB SPL 8 Medline Paini et al.(18) 2009/USA 9 Medline Johnson et al. (24) 2006/England DPOAE L2 = 10 dB below L1, intensity not specified 10 Medline Korres et al. (25) 2009/England DPOAE f1 = 60 dB SPL, f2 = 45 dB SPL 11 Medline Prasher et al. (28) 2005/England TEOAE 80 dB SPL DPOAE L1 = 5 dB SPL, L2 = 55 dB SPL 12 Medline Bockstael et al. (21) 2008/USA TEOAE 86 dB SPL DPOAE L1 = 75 dB SPL, L2 = 70 dB SPL 13 Medline Lapsley Miller et al. (29) 2006/USA TEOAE 74 dB pSPL click DPOAE L1 = 57 dB SPL, L2= 45 dB SPL L1 = 59 dB SPL, L2 = 50 dB SPL L1 = 61 dB SPL, L2 = 55 dB SPL L1 = 65 dB SPL, L2 = 45 dB SPL 14 Medline Santos et al. (17) 2007/USA TEOAE 80 dB. DPOAE L1 = 65 dB HL, L2 = 55 dB HL 15 Medline Sisto et al. (26) 2007/USA TEOAE 80 dB click DPOAE L1 = 65 dB & L2 = 55 dB L1 = 75 dB & L2 = 70 dB L1 = L2 = 70 dB 16 Medline Seixas et al. (19) 2004/England DPOAE L1 = 65 dB SPL & L2 = 55 dB SPL Also registered regarding rising stimulus level (L1 = 35–80 dB SPL in steps of 5 dB; L2 = L1–10) 17 Medline Seixas et al. (20) 2005/England DPOAE L1 = 65 dB SPL, L2 = 55 dB SPL Also registered regarding rising stimulus level (L1 = 35–80 dB SPL in steps of 5 dB; L2 = L1–10) 18 Medline Job, Raynal, Kossowski (30) 2007/Switzerland DPOAE L1 = 65 dB, L2 = 55 dB 19 Medline Balatsouras (27) 2004/Poland DPOAE L1 = L2 = 70 dB SPL Legend: OAE, otoacoustic emissions; TEOAE, transient-evoked otoacoustic emissions; DPOAE, distortion product otoacoustic emissions; L1, L2, stimulus intensities; dB SPL and dB HL, decibels in sound pressure level.

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individuals evaluated was 3256, with 2246 males, 397 females, and 612 unspecified. The participation of males was greater than that of females, which reflects the overall lower number of women in the professional categories evaluated. Regarding age, participants ranged from a minimum age of 14 years (22) to a maximum of 77 (18). In the variation of the EOAE findings, 1 study showed that the greater the subject’s age, the greater the increase in tonal thresholds, while DPOAE thresholds decrease (19). In this study, which divided the subjects into 4 age groups (age, up to 20 years, 20–29 years, 30– 39 years, and over 40 years), it was observed that increasing age significantly influenced (p > 0.05) the amplitude of the EOAE. In relation to the type of test chosen in the studies to investigate EOAE, of the 7 articles that are available in the national LILACS databases, 5 used DPOAE (4,23,12,22,31) and only 2 used both tests (15,16). Of the 12 international papers in the Medline database, 6 used DPOAE (24,25,19,20,27,30) and 6 used both tests (18,28,21,12,29,17,13,26). It is suggested that DPOAE have characteristics that facilitate a more accurate diagnosis. For example, examiners can perform frequency and variation band analysis of responses depending on stimulus intensity (32). The examiner can vary the intensity, using the protocols L1 = L2 = 70 dB SPL or L1 = 65 dB SPL and L2 = 55 dB SPL (65/ 55 protocol). As to the stimulus intensity, in the LILACS database, national articles varied intensities between L1 and L2, with the most frequently used intensity of L1 = 65 dB SPL and L2 = 55 dB SPL (12,15-17,20,22,26,28,30,31). In the Medline database, although the values L1 = 65 dB SPL and L2 = 55 dB SPL were also used (26), there is a wide variation of stimulus intensities (21,23,25-27,29). Analysis of the DPOAE at different intensities of stimulation must be regarded very carefully, because it is likely that different mechanisms are responsible for the production of increasing or decreasing the sound intensity. Recent research indicates that the largest DPOAE amplitudes are obtained when L1 is more intense than L2 (L1 > L2) by up to 10 dB (33). The lower intensity stimuli are more sensitive and accurate in the diagnosis of mild and moderate sensorineural hearing loss, which permits the variation of intensity to be used to differentiate degrees of mild and moderate hearing loss. That is, the 65/55 protocol appears to be more sensitive in detecting mild hearing loss.

However, it is noteworthy that the proper adjustment of the probe is essential for recording otoacoustic emissions. As well as being sensitive to noise created by the environment or the patient himself, it is a highly sensitive procedure for disorders of the external ear and middle, thus generating possible false-positives (35). Moreover, the fact is indisputable that this procedure does not exclude the possibility of false-negative result, that is, integrity of cochlear physiology in auditory neuropathy. In our review, only one study cited the possibility of false-positive and false-negative results, the causal factors that could have been calibration problems, noise level during the test and test-retest variability (29).

FINAL COMMENTS In the universe that was analyzed, we observed that EOAE testing has been used effectively in the detection of cochlear changes and the early diagnosis of NIHL. The literature reviewed publications that established results that can be considered as important parameters for subsequent applications of EOAE in workers exposed to noise. We suggest that further epidemiological studies should be carried out to analyze the effectiveness of EOAE in workers exposed simultaneously to noise and other environmental contaminants (solvents, asphyxiants, metals, and pesticides), as well efforts towards suppression of the hazards in the occupational area.

REFERENCES 1. Gonçalves CGO. Análise do Programa de Apoio e Reabilitação para trabalhadores portadores de PAIR em uma metalúrgica. Distúrb Comun. 2007 abr [acesso em 2010 out 8]; 19 (1): 103-116. Disponível em: www.pucsp.br/ revistadisturbios/artigos/Artigo_512.pdf 2. Pinotti KSA, Corazza MCA, Alcarás PAS. Avaliação Eletrofisiológica do Nervo Auditivo em Pacientes Normoouvintes com Ausência do Reflexo Estapediano. Arq. Inter. Otorrinolaringol. [serial on the Internet]. 2009 [acesso em 2010 jun 08]; 13 (4):386-393. Disponível em: http:// www.arquivosdeorl.org.br/conteudo/ acervo_port.asp?Id=647 3. Almeida SIC de, Albernaz PLM, Zaia P A, Xavier O G, Karazawa E H I. História natural da perda auditiva ocupacional provocada por ruído. Rev. Assoc. Med. Bras.

Int. Arch. Otorhinolaryngol., São Paulo - Brazil, v.16, n.4, p. 515-522, Oct/Nov/December - 2012.

520


Evoked otoacoustic emissions in workers exposed to noise: A review.

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[serial on the Internet]. 2000 June [acesso em 2010 jun 08]; 46 (2): 143-158. Disponível em: http://www.scielo.br/ scielo.php?script=sci_arttext&pid=S010442302000000200009&lng=en. doi: 10.1590/S010442302000000200009. 4. Marques FP, Costa EA da. Exposição ao ruído ocupacional: alterações no exame de emissões otoacústicas. Rev. Bras. Otorrinolaringol. [serial on the Internet]. 2006 Jun [acesso em 2010 jun 08]; 72 (3): 362-366. Available from: http:// www.scielo.br/scielo.php?script=sci_arttext&pid=S003472992006000300011&lng=en. doi: 10.1590/S003472992006000300011. 5. Dunn DE. Cochlea morphology associated with overexposure to noise. Journal of the Ohio Speech and Hearing Associating. 1987:22-28. 6. Gonçalves CGO. O ruído, as alterações auditivas e o trabalho: estudos de casos em indústrias metalúrgicas em Piracicaba. [Tese de Doutorado em Saúde Coletiva]. Campinas: UNICAMP; 2003. 7. Oliveira JAA. Fisiologia clínica da audição - cóclea ativa. In: Nudelman AL (org.), Perda Auditiva Induzida pelo Ruído. Porto Alegre: Bagaggem, 1997, p. 101-142. 8. Brasil. Portaria No.19 de 9 de abril de 1998. Estabelecem diretrizes e parâmetros mínimos para avaliação e acompanhamento da audição dos trabalhadores expostos a níveis de pressão sonora elevados. NR 7 - Programa de Controle Médico de Saúde Ocupacional. Diário Oficial da União 30 dezembro de 1994. p. 21278. 9. Morata TC, Little MB. Suggested guidelines for studying the combined effects of occupational exposure to noise and chemicals on hearing. Noise and Health 2002; 4 (14): 73 - 87. 10. Pialarissi PR, Gattaz G. Emissões Otoacústicas: Conceitos Básicos e Aplicações Clínicas. Internat. Arch. of Otorhinolaringol. [serial on the internet] 1997 [acesso em 2010 abr 22]; Vol1. Num2. 13p. Available from: http:// www.arquivosdeorl.org.br/conteudo/ acervo_port.asp?id=13 11. Lazmar A. Diagnóstico da doença profissional induzida pelo ruído. In: Nudelmann AA et al (Org.) Perda Auditiva Induzida pelo Ruído. Porto Alegre: Bagagem Comunicações, 1997, p.153-162. 12. Guida HL, Morini RG, Cardoso ACV. Avaliação Audiológica e de Emissões Otoacústicas em Indivíduos Expostos a Ruído e Praguicidas. Arq. Int. Otorrinolaringol. [internet]. 2009 [acesso em 2010 jun 08]; 13 (3):264-269.

Available from: http://www.arquivosdeorl.org.br/conteudo/ acervo_port.asp?id=626 13. Probst R, Harris FP, Hauser R. Clinical monitoring using otoacoustic emissions. British Journal of Audiology.1993, 27:85-90. 14. Souza DV de, Frota SMMC. Estudo Comparativo das Emissões Otoacústicas Evocadas em Militares Expostos e não Expostos ao Ruído. [Dissertação de Mestrado Profissionalizando em Fonoaudiologia]. Rio de Janeiro: Universidade Veiga de Almeida; 2009. 107p. [acesso em 2010 abr 22]. 15. Amorim RB, Lopes AC, Santos KTP dos, Melo ADP, Lauris JRP. Alterações Auditivas da Exposição Ocupacional em Músicos. Arq. Int.Otorrinolaringol. [internet]. 2008 [acesso em 2010 jun 08]; Available from: http:// www.arquivosdeorl.org.br/conteudo/ acervo_port.asp?id=544 16. Maia JRF, Russo ICP. Estudo da audição de músicos de rock and roll. Pró-Fono R. Atual. Cient. [online]. 2008, vol. 20, n.1 [acesso em 2010 jun 08]; pp. 49-54. 17. Santos L, Morata TC, Jacob LC, Albizu E, Marques JM, Paini M. Music exposure and audiological findings in Brazilian disc jockeys (DJs). Int J Audiol. 2007 May; 46 (5): 223-31. 18. Paini MC, Morata TC, Corteletti LJ, Albizu E, Marques JM, Santos L. Audiological findings among workers from Brazilian small-scale fisheries. Ear Hear. 2009 Feb;30 (1):8-15. 19. Seixas NS, Kujawa SG, Norton S, Sheppard L, Neitzel R, Slee A. Predictos of hearin threshold levels and distotion product otoacoustic emissions among noise exposed young adults) Occup Environ Med. 2004; 61:899–907. 20. Seixas NS, Goldman B, Sheppard L, Neitzel R, Norton S, Kujawa SG. Prospective noise induced changes to hearing amog construction industry apprentices. Occup Environ Med. 2005; 62:309–317. 21. Bockstael A, Keppler H, Dhooge I, D’haenens W, Maes L, Philips B, Vinck B. Effectiveness of hearing protector devices in impulse noise verified with transiently evoked and distortion product otoacoustic emissions. Int J Audiol; 47 (3): 119-33, 2008 Mar. 22. Fiorini AC, Parrado-Moran MES. Emissões otoacústicas produto de distorção: estudo de diferentes relações de níveis sonoros no teste em indivíduos com e sem perdas auditivas. Rev. Distúrb. Comun;17 (3):385-396, dez. 2005. 23. Alvarenga KF, et al. Emissões otoacústicas - produto de

Int. Arch. Otorhinolaryngol., São Paulo - Brazil, v.16, n.4, p. 515-522, Oct/Nov/December - 2012.

521


Evoked otoacoustic emissions in workers exposed to noise: A review.

Alcarás et al.

distorção em indivíduos expostos ao chumbo e ao ruído.Rev. Bras. Otorrinolaringol. [online]. 2003, vol.69, n.5, pp. 681686. ISSN 0034-7299. doi: 10.1590/S003472992003000500014.

30. Job A, Raynal M, Kossowski M. Susceptibility to tinnitus revealed at 2 kHz range by bilateral lower DPOAEs in normal hearing subjects with noise exposure. AudiolNeurootol.2007; 12 (3): 137-44.

24. JohnsonAC, MorataTC, Lindblad AC, Nylen PR, Svensson EB, Krieg E, et al. Audiological findings in workers exposed to styrene alone or in concert with noise. Noise Health; 8 (30): 45-57, 2006 Jan-Mar.

31. Parrado-Marron MES, e Fiorini AC. Aplicações clínicas das emissões otoacústicas-produto de distorção. Distúrb. Comun;14 (2):237-261, jun. 2003.32.

25. Korres GS, Balatsouras DG, Tzagaroulakis A, Kandiloros D, Ferekidou E, Korres S. Distortion product otoacoustic emissions in an industrial setting. Noise Health; 11 (43): 103-10, 2009 Apr-Jun. 26. Sisto R, Chelotti S, Moriconi L, Pellegrini S, Citroni A, Monechi V, et al. Otoacoustic emission sensitivity to low levels of noise-induced hearing loss. J Acoust Soc Am.2007 Jul; 122 (1): 387-401. 27. Balatsouras DG. The evaluation of noise-induced hearing loss with distortion product otoacoustic emissions. Med Sci Monit. 2004 May; 10 (5): CR218-22. 28. Prasher D, Al-Hajjaj H, Aylott S, Aksentijevic A.Effect of exposure to a mixture of solvents and noise on hearing and balance in aircraft maintenance workers. Noise Health; 7 (29): 31-9, 2005 Oct-Dec. 29. Lapsley Miller JA, Marshall L, Heller LM, Hughes LM. Low-level otoacoustic emissions may predict susceptibility to noise-induced hearing loss. J Acoust Soc Am. 2006 Jul; 120 (1): 280-96.

32. Lacerda ABM, Morata TC. O risco de perda auditiva decorrente da exposição ao ruído associada a agentes químicos. In: Morata, TC, Zucki F. (Org). Saúde Auditiva – Avaliação de Riscos e Prevenção. São Paulo: Plexus, 2010, 99-117. 33. Kos MI, Almeida K de, Frota S, Hohino ACH. Emissões otoacústicas produto de distorção em normo ouvintes e em perdas auditivas neurossensoriais leve e moderada com os protocolos 65/55 dB NPS E 70/70 dB NPS.Rev. CEFAC [online]. 2009, vol.11, n.3, pp. 465-472. ISSN 1516-1846. doi: 10.1590/S1516-18462009000300014. 34. Souza LCA, Piza MRT, Alvarenga KF, Coser PL. Eletrofisiologia da audição eemissões otoacústicas: princípios e aplicações clínicas. São Paulo: Tecmedd, 2008. p.122123. 35. Durante AS. Emissões Otoacústicas. In: Fernandes FDM, Mendes BCA, Navas ALPGP. (Org). Tratado de Fonoaudiologia. 2 ed. São Paulo: Roca, 2009, 79. ISBN: 97885-7241-828-7.

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Int. Arch. Otorhinolaryngol. 2012;16(4):523-526. DOI: 10.7162/S1809-97772012000400015

Case Report

Laryngeal Leishmaniasis Bruno Teixeira de Moraes1, Francisco de Souza Amorim Filho2, José Caporrino Neto3, Paulo Saraceni Neto4, José Elson Santiago de Melo Júnior5. 1) ENT. Master in Health Sciences Department of Otolaryngology and Head and Neck Surgery, Federal University of São Paulo. 2) Head and Neck Surgeon. PhD in Health Sciences Department of Otolaryngology and Head and Neck Surgery, Federal University of São Paulo. 3) ENT. Assistant Professor, Department of Otolaryngology and Head and Neck Surgery, Federal University of São Paulo. 4) Medical. Resident Department of Otolaryngology and Head and Neck Surgery, Federal University of São Paulo. 5) Physician. Specializing Department of Otolaryngology and Head and Neck Surgery, Federal University of São Paulo. Institution:

Division of Laryngology and Voice of the Department of Otolaryngology at the Federal University of São Paulo. São Paulo / SP - Brazil. Correspondence to: Bruno Teixeira de Moraes – 957 Pedro de Toledo Street - Vila Clementino - São Paulo / SP - Brazil - Zip code: 04039032 - Telephone: (+55 11) 5573-2740 - E-mail: moraesbruno.orl@hotmail.com Article submitted on August 7, 2010. Approved on October 24, 2010.

SUMMARY Introduction: Leishmaniasis is classified into three clinical presentations: visceral, coetaneous and mucocutaneous. The latter is usually secondary to hematogenous spread after months or years of skin infection and can manifest as infiltrative lesions, ulcerated or vegetating in nose, pharynx, larynx and mouth, associated or not with ganglionics infarction. Laryngeal involvement is part of the differential diagnosis of lesions in this topography as nonspecific chronic laryngitis, granulomatosis and even tumors of the upper aerodigestive tract presenting atypical evolution. Sometimes it is difficult for the correct diagnosis of Leishmaniasis, with description of cases in the literature were conducted improperly. Objective: The objective of this study is to report a case of laryngeal Leishmaniasis addressing the difficulty of diagnosis, complications and treatment applied. Case Report: A patient with pain throat, dysphagia, odynophagia, dysphonia and weight loss, with no improvement with symptomatic medication. At telelaringoscopy, infiltrative lesion showed nodular supraglottis. He underwent a tracheotomy for airway obstruction and biopsy with immunohistochemical study for a definitive diagnosis of laryngeal Leishmaniasis. The patient was referred to the infectious diseases that initiated treatment with N-methylglucamine antimoniate with satisfactory response to therapy. Final Comments: Faced with a clinical suspicion of granulomatous diseases, it is essential to follow protocol laboratory evaluation associated with histological injury, to get a precise definition etiological without prolonging the time of diagnosis. Medical treatment for mucosal Leishmaniasis, recommended by the World Health Organization, was adequate in the case of laryngeal disorders, with complete resolution of symptoms. Keywords: Leishmaniasis; mucocutaneous Leishmaniasis; chronic granulomatous disease; larynx.

INTRODUCTION Leishmaniasis is an infectious granulomatous disease; non-contagious disease caused by protozoan species Leishmania brasiliensis, L. amazonensis, L. panamensis and Leishmania guyanensis, typically found in the Americas. Its transmission occurs through the bite of sandflies insects, whose genre most often found in Brazil is Lutzomya. Over the past 20 years, the occurrence of this disease is growing rapidly, both in magnitude and geographical expansion, with outbreaks in various regions of the country and, more recently, in the Amazon area, related to the predatory process of colonization (1).

Traditionally, the disease is classified into three clinical presentations: visceral (Kala-azar), coetaneous and mucocutaneous. The latter is usually secondary to hematogenous spread after months or years of skin infection and can manifest as infiltrative lesions, ulcerated or vegetating in nose (most common site), pharynx, larynx and mouth, bloating associated or not with lymph node (2). The involvement of mucosa is dependent on the combination of virulence of the parasite and cellular host immune response. Among the population of infected individuals, 1 to 10% occurs with mucosal involvement; however, the specific factors that will determine which patients will develop the mucocutaneous Leishmaniasis are still not well understood (3).

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Low prevalence, laryngeal involvement Leishmaniasis is part of the differential diagnosis of lesions in this topography as nonspecific chronic laryngitis, and even granulomatosis of upper aerodigestive tract tumors that exhibit atypical evolution (4, 5). Sometimes it is difficult for the correct diagnosis of Leishmaniasis, with description of cases in the literature were conducted initially as malignancy, including undergoing radiotherapy, with subsequent confirmation of infectious etiology (6). The objective of this study is to report a case of laryngeal Leishmaniasis addressing their diagnostic difficulty, complications and treatment applied.

Figure 1. Laryngoscopy Pretreatment.

CASE REPORT SJS patient, male, 51 years old, black, mason, born in União dos Palmares - AL, and living in Sao Paulo - SP, was treated at the Otolaryngology department of a tertiary hospital in São Paulo, with reports of “sore throat” there three years, which has evolved over the past four months with dysphagia, odynophagia, dysphonia and weight loss of about 8 pounds in this period, no improvement with symptomatic medication. He denied fever, ear or respiratory complaints. Smoking history presented as moderate, severe alcoholics without a history of hypertension, diabetes mellitus or infectious diseases. On physical examination, with regular general condition, without significant changes in the respiratory, cardiovascular or abdomen. At telelaringoscopy, nodular infiltrative lesion was visualized in supraglottis involving the epiglottis, aryepiglottic, looking vegetating in left piriformis sinus and arytenoids edema. The vocal folds were mobile and without structural lesions with complete glottal closure (Figure 1). Preoperative tests were ordered, then the patient underwent suspension laryngoscopy with biopsy of the lesion and the histopathology revealed the case of an ulcerated inflammatory process. Three weeks after this biopsy, the patient developed dyspnea and worsening of dysphagia, accepting only pasty-liquid diet. Tracheotomy was performed and new biopsy showed that the atypical lymphoid infiltration histopathology. The piece was sent to perform immunohistochemistry to detect amastigote of Leishmania sp. in the sample. The patient was referred to the infectious diseases that initiated treatment with N-methylglucamine antimoniate at a dose of 20mg/kg/day, intramuscularly, for

Figure 2. Laryngoscopy Post-treatment.

30 days with outpatient and uneventful. There was significant improvement of the table early in the treatment, control laryngoscopy after the 30th day showed resolution of the lesions. Then, the tracheotomy was performed decannulation (Figure 2). Three months after treatment, the patient presented with significant improvement of his general condition and nutritional asymptomatic and in their professional activities.

DISCUSS Leishmaniasis is rarely detected early on. The patient usually presents one or few skin lesions, which appear three to ten weeks after inoculation, with a tendency to spontaneous healing in a few months, even without treatment. In some cases the lesions remain active for several years and it is estimated that 3 to 5% may develop with subsequent emergence of mucosal

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lesions by hematogenous spread. In the case reported the presentation was mucosa of unknown origin, since there was no coetaneous lesion. It is believed that such would probably be associated with subclinical infections or minor injuries, non-ulcerated, with rapid evolution and that would have gone unnoticed without noticeable scarring (1). Pharyngolaryngeal involvement can be intense enough to cause dysphagia, dyspnea, dysphonia, sore throat and cough. A peculiarity of this case differs from that literature is the absence of nasal lesions which are often found in the initial shape of the mucosal Leishmaniasis. Even this is a parameter used in the differential diagnosis of diseases such as tuberculosis and laryngeal Paracoccidioidomycosis who rarely have associated nasal lesions (7).

In the case of infectious diseases with risk of contamination, the diagnosis should be established as soon as possible. The interval between onset of symptoms and diagnosis in a way reflects the ease of access to health services as well as efficiency in diagnosis. The regimen used was satisfactory. The same is in accordance with the recommendations of the World Health Organization (WHO), which recommends Nmethylglucamine antimoniate as first choice at a dose of 20mg/kg/day lasting at least 30 days. In patients with contraindications (pregnancy due to teratogenicity) or refractory to standard treatment, should be used amphotericin B (10).

FINAL COMMENTS The laryngoscopy usually demonstrates an extensive inflammatory component, with erythema and edema evident. The granulomatous associated ulcers are common and may also submit purulent exudates. In advanced disease, tissue destruction may be striking. Before this presentation, it is important hypotheses of other diseases as leprosy, sarcoidosis, syphilis, Wegner granulomatosis, systemic lupus erythematosus actinomycosis, Histoplasmosis and neoplasm (8, 9). By presenting a more gorgeous, both in terms of symptomatology and the findings of laryngoscopy, the patient was referred initially reported to the laryngeal lesion biopsy in an attempt to elucidate the diagnosis, rather than a complement careful laboratory evaluation. Given that the diagnosis of Leishmaniasis can be determined by parasitological examinations (direct search or culture), immunological tests (intradermal of Montenegro) or molecular tests (polymerase chain reaction), solving this case likely would have been anticipated if they were requested Routine tests for suspected cases of granulomatosis (VDRL, Montenegro reaction, PPD, serology for Histoplasmosis and Paracoccidioidomycosis, chest radiography). Especially because the cases of mucosal Leishmaniasis usually have strong positive intradermal of Montenegro, and secondly parasitological confirmation difficult due to the shortage parasite, which was evident by the need for two biopsies and complementation analysis with immunohistochemistry for the identification of amastigote (1) . Therefore, as research protocol for suspected etiologic granulomatosis in organs such as the larynx difficult access, should initially be requested laboratory tests and imaging, and case stay uncertain diagnosis, biopsy is indicated for the histological lesions. If the appearance of the lesion suggests malignancy, research through noninvasive tests and invasive must occur simultaneously to avoid delay diagnosis.

Before clinical suspicion with granulomatous diseases, it is vital following protocol associated with laboratory evaluation of histological injury to achieve a precise definition etiological without prolonging the time of diagnosis. Medical treatment for mucosal Leishmaniasis, recommended by WHO, was adequate in the case of laryngeal disorders, with complete resolution of symptoms.

REFERENCES 1. Manual de Vigilância da Leishmaniose Tegumentar Americana. 2a. ed. Brasília: Editora do Ministério da Saúde; 2007. 2. Grant A, Spraggs PD, Grant HR, Bryceson AD. Laryngeal leishmaniasis. J Laryngol Otol. 1994;108(12):1086-1088. 3. David CV, Craft N. Cutaneous and mucocutaneous leishmaniasis. Dermatol Ther. 2009;22(6):491-502. 4. Sizeland A. Leishmaniosis in third world. N Engl J Med. 1995;332(9): 610-1. 5. Lightfoot, Stanley A. J Am Board Fam Pract. 1997;10(5):374-6. 6. Ravisse P, Bensimon P, Lapicorey G. A case of laryngeal leishmaniasis with a long course. Bull Soc Pathol Exot Filiales. 1984 May-Jun;77(3):305-11. 7. Lessa MM et al. Leishmaniose Mucosa: aspectos clínicos e epidemiológicos. Braz J Otorhinolaryngol. 2007;73(6):843847. 8. Carvalho T, Dolci JEL. Avaliação clínica da influência do

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uso de glucantine em pacientes com Leishmaniose nasal. Acta ORL. 2006;24(2):77-82.

10. World Health Organization (WHO). The Leishmaniases: report of a WHO Expert Committee. Geneva, 1984. (Technical Report Series; 701).

9. Caporrino Neto J, Cervantes O, Jotz GP, Abrahão M. Doenças granulomatosas da Laringe. Acta Awho. 1998;17(1):6-10.

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Case Report

Severe complication of posterior nasal packing: Case Report José Antônio Pinto1, Pedro Paulo Vivacqua da Cunha Cintra2, Thiago Branco Sônego3, Carolina de Farias Aires Leal3, Marina Spadari Artico3, Josemar dos Santos Soares3. 1) President of the Brazilian Society of Laryngology and Voice (2001-2003). Director of the Center for Otolaryngology and Head and Neck of St. Paul. 2) Doctor in Otolaryngology, Faculty of Medicine, USP - Ribeirão Preto. Physician Assistant at the Center for Otolaryngology and Head and Neck of St. Paul. 3) Medical (a). Resident Center for Otolaryngology and Head and Neck of St. Paul. Institution:

Center for Otolaryngology and Head and Neck of São Paulo. São Paulo / SP - Brazil. Address for correspondence: - Alameda Nhambiquaras, 159 - Moema - São Paulo / SP - Brazil - Zip code: 04090-010 - Telephone: (+55 11) - 5573-1970 - E-mail: japorl@uol.com.br Article submitted on August 18, 2010. Approved on October 24, 2010.

SUMMARY Introduction: Severe Epistaxis is common in patients with head trauma, especially when associated with multiple fractures of the face and skull base. Several methods of controlling bleeding that can be imposed. The anterior nasal tapenade associated with posterior Foley catheter is one of the most widespread, and the universal availability of necessary materials or their apparent ease of execution. Methods: Case report on control of severe epistaxis after severe TBI, with posterior nasal packing by Foley catheter and control tomography showing multiple fractures of the skull base and penetration of the probe into the brain parenchyma. Conclusion: This is a rare but possible complication in the treatment of severe nose bleeds associated with fracture of the skull base. This brief report highlights risks related to the method and suggests some care to prevent complications related through a brief literature review. Keywords: epistaxis, fracture of the skull base, Craniocerebral Trauma.

INTRODUCTION Profuse nasal bleeding due to craniofacial trauma important are commonly associated with fractures of the facial bones and skull base (1). Several of these control techniques are described epistaxis, and the posterior tapenade with a Foley associated with anterior packing one of the most used, both by the relative ease of the procedure as the wide availability of materials (2). We report a case of using Foley catheter to control bleeding nose after polytrauma outcome with a severe and unusual.

CASE REPORT 50 year-old-man crashed presenting high loss of consciousness, deformity of the face and profuse nosebleeds. It was attended by emergency services and taken to the nearest hospital. Pa ¬ kept you lowered level of consciousness during the service showing score 6 Scale Glasgow. The measures were supportive, stabilizing the airway by endotracheal intubation, volume resuscitation, and stabilization of the cervical spine, posterior nasal tampanomanto with

Foley catheter in the left nostril and bilateral anterior gauze, which is effective. Performed plain radiographs of the cervical spine and face which was evidenced in facial bone fractures. Patient developed worsening of clinical well being routed to the larger hospital after stabilization. Performed computed tomography, facial bones and cervical spine which showed multiple fractures in the bones of the face and skull base as well as fracture of the odontoid process of the 2nd vertebra. Also evidenced intracerebral migration of Foley catheter with path to the posterior portion of the right parietal lobe through the ethmoid fracture. (Figure 1) Patient underwent craniotomy after 48 hours of trauma for drainage of subdural hematoma, viewing the withdrawal of the probe and control bleeding in his path. Patient referred to intensive care being kept sedated and on controlled breathing. Showed clinical improvement and neurological stimuli when responding to reduced sedation. Due to nasal drainage of cerebrospinal fluid with high flow underwent endoscopic sinus surgery on the 10th day of hospitalization for closing cerebrospinal fluid fistula high output in the ethmoid sinus, the migration path of the probe.

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balloon would only serve as a platform to support effectively the above buffer containing bleeding or a combination of these mechanisms (2). The allocation of the Foley catheter in these situations becomes critical because during the procedure does not need to have a portion thereof inserted into the nasal cavity, thus causing errors in positioning. In this case the insertion should be done under direct vision / indirect probe, where the floor of the nasal cavity, and confirmation of the presence of the same in the oropharynx before inflating the balloon are essential as is the use of larger diameter catheter possible (4) . Just as in the allocation of other probes to confirm the position with imaging test imposes greater security and the lateral skull radiograph usually enough to confirm this.

Figure 1. Axial CT scan of the skull showing through penetration of the ethmoid bone fracture path and intra cerebral Foley catheter.

The patient developed mild neurologic improvement, keeping vigil with important cognitive and left hemiplegic. Released from the intensive care unit on the 39th day of hospitalization being held in ward with tracheotomy and device pressure continuous positive airway pressure (CPAP) pending clinical stabilization after 3 episodes of pneumonia, for realization of fracture fixation on process odontoid.

In the medical literature there described 3 cases of intracranial migration of Foley catheter during packing later, all related to profuse epistaxis after severe craniofacial trauma and restricted to anterior and middle tank (3, 4, 5). In our report but the probe maintained a straight path being positioned in the left parietal lobe. Other reports of nasogastric tube after penetrating trauma, surgery on the skull base and also not related to trauma are described, demonstrating the anatomy of the region of weakness (6, 7, 8).

CONCLUSION This is a rare but possible complication in the treatment of severe nose bleeds associated with fracture of the skull base. This brief report highlights the risks related to the method and suggests some care to prevent complications, the main one being to verify the presence of the balloon probe oropharynx before the final positioning of the probe.

DISCUSSION Severe cranial trauma with changes in facial architecture, require special attention, by signposting high impact injuries and also by the common association with skull base fractures (3). The management of severe epistaxis associated with these fractures requires care possible weakness of this nasal wall. The techniques of posterior tapenade with Foley catheter associated with anterior packing are widely discussed and generally do not differ greatly in the literature, but the actual mechanism of action is not consensus. The main theses are that compression in the rear walls of the nasal cavity cause occlusion of bleeding vessels of the

REFERENCES 1. Hartley C, FRKD, Axon PR, MB, BS. The Foley catheter in epistaxis management - a scientific appraisal. Journal of Laryngology and Otology, 1994;108: 399-402. 2. Lee WC, Ku PKM, Hasselt CA. Foley Catheter Action in the Nasopharynx. Arch Otolaryngol Head Neck Surg, 2000;126:1130-1134. 3. Pawar SJ, Sharma RR, Lad SD. Intracranial migration of Foley catheter - an unusual complication. Journal of Clinical Neuroscience, 2003;10(2):248-249.

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4. Woo HJ, Bai CH, Song SY, Kim YD. Intracranial placement of a Foley catheter: A rare complication. OtolaryngologyHead and Neck Surgery, 2008;138:115-116

7. Pandey AK, Sharma Ak, Diyora BD, Sayal PP, Ingale HA, Radharkrishnan M. Inadvertent Insertion of Nasogastric Tube into the Brain. JAPI, 2004;52:322-333.

5. Blasco V, Heng Ban L, Velly L, Leone M, Gouin F. Brain placement of a duble balloon catheter after extensive craniofacial trauma. Annales Françaises d´Anesthésie et de Réanimation, 2008;27:843-845.

8. Genú PR, et al. Inadvertent Intracranial Placement of a Nasogastric Tube in a Patient With Severe Craniofacial Trauma: A Case Report. J Oral Maxillofac Surg, 2004;62:14351438.

6. Arslantas A, Durmaz R, Cosan E, Tel E. Inadvertent insertion of a nasogatric tube in a patient with head trauma. Child’s Nerv Syst, 2001.17:112-114.

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Case Report

Recurrence of atypical fibroxanthoma. Diagnosis and treatment Leandro Ricardo Mattiola1, Lyzandro Mattiola2, Giovani Mattiola3, Sandra Zucchi de Moraes Mattiola4, Carlos Eduardo Moura4, Alexandre Kirschnick5. 1) 2) 3) 4) 5)

Specialist in Otolaryngology. Otolaryngologist. Specialist Surgical Practice. Surgeon General. Medical Student. Specialist in Anesthesiology. Anesthesiologist. Specialist in Pathology. Pathologist.

Institution:

Clinical Port Union Association of Protection of Motherhood and Childhood. Port Union / SC - Brazil. Correspondence to: Ricardo Leandro Mattiola â&#x20AC;&#x201C; 33 Matos Costa Street, SL402 - Centro - Porto Union / SC - Brazil - Zip code 89400-000. Telephone: (+55 42) 3523-4050 - E-mail: lmattiola@gmail.com Article submitted on August 19, 2010. Approved on February 5, 2011.

SUMMARY Introduction: The soft tissue sarcomas (SPM) accounts for only 1% of malignant tumors of the adult population. The SPM is the most frequent malignant fibrous histiocytoma (MFH) that exhibits behavior characterized by the tendency to invasion of adjacent tissue and metastatic spread early. One of its variants is the atypical fibroxanthoma (FA). Objective: To describe a case of probable recurrence of AF underwent surgical treatment and presentation of a literature review. Case report: Patient female, 63 years, presenting with a mass in the face about four inches and a history of prior resection of the lesion in the same topography. The patient underwent surgical resection with a diagnosis of AF. Conclusion: The FA is a rare tumor histological diagnosis difficult. The correct histological diagnosis and patient follow-up are essential. Keywords: sarcoma; malignant fibrous histiocytoma; neoplasms of soft tissue neoplasms ENT.

INTRODUCTION Of the malignant tumors of the adult population only 1% are soft tissue sarcomas (SPM) (1). Of these, 5 to 16% occur in the head and neck (2.3). The malignant fibrous histiocytoma (MFH) is a rare tumor and there are few cases described in the literature, and thus difficult to define prognosis and treatment4. It was described in the 60s as a distinct type of SPM, and has been the most common histological type diagnosed since. The atypical fibroxanthoma (FA) is one of its variants. The SPM exhibit aggressive behavior, tendency to invasion and metastatic spread early. We present a case of probable recurrence of AF after two years, surgical treatment and a brief review of the literature.

reported history of resection of a skin lesion on the same location for about two years. Whose histopathology was inconclusive on histological lineage, however, assured clear margins and no additional study was conducted for a conclusive diagnosis.

CASE REPORT

Physical examination revealed subcutaneous swelling in the left side of fibro-elastic consistency, adjusting, measuring approximately four by two centimeters, movable with respect to the depth and apparently fixed to the overlying skin, where scar visualized approximately three inches, corresponding prior to surgery. He had no palpable cervical lymph nodes. Computed tomography (CT) revealed an increase in volume in the subcutaneous tissue of the left face, with contrast medium uptake and cleavage plane with the left parotid gland deeply. We performed fine needle aspiration biopsy that showed only atypical cells. During this period there was an increase in lesion volume and apparent infiltrating the epidermis.

Female patient, 63 years old, came to us complaining of swelling in the face (cheek), left, with six months of evolution and rapid growth in the past two months. She reported no other symptoms and disorders. However,

Due to suspicion of malignancy with rapid evolution, we opted for surgical resection of the lesion accompanied by frozen section intraoperative examination. This has not been able to define the histological lineage, but confirmed

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that it was invasive malignancy. Resection was performed with safety margins and included the overlying skin. Primary closure was performed and postoperatively the patient developed salivary fistula, treated with pressure dressings and healing after 15 days. Pathology showed undifferentiated malignant neoplasm characterized by proliferation of spindle cells, pleomorphic epithelioid and some involving the dermis and subcutaneous tissue. Observing occasional mitotic figures. The surgical margins were free. The immunohistochemical study revealed for CD10 expression, favoring the diagnosis of atypical fibroxanthoma (malignant fibrous histiocytoma surface). The tumor was staged as N0 M0 pT1a - stage IIB (UICC 2006). It was chosen to carry out radiotherapy or chemotherapy. The patient had no signs of local recurrence or distant metastasis when, after four months was detected on clinical examination new tumor in the topography of the mandibular body left in an area that had no contact with the resected lesion. A biopsy of the tumor showed that it was FA. The patient was referred to a tertiary hospital to give the sequel treatment, since it required at this time a more extensive resection followed by reconstruction of the mandible. Which was done so as radiotherapy.

DISCUSSION The SPM represent only 1% of all cancers of the head and neck (5). They are grouped together because of similarities in their appearance pathological, clinical presentation and natural history, although they have different cellular origins (3.6). MFH is a rare tumor, but it can be in the region of the head and neck should be part of the differential diagnosis of primary cervical lesions. One of its variants is the FA. The clinical behavior is characterized by the tendency to invasion of adjacent soft tissues and early metastatic dissemination (7). Occasionally these tumors are associated with genetic syndromes or prior radiation. Most often there is no clear etiology (2). Men are more affected than women (3:2). The most common presentation is as painless swelling (5). Many symptoms may occur depending on the location of the tumor (2). Physical examination usually reveals sub mucosal or subcutaneous tumor with distortion or destruction of adjacent structures. CT and magnetic resonance imaging (MRI) scans are the choice in most cases and provide information about bone involvement, extension and lymph node metastasis in addition to size and location (2). These tests can be used in a complementary way, especially in surgical planning (8). However, for a histological diagnosis in addition to the microscopic characteristics, it is necessary to perform immunohistochemical analysis (9).

Figure 1. Tumor in the subcutaneous tissue of the left cheek. It is observed cleavage plane with glula to deep left.

The prognostic factors are histology grade, location, size and lymph node involvement (7). MFH is generally considered a lesion of high-grade malignancy (10,11). Regarding location in the head and neck, is considered a worse prognosis with higher recurrence rates and lower disease-specific survival (12). Tumors larger than three centimeters in diameter negatively affect the prognosis. Literature data show that surgical safety margin is among the most important prognostic factors affecting local control, although its significance as a determinant of survival remains uncertain (13). In the study of Belal et al. (3), positive microscopic margins were associated with increased local recurrence. This author also found a significant correlation between adequate margins and disease-free survival and overall survival. In the head and neck high rates of positive margins are reflective of the closeness of relationships between adjacent structures. Local recurrence occurs in approximately 20% of cases, but the biggest cause of death is distant metastasis. The survival rate is 40% in the largest series, ranging from 19 to 75% (5). The authors differ if the local recurrence itself is a cause of distant metastases and increased mortality (5.14). The mainstay of treatment is wide surgical resection with clear margins (1.3). Some authors consider elective neck dissection is not necessary since regional metastases are uncommon. Postoperative radiotherapy is essential for banks affected (3). It is also recommended for unresectable tumors and margins slim. The role of adjuvant chemotherapy is controversial (3), its primary indication is for cases of metastatic disease (15). In the case of AF patients had a facial tumor with no metastases and that probably it was a local recurrence of

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resected lesion two years ago, but without histopathological diagnosis. We opted for surgical treatment, associated with intraoperative frozen due to great suspicion of malignancy, diagnostic difficulty and rapid progression at the time of preoperative investigation. The intraoperative frozen was not able to define the histological diagnosis, as this can only be determined after immunohistochemistry. After the histological diagnosis of AF (HFM) neck dissection was not performed due to lack of commitment to regional clinical and radiological evaluations. Also we decided not to radiotherapy of believing in a small possibility of recurrence due to tumor staging and the wide margins of resection (minimum of 1 cm) secured by microscopic analysis. The literature is unclear as to the minimum margin of safety. Chemotherapy was not used in view of the controversies reported in the literature. But after four months of surgery was the emergence of new tumor in the left side, which after biopsy showed that it was FA. The patient was referred to a tertiary hospital for treatment to follow.

Arquivos Internacionais de Ororrinolaringologia, 2006, 103:242-244. 5. Huber GF, Matthews TW, Dort JC. Soft-tissue sarcomas of the head and neck: a retrospective analysis of the Alberta experience 1974 to 1999. Laryngoscope, 2006;116:780-85. 6. Fujimura T, Okuyama R, Terui T, Okuno K, Masu A, Masu T, Chiba S, Kunii T, Tagami H, Aiba S. Myxofibrosarcoma (myxoid malignant fibrous histiocytoma) showing cutaneous presentation: report of two cases. J Cutan Pathol, 2005;32:512-15. 7. Rosenberg SA, Glatestein EJ. Perspectives on the role of surgery and radiation therapy in the treatment of soft tissue sarcomas of the extremities. Semin Oncol, 1981;8:190-200. 8. Patel SC, Silbergleit R, Talati SJ. Sarcomas of the head and neck. Top Magn Reson Imaging, 1999;10:362-375. 9. Han M, Lee BJ, Jang YJ, Chung YS. Clinical value of officebased endoscopic incisional biopsy in diagnosis of nasal cavity masses. Otol Head & Neck Surg, 2010;143:341-347.

CONCLUSION The FA is a rare and difficult histological diagnosis. Surgery with wide resection of the lesion is the mainstay of treatment. The identification of tumor histology is of fundamental importance, as well as the postoperative follow-up. In this case the histological diagnosis of the primary lesion would provide better preoperative planning and early surgical intervention after local recurrence.

10. Farhood AI, Hajdu SI, Shiu MH. Soft tissue sarcomas of the head and neck in adults. Am J Surg, 1990;160:365-69. 11. Lawrence W Jr. Operative management of soft tissue sarcomas: impact of anatomic site. Semin Surg Oncol, 1994;10:340-46. 12. LeVay J, O’Sullivan B, Catton C. Outcome and prognostic factors in soft tissue sarcoma in the adult. Int J Radiat Oncol Biol Phys, 1993;27:1091-99.

REFERENCES 1. Salo JC, Lewis JJ, Woodruff JM. Malignant fibrous histiocytoma of the extremity. Cancer, 1999;85:1765-72. 2. Sturgis EM, Potter BO, Sarcomas of the head and neck region. Curr Opin Oncol, 2003;15:239-52. 3. Belal A, Kandil A, Allam A, Khafaga Y, Husseiny G, ElEnbaby A, Memon M, Younge D, Moreau P, Gray A, Schultz A. Malignant fibrous histiocytoma a retrospective study of 109 cases. Am J Clin Oncol, 2002;25(1):16-22.

13. Evans RA. Soft tissue sarcoma: the enigma of local recurrence. J Surg Oncol, 1993;53:88-91. 14. Pisters PW, Harisson LB, Leung DH. Long-term results of a prospective randomized trial of adjuvant brachytherapy in soft tissue sarcoma. J Clin Oncol, 1996;14:859-68. 15. Fell W, Housini I, Marple B. Radiation-induced malignant fibrous histiocytoma of the head and neck. Otolaryngol Head Neck Surg, 1998;118:527-529.

4. Barbosa FH, Rangel MO, Coelho SR. Patrocínio JA, Patrocínio LG. Histiocitoma fibroso maligno de laringe.

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Index of article in volume 16

A A study of the high-frequency hearing thresholds of dentistry professionals ................................................ 16 (2): 226-231 Age at the diagnosis and in the beginning of intervention from hearing impaired children, in a public Brazilian hearing health service ................................................................................................................................... 16 (1): 44-49 Analysis of the masticatory process of asthmatic children: Clinical and electromyographic research ......... 16 (3): 358-364 Applicability of the free field Sustained Auditory Attention Ability Test (SAAAT) ......................................... 16 (2): 269-277 Assessment of nasal patency after rhinoplasty through the Glatzel mirror ................................................... 16 (3): 341-345 Audition and exhibition to toluene - a contribution for the theme ................................................................ 16 (2): 246-258 Auditory hallucinations in tinnitus patients: Emotional relationships and depression .................................... 16 (3): 322-327 Auditory middle latency response in children with learning difficulties ........................................................ 16 (3): 335-340

B Bone-anchored hearing aid (BAHA):: indications, functional results, and comparison with reconstructive surgery of the ear .......................................................................................................................................... 16 (3): 400-405

C Caracterization from hearing thresholds from dentists in a poulation from Curitiba city / PR, Brazil .......... Clinical and tomography evolution of frontal osteomyelitis: Case report ..................................................... Cochlear condition and olivocochlear system of gas station attendants exposed to organic solvents .......... Cochlear implantation in patient with Dandy-walker syndrome .................................................................. Cochlear implants: our experience and literature review ............................................................................. Comparative study of continuous lateral osteotomy and microperforating osteotomy in patients undergoing primary rhinoplasty ................................................................................................................... Correlation between brain injury and dysphagia in adult patients with stroke ............................................. Correlation between nasopharyngoscopy and cephalometry in the diagnosis of hyperplasia of the pharyngeal tonsils ......................................................................................................................................... Cough: neurophysiology, methods of research, pharmacological therapy and phonoaudiology .................

16 (1): 32-38 16 (1): 130-134 16 (1): 50-56 16 (3): 410-413 16 (4): 476-481 16 (3): 382-386 16 (3): 313-321 16 (2): 209-216 16 (2): 259-268

E Effects of hearing aids in the balance, quality of life and fear to fall in elderly people with sensorineural hearing loss ................................................................................................................................................... Electronic data collection for analysis of surgical maneuvers on patients submetted to rhinoplasty ............. Epidemiological profile of 277 patients with facial fractures treated at the emergency room at the ENT Department of Hospital do Trabalhador in Curitiba / PR, in 2010 ...................................................... Evaluation from the quality of life in the oral breathers patients ................................................................... Evaluation of quality of life of patients with benign paroxysmal positional vertigo associated with Meniereâ&#x20AC;&#x2122;s disease pre and post vestibular rehabilitation .............................................................................. Evaluation of the benefit of amplification in children fitted with hearing aids ............................................... Evaluation of the benefit with the use of the sound amplification inchildren and teenagers .......................... Evoked otoacoustic emissions in workers exposed to noise: A review ......................................................... Expectation as a factor of influence on the success of use of hearing aids in elderly individuals .................... Extramedullary plasmacytoma of the larynx .................................................................................................

16 (2): 156-162 16 (4): 497-501 16 (4): 437-444 16 (1): 74-81 16 (4): 430-436 16 (2): 170-178 16 (1): 82-90 16 (4): 515-522 16 (2): 201-208 16 (3): 410-413

F Fracture of the temporal bone in patients with traumatic brain injury .......................................................... 16 (1): 62-66 Fungus ball of the paranasal sinuses: Report of two cases and literature review ........................................... 16 (2): 286-290

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H Hearing symptoms personal stereos ............................................................................................................. 16 (2): 163-169

I Intensity of noise in the classroom and analysis of acoustic emissions in schoolchildren .............................. 16 (1): 91-95

L Laryngeal complications by orotracheal intubation: Literature review ........................................................ Laryngeal Leishmaniasis ............................................................................................................................... Lateral intercrural suture in the caucasian nose: Decreased domal divergence angle in endonasal rhinoplasty without delivery ......................................................................................................................... Limits on quality of life in communication after total laryngectomy ..............................................................

16 (2): 236-245 16 (4): 523-526 16 (2): 232-235 16 (4): 482-491

M Mastoidectomy: anatomical parameters x surgical difficulty ........................................................................ 16 (1): 57-61 Middle ear resonance in infants: Age effects .................................................................................................. 16 (3): 353-357 Multifrequency tympanometry in infants ....................................................................................................... 16 (2): 186-194

N Nasal septum perforation in patient with pyoderma gangrenosum .............................................................. Nasolabial bilateral cyst as cause of the nasal obstruction: Case report and literature review .................... Nose tip refinement using interdomal suture in caucasian nose ..................................................................... Not carious lesions: the challenge of the multidisciplinary diagnosis ............................................................

16 (2): 278-281 16 (1): 121-125 16 (3): 391-395 16 (1): 96-102

P Partial glossectomy as an auxiliary method to orthodontic treatment of dentofacial deformity ................... Perception of parents about the auditory attention skills of his kid with cleft lip and palate: retrospective study . Pharyngeal swallowing phase and chronic cough ........................................................................................ Prelingual deafness: Benefits from cochlear implants versus conventional hearing aids ................................ Prevalence of auditory changes in newborns in a teaching hospital .............................................................. Prevalence of noise-induced hearing loss in drivers ...................................................................................... Prevalence of tinnitus in elderly individuals with and without history of occupational noise exposure ......... Prevalence of tinnitus in workers exposed to noise and organophosphates ................................................. Profile of cochlear implant users of the city of Manaus ................................................................................. Proposed computerized protocol for epidemiological study of patients undergoing microsurgery of the larynx .

16 (3): 414-417 16 (1): 115-120 16 (4): 502-508 16 (3): 387-390 16 (2): 179-185 16 (4): 509-514 16 (2): 222-225 16 (3): 328-334 16 (4): 452-459 16 (3): 346-352

Q Quality of life and deglutition after total laryngectomy ................................................................................. 16 (4): 460-465

R Real ear unaided gain and its relation with the equivalent volume of the external and middle ear ................ 16 (3): 365-370 Recognition of sentences in silence, and at noise, in free Field, in carriers from hearing loss from moderate degree .......................................................................................................................................... 16 (1): 16-25

Int. Arch. Otorhinolaryngol., S達o Paulo - Brazil, v.16, n.4, Oct/Nov/December - 2012.

534


Index of article in volume 16

Recurrence of atypical fibroxanthoma. Diagnosis and treatment .................................................................. Rehabilitation of oropharyngeal dysphagia in children with cerebral palsy: A systematic review of the speech therapy approach ............................................................................................................................. Relationship between lead in the blood and performance in the abilities from hearing process ................... Relationship between the findings of pure-tone audiometry and otoacoustic emission tests on military police personnel ........................................................................................................................................... Relationship between vocal symptoms in college students and their possible causes ................................... Remote hearing aid fitting: Tele-audiology in the context of Brazilian Public Policy ..................................... Respiratory muscle strength in asthmatic children ....................................................................................... Rhinoplasty and facial asymmetry: Analysis of subjective and anthropometric factors in the Caucasian nose ..

16 (4): 530-532 16 (3): 396-399 16 (1): 39-43 16 (1): 67-73 16 (3): 306-312 16 (3): 371-381 16 (4): 492-496 16 (4): 445-451

S Severe complication of posterior nasal packing: Case Report ...................................................................... 16 (4): 527-529 Single-stage laryngotracheal reconstruction for the treatment of subglottic stenosis in children .................. 16 (2): 217-221

T The descriptive review, from recurrent respiratory papillomatosis of the disease, an enigmatic ................. 16 (1): 108-114 Tongue Abscess: Case Report ...................................................................................................................... 16 (1): 126-129 Treatment of retroauricular keloids: Revision of cases treated at the ENT service of HC/UFPR ................. 16 (2): 195-200

V Vestibular evoked myogenic potential .......................................................................................................... 16 (1): 103-107 Vestibular schwannoma: 825 cases from a 25-year experience ................................................................... 16 (4): 466-475 Vestibular system paresis due to emergency endovascular catheterization ................................................. 16 (2): 282-285

W What are the audiometric frequencies affected are the responsible for the hearing complaint in the hearing loss for ototoxicity after the oncological treatment? ........................................................................ 16 (1): 26-31

Int. Arch. Otorhinolaryngol., S達o Paulo - Brazil, v.16, n.4, Oct/Nov/December - 2012.

535


Index of authors in volume 16

A Abad EC .......................... Alcarás PAS ...................... Almeida Filho N ............... Almeida TSA .................... Alonso N .......................... Alvarenga KF .................... Amaral SM ........................ Amorim Filho FS .............. André KD ......................... Araújo AMB ...................... Artico MS ......................... Artico MS ......................... Augusto LSC .................... Aurélio NHS ..................... Azevedo JA ....................... Azzi VJB ...........................

16 (1): 16 (4): 16 (1): 16 (2): 16 (3): 16 (1): 16 (1): 16 (4): 16 (3): 16 (4): 16 (3): 16 (4): 16 (2): 16 (1): 16 (2): 16 (4):

96-102 515-522 91-95 286-290 341-345 39-43 96-102 523-526 353-357 460-465 410-413 527-529 246-258 82-90 278-281 430-436

16 (4): 16 (4): 16 (2): 16 (2): 16 (4): 16 (4): 16 (2): 16 (2): 16 (4): 16 (3): 16 (3): 16 (2): 16 (4): 16 (3): 16 (3): 16 (1): 16 (3): 16 (3): 16 (3): 16 (4): 16 (4): 16 (3): 16 (3): 16 (2): 16 (4): 16 (2): 16 (3): 16 (3): 16 (2): 16 (2): 16 (2): 16 (4): 16 (3): 16 (3): 16 (2):

460-465 482-491 259-268 195-200 445-451 437-444 195-200 179-185 476-481 365-370 371-381 195-200 445-451 410-413 371-381 44-49 322-327 387-390 400-405 466-475 497-501 382-386 391-395 232-235 445-451 209-216 387-390 365-370 163-169 286-290 286-290 466-475 387-390 400-405 236-245

16 (2): 16 (4): 16 (2): 16 (3): 16 (1): 16 (2): 16 (1):

156-162 523-526 282-285 328-334 67-73 286-290 44-49

B Balata PMM ...................... Balata PMM ...................... Balbani APS ....................... Ballin AC ........................... Ballin AC ........................... Ballin CR ........................... Ballin CR ........................... Barbosa MA ..................... Barreto VMP .................... Bastos BG ......................... Battistella LR .................... Becker RV ......................... Becker RV ......................... Bellotto S .......................... Bento RF .......................... Bento RF .......................... Bento RF .......................... Bento RF .......................... Bento RF .......................... Bento RF .......................... Berger C ........................... Berger CAS ....................... Berger CAS ....................... Berger CAS ....................... Berger CAS ....................... Berwig LC ........................ Bittencourt AG ................. Blasc WQ ......................... Borja ALVF ....................... Bosi GR ............................ Braga GL .......................... Brito Neto RV .................. Brito R .............................. Brito R .............................. Brito VA ...........................

C Canto RST ........................ Caporrino Neto J ............. Caputti C ......................... Cardoso ACV .................. Cardoso ACV .................. Carli A .............................. Carvalho ACM .................

Carvalho B ....................... Carvalho B ....................... Carvalho B ....................... Carvalho LRL ................... Carvalho TBO .................. Carvallo RMM .................. Castro CMMB .................. Castro FB ......................... Castro JDV ....................... Catani GSA ....................... Cavalho GB ...................... Cavichiolo JB .................... Chaves ADD .................... Cheik NC ......................... Cintra PPVC .................... Corrêa ECR ..................... Correa LHL ..................... Costa CC ......................... Costa GL ......................... Costa MJ .......................... Costa MJ .......................... Costa MJ .......................... Couto MIV ....................... Cronenberg EV ................. Cunha DA ........................ Cunha DA ........................ Cunha DA ........................ Cunha RA ......................... Cunha RA .........................

16 (2): 16 (3): 16 (4): 16 (2): 16 (1): 16 (3): 16 (3): 16 (1): 16 (1): 16 (3): 16 (2): 16 (2): 16 (4): 16 (2): 16 (4): 16 (2): 16 (1): 16 (4): 16 (1): 16 (1): 16 (1): 16 (2): 16 (2): 16 (3): 16 (3): 16 (4): 16 (4): 16 (3): 16 (4):

195-200 346-352 445-451 170-178 126-129 353-357 358-364 62-66 57-61 346-352 236-245 195-200 482-491 156-162 527-529 209-216 74-81 502-508 32-38 16-25 82-90 201-208 170-178 341-345 358-364 460-465 492-496 358-364 492-496

D Dedivitis RA ...................... 16 (3): 414-417 Delecrode CR ................... 16 (3): 328-334 Drozdz DRC .................... 16 (4): 502-508

E Eneas LV .......................... 16 (2): 217-221 Enoki AM .......................... 16 (1): 121-125

F Fagundes MSC .................. Felipe L ............................ Felix F ............................... Feniman MR ..................... Feniman MR ..................... Feniman MR ..................... Feniman MR ..................... Fernandes ACP ................. Fernandes AM .................. Fernandes DPP ................. Ferrari DV ........................ Ferrari GMS ..................... Ferreira LP ....................... Filletti F ............................ França DMVR ................... Franco ES ......................... Freitas MR ........................ Freitas R ........................... Freitas TD ........................ Frizzo ACF ....................... Frizzo ACF ....................... Frota AE .......................... Funayama CAR .................

16 (4): 16 (1): 16 (2): 16 (1): 16 (1): 16 (2): 16 (2): 16 (3): 16 (1): 16 (1): 16 (3): 16 (1): 16 (3): 16 (1): 16 (4): 16 (2): 16 (1): 16 (4): 16 (3): 16 (3): 16 (3): 16 (2): 16 (3):

497-501 103-107 278-281 115-120 39-43 186-194 269-277 335-340 126-129 121-125 365-370 44-49 306-312 91-95 515-522 246-258 57-61 497-501 328-334 328-334 335-340 232-235 335-340

Furkim AM ....................... 16 (3): 313-321

G Gândara M ....................... Garbi S ............................. Ghirardi ACAM ................ Gomez MVSG .................. Gonçalves CGO ............... Gonçalves CGO ............... Gonçalves DU .................. Gonçalves GA ................... Gonçalves TS .................... Grangeiro ERN ................. Gravina PR ........................ Guerra JR .......................... Guida HL .......................... Guillaumon HR .................. Guimarães VC ..................

44-49 44-49 306-312 26-31 32-38 515-522 103-107 32-38 39-43 278-281 341-345 306-312 67-73 91-95 179-185

H Hamerschmidt R .............. 16 (3): 410-413 Hirata GC ........................ 16 (3): 396-399 Hurtado JGGM ................. 16 (4): 445-451

I Ido Filho JM ..................... 16 (3): 346-352 Ikari AS ............................. 16 (3): 400-405 Issac ML ........................... 16 (3): 335-340

J Jesus EPF .......................... 16 (4): 476-481 Jurkiewicz AL .................... 16 (3): 313-321

K Kayode AS ........................ Kiesewetter A ................... Kingma H ......................... Kirschnick A ..................... Klas RM ............................ Kuhl G .............................. Kulay LA ...........................

16 (1): 16 (3): 16 (1): 16 (4): 16 (4): 16 (2): 16 (2):

108-114 400-405 103-107 530-532 515-522 217-221 246-258

16 (4): 16 (1): 16 (2): 16 (3): 16 (2): 16 (4): 16 (3): 16 (4): 16 (1): 16 (1): 16 (1): 16 (1): 16 (1): 16 (2): 16 (1): 16 (4): 16 (4): 16 (4): 16 (1): 16 (3):

515-522 32-38 156-162 313-321 269-277 509-514 410-413 527-529 16-25 130-134 130-134 130-134 26-31 170-178 130-134 460-465 482-491 476-481 32-38 306-312

L Lacerda ABM ................... Lacerda ABM ................... Lacerda CF ...................... Lange MC ......................... Lauris JRP ......................... Lauris JRP ......................... Leal CFA .......................... Leal CFA .......................... Lessa AH .......................... Lessa BF ........................... Lessa HA .......................... Lessa MM ......................... Liberman PHP .................. Lichtig I ............................ Lima CMF ........................ Lima LM ........................... Lima LM ........................... LimaFVF .......................... Lobato DCB .................... Loiola CM ........................

Int. Arch. Otorhinolaryngol., São Paulo - Brazil, v.16, n.4, Oct/Nov/December - 2012.

536

16 (1): 16 (1): 16 (3): 16 (1): 16 (1): 16 (4): 16 (1): 16 (1): 16 (1): 16 (2): 16 (3): 16 (3): 16 (1): 16 (1): 16 (2):


Index of authors in volume 16

Lopes AC ......................... Lopes AC ......................... Lopes AC ......................... Lopes AS .......................... Lopes LF .......................... Lopes PMB ....................... Lucia MCS ........................ Luders D .......................... Luz TS ..............................

16 (1): 16 (2): 16 (4): 16 (1): 16 (1): 16 (4): 16 (3): 16 (4): 16 (2):

39-43 226-231 509-514 82-90 26-31 509-514 322-327 515-522 163-169

16 (2): 16 (4): 16 (3): 16 (2): 16 (1): 16 (3): 16 (4): 16 (4): 16 (2): 16 (4): 16 (1): 16 (2): 16 (3): 16 (2): 16 (1): 16 (4): 16 (3): 16 (1): 16 (4): 16 (4): 16 (4): 16 (4): 16 (2): 16 (2): 16 (4): 16 (3): 16 (2): 16 (2): 16 (3): 16 (3): 16 (2): 16 (4): 16 (2): 16 (3): 16 (3): 16 (2): 16 (4): 16 (4): 16 (2): 16 (1): 16 (4): 16 (1): 16 (4): 16 (1): 16 (2): 16 (1): 16 (4): 16 (2): 16 (4):

186-194 497-501 346-352 278-281 96-102 346-352 497-501 502-508 217-221 492-496 74-81 222-225 371-381 217-221 32-38 476-481 313-321 44-49 530-532 530-532 530-532 530-532 226-231 222-225 523-526 341-345 201-208 222-225 341-345 335-340 217-221 437-444 232-235 391-395 410-413 195-200 497-501 445-451 269-277 115-120 523-526 62-66 437-444 39-43 186-194 121-125 452-459 236-245 530-532

M Macedo CC ..................... Macedo E ......................... Macedo Filho ED ............. Maia CBC ......................... Maia KD ........................... Malafaia O ........................ Malafaia O ........................ Mancopes R ...................... Manica D .......................... Marcelino AMFC .............. Marcelino TF .................... Marchiori LLM ................. Marone SAM .................... Marostica PJC .................. Marques JM ...................... Martins MBB ..................... Massi G ............................ Matas CG ......................... Mattiola G ........................ Mattiola L ......................... Mattiola LR ....................... Mattiola SZM ................... Melo ADP ......................... Melo JJ .............................. Melo Júnior JES ................. Mendes RRS ...................... Menegotto IH ................... Meneses CL ...................... Meneses JVL ..................... Menezes PL ...................... Meotti CD ........................ Miksza AF ......................... Mocelin M ......................... Mocelin M ......................... Mocelin M ......................... Mocellin M ........................ Mocellin M ........................ MocellinM ......................... Mondelli MFCG ................ Mondelli MFCG ................ Moraes BT ........................ Moraes JFS ....................... Moraes RS ........................ Moraes TFD ..................... Moraes TFD ..................... Morais MS ........................ Moreira SC ....................... Mota LAA ........................ Moura CE .........................

N Nascimento GKBO .......... 16 (3): 358-364

Neto ABM ........................ 16 (4): 502-508 Nunes MCA ..................... 16 (3): 313-321

Quevedo LS ..................... 16 (1): 50-56

Santos Jr RC ..................... Santos RMR ...................... Santos RS .......................... Santos RS .......................... Santos SN ......................... Santos VS ......................... Saraceni Neto P ................ Schmitz LM ...................... Schultz C .......................... Schuster LC ..................... Schweiger C ..................... Secchi MMD ..................... Serafini F ........................... Serpa EO .......................... Sguillar DA ........................ Silva AMT ......................... Silva AMT ......................... Silva EGF .......................... Silva HJ ............................. Silva HJ ............................. Silva HJ ............................. Silva HJ ............................. Silva LO ............................ Simoceli L ......................... Siqueira MA ...................... Smith MM ........................ Soares CMC ..................... Soares JS ........................... Socher DD ....................... Socher JA ......................... Sônego TB ........................ Sônego TB ........................ Sousa AL .......................... Souza LA .......................... Souza SR ........................... Souza TC ......................... Stahlke Jr HJ .....................

R

T

O Oliveira AKP ..................... Oliveira Jesus PRO ............ Oliveira JHP ...................... Oliveira MPRPB ................ Oliveira PRG ..................... Otowiz VG .......................

16 (3): 16 (4): 16 (4): 16 (1): 16 (1): 16 (4):

410-413 502-508 460-465 96-102 121-125 509-514

16 (1): 16 (2): 16 (2): 16 (3): 16 (4): 16 (3): 16 (1): 16 (4): 16 (4): 16 (1): 16 (4): 16 (3): 16 (3): 16 (4): 16 (3): 16 (4): 16 (1): 16 (1): 16 (3): 16 (3): 16 (1):

16-25 278-281 232-235 391-395 452-459 371-381 57-61 460-465 482-491 57-61 466-475 313-321 410-413 527-529 346-352 497-501 44-49 121-125 382-386 341-345 74-81

P Padilha CB ........................ Paes V ............................... Pasinato R ......................... Pasinato R ......................... Pedrett MS ....................... Penteado SP ..................... Pereira Jr AR ..................... Pernambuco LA ................ Pernambuco LA ................ Pinheiro SD ....................... Pinna MH .......................... Pinto GS ........................... Pinto JA ............................ Pinto JA ............................ Pinto JSP ........................... Pinto JSP ........................... Pinto MM ......................... Pizarro GU ....................... Pizzamiglio DS .................. Pochat VD ....................... Popoaski C .......................

Q Raimundo JC .................... Ramos SL ......................... Régis RMFL ....................... Régis RMFL ....................... Rezende RK ...................... Ribas A ............................. Ribeiro TB ........................ Riccio JLN ........................ Rissatto ACS .................... Rito HC ............................ Ritzel RA ...........................

16 (1): 16 (3): 16 (3): 16 (4): 16 (3): 16 (1): 16 (2): 16 (2): 16 (2): 16 (2): 16 (2):

44-49 371-381 358-364 460-465 410-413 32-38 195-200 278-281 269-277 278-281 209-216

Teixeira TS ....................... Tochetto TM ................... Torre AAGD .................... Torres EMO ..................... Trindade MS ..................... Tsuji RK ............................ Tunãs ITC ........................

16 (4): 16 (3): 16 (3): 16 (3): 16 (1): 16 (4): 16 (4): 16 (1): 16 (1): 16 (2): 16 (2): 16 (1): 16 (1): 16 (2): 16 (2): 16 (2): 16 (4): 16 (3): 16 (4): 16 (4): 16 (3): 16 (4): 16 (2): 16 (2): 16 (1): 16 (2): 16 (2): 16 (4): 16 (4): 16 (4): 16 (3): 16 (4): 16 (1): 16 (1): 16 (4): 16 (1): 16 (3):

476-481 322-327 396-399 313-321 16-25 482-491 523-526 74-81 26-31 201-208 217-221 62-66 91-95 209-216 282-285 209-216 502-508 358-364 460-465 492-496 358-364 482-491 156-162 282-285 50-56 217-221 232-235 527-529 430-436 430-436 410-413 527-529 67-73 130-134 482-491 115-120 346-352

16 (1): 16 (1): 16 (3): 16 (1): 16 (4): 16 (3): 16 (1):

115-120 50-56 387-390 82-90 502-508 387-390 96-102

V Verde RCL ....................... 16 (1): 130-134

W

S Sakae TM ......................... Salmen FS ......................... Salvador KK ..................... Samelli AG ........................ Sanches RA ....................... Sanches SGG .................... Sanchez TG ...................... Santos ACG ..................... Santos CC ........................ Santos CC ........................ Santos HMP .....................

16 (1): 16 (3): 16 (1): 16 (1): 16 (1): 16 (3): 16 (3): 16 (4): 16 (4): 16 (2): 16 (2):

74-81 414-417 39-43 44-49 126-129 353-357 322-327 476-481 509-514 226-231 282-285

Weiss G ............................ 16 (4): 502-508 Weyne S ........................... 16 (1): 96-102

X Ximenes Filho JA .............. 16 (1): 57-61

Y Ykeda RBA ........................ 16 (4): 437-444 Ykeda RBA ........................ 16 (4): 437-444

Int. Arch. Otorhinolaryngol., São Paulo - Brazil, v.16, n.4, Oct/Nov/December - 2012.

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International Archives of Otorhinolaryngology  

16(4) 2012

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