Hearing Preservation Outcomes With Standard Length Electrodes in Adult Cochlear Implantation and the Uptake of Electroacoustic Stimulation Background: Cochlear implantation with preservation of residual low-frequency hearing enables patients to utilize acoustic and electrical stimulation. It is widely accepted that preservation of residual low-frequency hearing is beneficial in both background noise and for music appreciation. The extent to which patients may benefit is not fully understood, but the importance of these concepts is reflected in electrode design developments and also refinement of surgical technique. Greater understanding is needed around factors that may affect hearing preservation. This study reports experience in adults using standard length cochlear implant arrays. Objective: The study reviews hearing preservation outcomes using the HEARRING GROUP method for factors such as gender, electrode type, insertion depth, laterality, preoperative hearing level, and time between surgery and audiogram. Furthermore, the study reviews rates of electroacoustic stimulation use in those with postoperative functional residual low-frequency hearing. Methodology: Retrospective case series. Inclusion criteria: preoperative ≤ 85 dB HL at 250 Hz and aged ≥ 18 years. The hearing preservation percentages were calculated using the HEARRING group formula S=[1 − ((PTApost − PTApre)/(PTAmax − PTApre))*100]%. . Preservation of > 75% was considered complete, 25 to 75% partial, and 1 to 25% minimal. Standardized operative technique with facial recess approach, posterior tympanotomy, and minimally traumatic round window insertion was performed for each implant. Results: Fifty-three implantations in 52 patients met the inclusion criteria. The mean age at implantation was 55.5 years. The average time since the last audiogram was 10 months. The mean average total pre and postoperative pure-tone averages were 92.4 dB, 99.2 dB, respectively, using minimum reporting standards for adult cochlear Implant (CI). Thirty percent demonstrated complete hearing preservation, 35.8% partial hearing preservation, and 20.8% minimal hearing preservation. Overall, mean hearing preservation was 52.9%. Sex, age at implantation, insertion depth, lateral versus perimodiolar electrode, and preoperative hearing level did not statistically significantly affect rates of hearing preservation in our study. There was a statistically significant deterioration in hearing preservation outcomes difference at 3 months compared with 12 months postoperatively. Only two patients within our study out of 17 with functional postoperative hearing went on to use electroacoustic stimulation. Conclusion: Hearing preservation varies between patients and postoperative outcomes are difficult to predict. This study adds to existing literature in terms of likelihood of hearing preservation following cochlear implantation. In turn, this improves our ability to counsel patients as to the chances of preserving residual low-frequency hearing postoperatively and their ability to use electroacoustic stimulation. Address correspondence and reprint requests to Laura Harrison, F.R.C.S., B.M.B.S., B.Medsci., UCL Ear Institute, 332 Gray's Inn Road, London WC1X 8DA, UK; E-mail: lauraharrison707@gmail.com The authors disclose no conflicts of interest. Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

A Structural Analysis of Tympanic Compartments of the Middle Ear in Patients With Down's Syndrome: A Temporal Bone Study Hypothesis: There may be findings peculiar to the temporal bones of children with Down's syndrome (DS). The purpose of this study is to investigate the temporal bone histopathology of the children with DS. Background: Otitis media with effusion is a highly prevalent condition with DS. Knowledge of the volume of the tympanic compartments and the area of the tympanic isthmus might be important to find out the pathogenesis of highly prevalent otitis media with effusion in those patients. Methods: We compared the volume of the epitympanum, mesotympanum, and the areas of the tympanic isthmus and tympanic orifice of eustachian tube in temporal bones from patients with DS. We also investigated the eustachian tube histopathologically. Results: The mean volume of the epitympanum and the mesotympanum was significantly smaller in the DS group than the control group. We found no significant difference in the mean diameter of the protympanic opening and tympanic orifice between the two groups. The mean narrowest area of the aerated and bony tympanic isthmus also was not significantly different between the two groups. An immature development of eustachian tube and cartilage was seen. We found mesenchyme remaining at the epitympanum and/or mesotympanum in all specimens in the DS group, and in five specimens in the control group. Conclusion: In the presence of the small middle ear, poorly developed eustachian tube, and tensor muscle, a vicious circle occurs, making otitis media with effusion difficult to resolve. Address correspondence and reprint requests to Sebahattin Cureoglu, M.D., Ph.D., Department of Otolaryngology—Head and Neck Surgery, University of Minnesota, Lions Research Building, Room 210, Mayo Mail Code 2873, 2001 6th Street SE, Minneapolis, MN 55455; E-mail: cureo003@umn.edu This project was funded by the International Hearing Foundation; the 5 M Lions International; and the Starkey Foundation. The authors disclose no conflicts of interest. Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Insertion Depth for Optimized Positioning of Precurved Cochlear Implant Electrodes Hypothesis: Generic guidelines for insertion depth of precurved electrodes are suboptimal for many individuals. Background: Insertion depths that are too shallow result in decreased cochlear coverage, and ones that are too deep lift electrodes away from the modiolus and degrade the electro-neural interface. Guidelines for insertion depth are generically applied to all individuals using insertion depth markers on the array that can be referenced against anatomical landmarks. Methods: To normalize our measurements, we determined the optimal position and insertion vector where a precurved array best fits the cochlea for each patient in an IRB-approved, N = 131 subject CT database. The distances from the most basal electrode on an optimally placed array to anatomical landmarks, including the round window (RW) and facial recess (FR), was measured for all patients. Results: The standard deviations of the distance from the most basal electrode to the FR and RW are 0.65 mm and 0.26 mm, respectively. Owing to the high variability in FR distance, using the FR as a landmark to determine insertion depth results in >0.5 mm difference with ideal depth in 44% of cases. Alignment of either of the two most proximal RW markers with the RW would result in over-insertion failures for >80% of cases, whereas the use of the third, most medial marker would result in under-insertion in only 19% of cases. Conclusions: Normalized measurements using the optimized insertion vector show low variance in distance from the basal electrode position to the RW, thereby suggesting it as a better landmark for determining insertion depth than the FR. Address correspondence and reprint requests to Rueben A. Banalagay, 2301 Vanderbilt Pl., VU Station B #351679, Nashville, TN 37235; E-mail: rueben.a.banalagay@vanderbilt.edu The content is solely the responsibility of the authors and does not necessarily represent the official views of this institute. R.F.L. is a consultant with Advanced Bionics, Johnson&Johnson, Ototronix, and Medel. This research was supported in part by grants R01DC014037, R01DC008408, and R01DC014462 from the National Institute on Deafness and Other Communication Disorders. IRB approval number 090155. The authors disclose no conflicts of interest. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Potential Ototopical Antiseptics for the Treatment of Active Chronic Otitis Media: An In-Vitro Evaluation Objectives: Primary: to compare, in vitro, the antimicrobial activity of different antiseptic agents versus quinolone drops, against the common organisms of chronic otitis media. Secondary: to examine the possible role of pH on the antimicrobial activity of the antiseptic solutions. Methods: Three antiseptic powders (boric acid; iodine; and a 1:1 combination of these two) and four solutions (2% boric acid; 2% acetic acid; 3.25% aluminum acetate; and 5% povidone iodine) were tested against five bacteria and two fungi common in chronic otitis media, using both agar plates and the modified broth dilution method. These results were compared with the antimicrobial activity of quinolone drops. The potential role of pH of solutions was tested by reducing the acidity of the agents and repeating the broth dilution. Results: Of the powders, iodine, and iodine/boric acid combined, are very effective against all organisms. Boric acid powder showed moderate effectiveness against all organisms. All solutions performed poorly on the agar plates. 5% povidone iodine has good effectivity when tested with the broth dilution method. 3.25% aluminum acetate had the best activity against Pseudomonas aeruginosa. Conclusion: Boric acid powder and 5% povidone iodine solution show promise for clinical use. Boric acid powder has proven clinical effectiveness. 5% povidone iodine requires further clinical research. Although very effective in vitro, iodine powder is toxic to tissues and cannot be recommended for clinical use. The pH of solutions does not seem to play a significant role in their antimicrobial activity in vitro. Address correspondence and reprint requests to Andries Francois van Straten, F.C.O.R.L. (SA), Faculty of Medicine and Health Sciences, Room 5054, Clinical Building, Building 91, Francie van Zijl Drive, Tygerberg, 7505 Cape Town, South Africa; E-mail: vanstraten.andre@gmail.com Address for reprints: Same as for correspondence. The authors disclose no conflicts of interest. Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Current Management of CPAP After Otologic and Neurotologic Surgery Background: Obstructive sleep apnea is a highly prevalent disorder often treated with continuous positive airway pressure (CPAP). CPAP transmits high pressures through the Eustachian tube, and has significant implications for patients undergoing surgery of the middle ear, inner ear, and lateral skull base. In such patients, nothing is known regarding the likelihood of surgical complications with CPAP use, or medical complications with its cessation. No consensus or guidelines exist for postoperative management of this vitally important but potentially hazardous therapy. Objective: To gain an understanding of the current state of practice with regards to postoperative CPAP management in patients undergoing middle ear, stapes, cochlear implant, and lateral skull base surgeries. Methods: An electronic survey was sent to all members of the American Neurotology Society via email. Results: The survey was completed by 54 neurotologists. Duration of postoperative CPAP limitation had similar distribution for surgery of the middle ear, stapes, and skull base: fewer surgeons recommend immediate use, with more advising ≤1 week and ≥2 week abstinence. For cochlear implantation, immediate use is most commonly advocated. The rationale for restricting postoperative CPAP use varied by surgery type. Subgroup analysis showed no variations by region; however, surgeons with >15 years of experience tend to advocate for earlier return to CPAP than those with less experience. Conclusion: Current neurotology practice varies widely concerning CPAP management after otologic and neurotologic surgeries, both with regard to duration of CPAP abstinence and in rationale for its limitation. Address correspondence and reprint requests to Nathan D. Cass, M.D., University of Michigan Medical School, Ann Arbor, MI 48109; E-mail: ncass@med.umich.edu No sources of funding were received for this study. S.C.B. received research funding from Oticon Medical and Cochlear Corporation, honorarium from Acclarent. The authors disclose no conflicts of interest. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Quality of Otology and Neurotology Research in Otolaryngology Journals Objective: To identify trends in the quality of otology studies published in general otolaryngology journals over a 20-year period. Study Design: Retrospective analysis. Methods: Otologic and neurotologic papers from 1997, 2007, and 2017 were identified in the three general otolaryngology journals with the highest Eigenfactor scores: the Laryngoscope, European Archives of Otorhinolaryngology, and Otolaryngology–Head and Neck Surgery. The studies were reviewed and assigned level of evidence (LoE) based on standards set by the Centres for Evidence Based Medicine (CEBM). One-way analysis of variance were calculated with a 95% bootstrap sensitivity analysis performed. Results: A total of 786 otology articles were reviewed for level of evidence, of which 557 (70.8%) were original, clinical research, eligible for LoE assignation. Total publications increased for each year in all three journals. Both the absolute number and proportion of high evidence studies (level of evidence 1 and 2) increased with respect to time in all three journals. Lower evidence studies (level of evidence 3, 4, or 5) made up 66.8% of total publications in 2017. There was a reduction in average level of evidence (towards higher quality evidence) by 0.431 units from 1997 to 2017 (Diff = –0.431 between 1997 and 2017, p < 0.001). There was no significant difference in rate of change of level of evidence between 1997 and 2007 and 2007 and 2017 (0.033, p = 0.864). Conclusion: Over a 20-year period the number of total publications increased with time. The majority of otology publications in 2017 were lower evidence studies, though significant increases in the number and proportion of high evidence studies in general otolaryngology journals were observed throughout the study period. Address correspondence and reprint requests to Daniel H. Coelho, M.D., Otolaryngology–Head & Neck Surgery, Virginia Commonwealth University School of Medicine, PO Box 980146, Richmond, VA 23298-0146; E-mail: daniel.coelho@vcuhealth.org Funding: Statistical analysis was supported by the Biostatistics Consulting Laboratory, which is partially supported by Award No. UL1TR002649 from the National Institutes of Health's National Center for Advancing Translational Science. Financial Disclosures: None. The authors disclose no conflicts of interest. Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

The National Landscape of Acute Mastoiditis: Analysis of the Nationwide Readmissions Database Objective: To determine risk factors for readmission, prolonged length of stay, and discharge to a rehabilitation facility in patients with acute mastoiditis. Trends in treatment and complication rates were also examined. Study Design: Retrospective cohort study. Setting: Nationwide Readmissions Database (2013, 2014). Patients: Pediatric and adult patients in the Nationwide Readmissions Database with a primary diagnosis of acute mastoiditis. Interventions: Medical treatment, surgical intervention. Outcome Measures: Rates of and risk factors for readmission, prolonged length of stay, and discharge to a rehabilitation facility. Procedure and complication rates were also examined. Results: Four thousand two hundred ninety-five pediatric and adult admissions for acute mastoiditis were analyzed. The overall rates of readmission, prolonged length of stay, and discharge to a rehabilitation facility were 17.0, 10.4, and 10.2%, respectively. Children 4 to 17 years of age had the highest rates of intracranial complications, and children ≤3 years were most likely to undergo operative intervention. Any procedure was performed in 31.2% of cases, and undergoing myringotomy or mastoidectomy was associated with lower rates of readmission but higher rates of prolonged length of stay. Those with intracranial complications and subperiosteal abscesses had the highest surgical intervention rates. Conclusions: Readmission, prolonged length of stay, and discharge to a rehabilitation facility are common in patients with acute mastoiditis with various sociodemographic and disease-related risk factors. While once a primarily surgical disease, a minority of patients in our cohort underwent procedures. Undergoing a surgical procedure was protective against readmission but a risk factor for prolonged length of stay. Address correspondence and reprint requests to Zachary G. Schwam, M.D., Mount Sinai Department of Otolaryngology—Head and Neck Surgery, 1 Gustave L. Levy Place, Box 1189, New York, NY 10029; E-mail: zachary.schwam@mountsinai.org G.B.W. is on the surgical advisory board for Oticon and Med-El. He consults for Med-El, cochlear, and Advanced Bionics. M.K.C. has received travel grants from Med-El, Cochlear, Stryker, educational research grants from Advanced Bionics, and has done clinical research with Advanced Bionics, Cochlear, and Otonomy. The abstract for this manuscript was selected as a poster presentation at the 2019 American Otological Society Meeting in Austin, Texas, May 3 to 5, 2019. The authors disclose no conflicts of interest. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

A Position Paper on Systematic and Meta-Analysis Reviews No abstract available

Association of Speech Recognition Thresholds With Brain Volumes and White Matter Microstructure: The Rotterdam Study Objectives: Brain volumetric declines may underlie the association between hearing loss and dementia. While much is known about the peripheral auditory function and brain volumetric declines, poorer central auditory speech processing may also be associated with decreases in brain volumes. Methods: Central auditory speech processing, measured by the speech recognition threshold (SRT) from the Digits-in-Noise task, and neuroimaging assessments (structural magnetic resonance imaging [MRI] and fractional anisotropy and mean diffusivity from diffusion tensor imaging), were assessed cross-sectionally in 2,368 Rotterdam Study participants aged 51.8 to 97.8 years. SRTs were defined continuously and categorically by degrees of auditory performance (normal, insufficient, and poor). Brain volumes from structural MRI were assessed on a global and lobar level, as well as for specific dementia-related structures (hippocampus, entorhinal cortex, parahippocampal gyrus). Multivariable linear regression models adjusted by age, age-squared, sex, educational level, alcohol consumption, intracranial volume (MRI only), cardiovascular risk factors (hypertension, diabetes, obesity, current smoking), and pure-tone average were used to determine associations between SRT and brain structure. Results: Poorer central auditory speech processing was associated with larger parietal lobe volume (difference in mL per dB increase= 0.24, 95% CI: 0.05, 0.42), but not with diffusion tensor imaging measures. Degrees of auditory performance were not associated with brain volumes and white matter microstructure. Conclusions: Central auditory speech processing in the presence of both vascular burden and pure-tone average may not be related to brain volumes and white matter microstructure. Longitudinal follow-up is needed to explore these relationships thoroughly. Address correspondence and reprint requests to André Goedegebure, Ph.D., Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus MC, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands; E-mail: a.goedegebure@erasmusmc.nl N.M.A. wrote the manuscript and analyzed the data. All authors discussed the results and implications and commented on the manuscript at all stages, and they were responsible for the study design. The Rotterdam Study is supported by the Erasmus Medical Center and Erasmus University, Rotterdam, The Netherlands; the Organization for Scientific Research; the Netherlands Organization for Health Research and Development; the Research Institute for Diseases in the Elderly; the Netherlands Genomics Initiative; the Ministry of Education, Culture, and Science; the Ministry of Health, Welfare, and Sports; the European Commission (DG XII); and the Municipality of Rotterdam. Hearing-related research within the Rotterdam Study is partly funded by The Heinsius Houbolt Foundation. Separately, N.M.A. is supported by the Intramural Research Program at the National Institute on Aging, Baltimore, Maryland (N.M.A. received funding). F.R.L., A.G., and P.H.C. report funding by Cochlear Ltd. The authors disclose no conflicts of interest. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Effect of Vestibular Schwannoma Size and Nerve of Origin on Posterior External Auditory Canal Sensation: A Prospective Observational Study Objective: Posterior external auditory canal (EAC) hypesthesia (Hitselberger's sign) has been previously described to occur in all vestibular schwannomas (1966) but has not been studied since. We hypothesized that sensory loss may be related to tumor size and sought to determine if this clinical sign could predict preoperative characteristics of vestibular schwannomas, intraoperative findings, and/or surgical outcomes. Study Design: Prospective observational study. Setting: Tertiary referral center. Patients: Twenty-five consecutive patients who underwent surgery for vestibular schwannoma. Intervention: Patients were tested for the presence of EAC hypesthesia or anesthesia. Main Outcome Measures: Preoperative, intraoperative, and postoperative findings were recorded, including facial nerve function, hearing function, tumor size, tumor nerve of origin, and extent of resection. Results: Twelve patients (48%) demonstrated either posterior EAC hypesthesia (11 patients) or anesthesia (1 patient). Sensory loss was a significant predictor of size (tumor maximal diameter) (p = 0.004). Median tumor diameter was 1.7 cm in the cohort with intact sensation versus 2.9 cm in the cohort with sensory loss. Patients with sensory loss were also significantly more likely to be associated with a superior vestibular nerve origin tumor (p = 0.01). Preoperative sensory loss did not significantly predict postoperative facial outcome (p = 0.10). Conclusion: Neurological exam findings may be overlooked in the workup of brain tumors. Posterior EAC hypesthesia is a predictor of tumor size and superior vestibular nerve origin. These findings may have implications for patient selection, particularly with the middle cranial fossa approach. Furthermore, given this relationship with tumor size, this clinical biomarker should be studied as a potential predictor of tumor growth. Address correspondence and reprint requests to Gautam U. Mehta, M.D., Division of Neurosurgery, House Institute, 2100 West 3rd Street, Ste 111, Los Angeles, CA 90057; E-mail: gmehta39@gmail.com The authors disclose no conflicts of interest. Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Detection of Unsuspected Coronavirus Disease 2019 Cases by Computed Tomography and Retrospective Implementation of the Radiological Society of North America/Society of Thoracic Radiology/American College of Radiology Consensus Guidelines Purpose: The purpose of this article was to report the utility of computed tomography (CT) for detecting unsuspected cases of Coronavirus disease 2019 (COVID-19) and the utility of the Radiological Society of North America (RSNA)/Society of Thoracic Radiology (STR)/American College of Radiology (ACR) consensus guidelines for COVID-19 reporting. Materials and Methods: A total of 22 patients of the 156 reverse transcriptase polymerase chain reaction confirmed COVID-19 patients who were hospitalized between March 27, 2020 and March 31, 2020 at our quaternary care academic medical center and who underwent CT imaging within 1 week of admission were included in this retrospective study. Demographics and clinical data were extracted from the electronic medical record system. Two thoracic radiologists independently categorized each CT study on the basis of RSNA/STR/ACR consensus guidelines. Disagreement in categorization was resolved by consensus discussion with a third thoracic radiologist. Results: At the time of imaging, 16 patients (73%) were suspected of COVID-19, and 6 patients (27%) were not. Common symptoms at presentation were fever (73%), cough (77%), and gastrointestinal symptoms (59%). An overall 63% of suspected COVID-19 patients exhibited shortness of breath, whereas 0 unsuspected COVID-19 patients did (P=0.02). On the basis of the RSNA consensus guidelines, 68%, 18%, 9%, and 5% of studies were categorized as “typical appearance,” “indeterminate appearance,” “atypical appearance,” and “negative for pneumonia,” respectively. There was no difference of category distribution between suspected and unsuspected COVID-19 patients (P=0.20), with “typical appearance” being the most prevalent in both (69% vs. 67%, respectively). Conclusions: It is important to recognize imaging features of COVID-19 pneumonia even in unsuspected patients. Implementation of the RSNA/STR/ACR consensus guidelines may increase consistency of reporting and convey the level of suspicion for COVID-19 to other health care providers, with “typical appearance” especially warranting further attention. Dr B.P.L. is a textbook author and editor for Elsevier and receives royalties for his prior work. Dr E.J.F. reports grant funding from the American College of Radiology Innovation Fund and the National Cancer Institute Research Diversity Supplement for work not related to this manuscript. The remaining authors declare no conflicts of interest. Correspondence to: Brent P. Little, MD, Department of Radiology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 (e-mail: blittle@partners.org). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Prevalence of Burnout Among Cardiothoracic Radiologists Purpose: Burnout is a psychological syndrome in response to chronic occupational stressors. The prevalence of burnout among medical professionals has been increasing, and recent studies have shown that radiologists are among those affected. We investigated the prevalence of burnout and assessed associated factors among cardiothoracic radiologists. Materials and Methods: Society of Thoracic Radiology members were invited to complete an anonymous cross-sectional survey that included an adapted Maslach Burnout Inventory and questions about demographics, work place characteristics, and stressors. Results: The survey response rate was 33.1% (290/874). Per-item response rate ranged from 94% to 100% with a median of 99%. The prevalence of emotional exhaustion was 66.8% (186/283), depersonalization was 79% (223/283), and low personal accomplishment was 23% (65/280). There were no statistically significant differences between academic and private practice. There was a trend toward worse burnout in women, but this was not statistically significant. Being in early career (0 to 10 y since fellowship) was associated with low personal accomplishment [odds ratio (OR): 2.07, 95% confidence interval (CI): 1.08-3.99]. Those working fewer than 51 hours per week were significantly less likely to report emotional exhaustion (OR: 0.55, 95% CI: 0.33-0.90). The odds of emotional exhaustion for those producing fewer than 7500 work relative value units per year were approximately half of those exceeding that number (OR: 0.46, 95% CI: 0.22-0.95). Conclusions: The prevalence of burnout among cardiothoracic radiologists is comparable to that reported for radiologists in other subspecialties such as musculoskeletal and interventional radiology. High work relative value unit productivity and longer work hours are associated with higher prevalence of burnout. The authors declare no conflicts of interest Correspondence to: Ronald L. Eisenberg, MD, Department of Radiology, Harvard University School of Medicine, Boston, MA 02215 (e-mail: rleisenb@bidmc.harvard.edu). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

A Novel Machine Learning-derived Radiomic Signature of the Whole Lung Differentiates Stable From Progressive COVID-19 Infection: A Retrospective Cohort Study Objective: This study aimed to use the radiomics signatures of a machine learning-based tool to evaluate the prognosis of patients with coronavirus disease 2019 (COVID-19) infection. Methods: The clinical and imaging data of 64 patients with confirmed diagnoses of COVID-19 were retrospectively selected and divided into a stable group and a progressive group according to the data obtained from the ongoing treatment process. Imaging features from whole-lung images from baseline computed tomography (CT) scans were extracted and dimensionality reduction was performed. Support vector machines were used to construct radiomics signatures and to compare differences between the 2 groups. We also compared the differences of signature scores in the clinical, laboratory, and CT image feature subgroups and finally analyzed the correlation between the radiomics features of the constructed signature and the other features including clinical, laboratory, and CT imaging features. Results: The signature has a good classification effect for the stable group and the progressive group, with area under curve, sensitivity, and specificity of 0.833, 80.95%, and 74.42%, respectively. Signature score differences in laboratory and CT imaging features between subgroups were not statistically significant (P>0.05); cough was negatively correlated with GLCM Entropy_angle 90_offset4 (r=−0.578), but was positively correlated with ShortRunEmphhasis_AllDirect_offset4_SD (r=0.454); C-reactive protein was positively correlated with Cluster Prominence_ AllDirect_offset 4_ SD (r=0.47). Conclusion: The radiomics signature of the whole lung based on machine learning may reveal the changes of lung microstructure in the early stage and help to indicate the progression of the disease. The authors declare no conflicts of interest. Correspondence to: Zhenyu Shu, MD, NO.158 Shangtang Road, Hangzhou City, Zhejiang Province 310014, China (e-mail: cooljuty@hotmail.com). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/ Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Review of Chest Radiograph Findings of COVID-19 Pneumonia and Suggested Reporting Language The diagnosis of coronavirus disease 2019 (COVID-19) is confirmed by reverse transcription polymerase chain reaction. The utility of chest radiography (CXR) remains an evolving topic of discussion. Current reports of CXR findings related to COVID-19 contain varied terminology as well as various assessments of its sensitivity and specificity. This can lead to a misunderstanding of CXR reports and makes comparison between examinations and research studies challenging. With this need for consistency, we propose language for standardized CXR reporting and severity assessment of persons under investigation for having COVID-19, patients with a confirmed diagnosis of COVID-19, and patients who may have radiographic findings typical or suggestive of COVID-19 when the diagnosis is not suspected clinically. We recommend contacting the referring providers to discuss the likelihood of viral infection when typical or indeterminate features of COVID-19 pneumonia on CXR are present as an incidental finding. In addition, we summarize the currently available literature related to the use of CXR for COVID-19 and discuss the evolving techniques of obtaining CXR in COVID-19-positive patients. The recently published expert consensus statement on reporting chest computed tomography findings related to COVID-19, endorsed by the Radiological Society of North American (RSNA), the Society of Thoracic Radiology (STR), and American College of Radiology (ACR), serves as the framework for our proposal. The authors declare no conflicts of interest. Correspondence to: Diana E. Litmanovich, MD, Department of Cardiothoracic Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215 (e-mail: dlitmano@bidmc.harvard.edu). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Cardiac Magnetic Resonance Imaging Feature Tracking Demonstrates Altered Biventricular Strain in Obese Subjects in the Absence of Clinically Apparent Cardiovascular Disease No abstract available

The Regimen of Computed Tomography Screening for Lung Cancer: Lessons Learned Over 25 Years From the International Early Lung Cancer Action Program We learned many unanticipated and valuable lessons since we started planning our study of low-dose computed tomography (CT) screening for lung cancer in 1991. The publication of the baseline results of the Early Lung Cancer Action Project (ELCAP) in Lancet 1999 showed that CT screening could identify a high proportion of early, curable lung cancers. This stimulated large national screening studies to be quickly started. The ELCAP design, which provided evidence about screening in the context of a clinical program, was able to rapidly expand to a 12-institution study in New York State (NY-ELCAP) and to many international institutions (International-ELCAP), ultimately working with 82 institutions, all using the common I-ELCAP protocol. This expansion was possible because the investigators had developed the ELCAP Management System for screening, capturing data and CT images, and providing for quality assurance. This advanced registry and its rapid accumulation of data and images allowed continual assessment and updating of the regimen of screening as advances in knowledge and new technology emerged. For example, in the initial ELCAP study, introduction of helical CT scanners had allowed imaging of the entire lungs in a single breath, but the images were obtained in 10 mm increments resulting in about 30 images per person. Today, images are obtained in submillimeter slice thickness, resulting in around 700 images per person, which are viewed on high-resolution monitors. The regimen provides the imaging acquisition parameters, imaging interpretation, definition of positive result, and the recommendations for further workup, which now include identification of emphysema and coronary artery calcifications. Continual updating is critical to maximize the benefit of screening and to minimize potential harms. Insights were gained about the natural history of lung cancers, identification and management of nodule subtypes, increased understanding of nodule imaging and pathologic features, and measurement variability inherent in CT scanners. The registry also provides the foundation for assessment of new statistical techniques, including artificial intelligence, and integration of effective genomic and blood-based biomarkers, as they are developed. I-ELCAP Investigators: Mount Sinai School of Medicine, New York, NY: Claudia I. Henschke, Principal Investigator, David F. Yankelevitz, Rowena Yip, Artit Jirapatnakul, Raja Flores, Andrea Wolf; Weill Cornell Medical College: Dorothy I. McCauley, Mildred Chen, Daniel M. Libby, James P. Smith, Mark Pasmantier; Cornell University: A. P. Reeves; CBNS, City University of New York at Queens College, Queens, NY; Steven Markowitz, Albert Miller; Fundacion Instituto Valenciano de Oncologia, Valencia, Spain: Jose Cervera Deval; University of Toronto, Princess Margaret Hospital, Toronto, ON, Canada: Heidi Roberts, Demetris Patsios; Azumi General Hospital, Nagano, Japan: Shusuke Sone, Takaomi Hanaoka; Clinica Universitaria de Navarra, Pamplona, Spain: Javier Zulueta, Juan P. de-Torres, Maria D. Lozano; Swedish Medical Center, Seattle, WA: Ralph Aye, Kristin Manning; Christiana Care, Helen F. Graham Cancer Center, Newark, DE: Thomas Bauer; National Cancer Institute Regina Elena, Rome, Italy: Stefano Canitano, Salvatore Giunta; St.Agnes Cancer Center, Baltimore, MD: Enser Cole; LungenZentrum Hirslanden, Zurich, Switzerland: Karl Klingler; Columbia University Medical Center, New York, NY: John H.M. Austin, Gregory D. N. Pearson; Hadassah Medical Organization, Jerusalem, Israel: Dorith Shaham; Holy Cross Hospital Cancer Institute, Silver Spring, MD: Cheryl Aylesworth; Nebraska Methodist Hospital, Omaha, NE: Patrick Meyers; South Nassau Communities Hospital, Long Island, NY: Shahriyour Andaz; Eisenhower Lucy Curci Cancer Center, Rancho Mirage, CA; Davood Vafai; New York University Medical Center, New York, NY: David Naidich, Georgeann McGuinness; Dorothy E. Schneider Cancer Center, Mills-Peninsula Health Services, San Mateo, CA: Barry Sheppard; State University of New York at Stony Brook, Stony Brook, NY: Matthew Rifkin; ProHealth Care Regional Cancer Center, Waukesha & Oconomowoc Memorial Hospitals, Oconomowoc, WI: M. Kristin Thorsen, Richard Hansen; Maimonides Medical Center, Brooklyn, NY: Samuel Kopel; Wellstar Health System, Marietta, GA: William Mayfield; St. Joseph Health Center, St. Charles, MO: Dan Luedke; Roswell Park Cancer Institute, Buffalo, NY: Donald Klippenstein, Alan Litwin, Peter A. Loud; Upstate Medical Center, Syracuse, NY: Leslie J. Kohman, Ernest M. Scalzetti; Jackson Memorial Hospital, University of Miami, Miami, FL; Richard Thurer, Nestor Villamizar; State University of New York, North Shore-Long Island Jewish Health System, New Hyde Park, NY: Arfa Khan, Rakesh Shah; The 5th Affiliated Hospital of Sun Yat-Sen University, Zhuhai, China: Xueguo Liu; Mercy Medical Center, Rockville Center, NY: Gary Herzog; Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan: Diana Yeh; National Cancer Institute of China, Beijing, China: Ning Wu; Staten Island University Hospital, Staten Island, NY: Joseph Lowry, Mary Salvatore; Central Main Medical Center: Carmine Frumiento; Mount Sinai School of Medicine, New York, NY: David S. Mendelson; Georgia Institute for Lung Cancer Research, Atlanta, GA: Michael V. Smith; The Valley Hospital Cancer Center, Paramus NJ: Robert Korst; Health Group Physimed/McGill University, Montreal, CA: Jana Taylor; Memorial Sloan-Kettering Cancer Center, New York, NY: Michelle S. Ginsberg; John Muir Cancer Institute, Concord, CA: Michaela Straznicka; Atlantic Health Morristown Memorial Hospital, Morristown, NJ: Mark Widmann; Alta Bates Summit Medical Center, Berkeley, CA: Gary Cecchi; New York Medical College, Valhalla, NY: Terence A.S. Matalon; St. Joseph’s Hospital, Atlanta, GA: Paul Scheinberg; Mount Sinai Comprehensive Cancer Center, Miami Beach, FL: Shari-Lynn Odzer; Aurora St. Luke’s Medical Center, Milwaukee, WI: David Olsen; City of Hope National Medical Center, Duarte, CA: Fred Grannis, Arnold Rotter; Evanston Northwestern Healthcare Medical Group, Evanston, IL: Daniel Ray; Greenwich Hospital, Greenwich, CT: David Mullen; Our Lady of Mercy Medical Center, Bronx, NY: Peter H. Wiernik; Baylor University Medical Center, Dallas, TX: Edson H. Cheung; Sequoia Hospital, Redwood City, CA: Melissa Lim; Glens Falls Hospital, Glens Falls, NY: Louis DeCunzo; Atlantic Medical Imaging, Atlantic City, NJ: Robert Glassberg; Karmanos Cancer Institute, Detroit, MI: Harvey Pass, Carmen Endress; Rush University, Chicago, IL: Mark Yoder, Palmi Shah; Building Trades, Oak Ridge, TN: Laura Welch; Sharp Memorial Hospital, San Diego, CA: Michael Kalafer; Newark Beth Israel Medical Center, Newark, NJ: Jeremy Green; Guthrie Cancer Center, Sayre, PA: James Walsh, David Bertsch; Comprehensive Cancer Centers of the Desert, Palm Springs, CA: Elmer Camacho; Dickstein Cancer Treatment Center, White Plains Hospital, White Plains, NY: Cynthia Chin; Presbyterian Healthcare, Charlotte, NC: James O’Brien; University of Toledo, Toledo, OH: James C. Willey. Dr D.F.Y. is a named inventor on a number of patents and patent applications relating to the evaluation of diseases of the chest including measurement of nodules. Some of these, which are owned by Cornell Research Foundation (CRF), are nonexclusively licensed to General Electric. As an inventor of these patents, Dr. D.F.Y. is entitled to a share of any compensation that CRF may receive from its commercialization of these patents. He is also an equity owner in Accumetra, a privately held technology company committed to improving the science and practice of image-based decision making. Dr D.F.Y. also serves on the advisory board of GRAIL. Dr C.I.H. is the President and serves on the board of the Early Diagnosis and Treatment Research Foundation. She receives no compensation from the Foundation. The Foundation is established to provide grants for projects, conferences, and public databases for research on early diagnosis and treatment of diseases. Dr C.I.H. is also a named inventor on a number of patents and patent applications relating to the evaluation of pulmonary nodules on CT scans of the chest, which are owned by Cornell Research Foundation (CRF). Since 2009, Dr C.I.H. does not accept any financial benefit from these patents including royalties and any other proceeds related to the patents or patent applications owned by CRF. The remaining authors declare no conflicts of interest. Correspondence to: Claudia I. Henschke, PhD, MD, Department of Radiology, P.O. Box 1234, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place New York, NY 10029 (e-mail: claudia.henschke@mountsinai.org). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/ Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Four-dimensional Flow Magnetic Resonance Imaging Quantification of Blood Flow in Bicuspid Aortic Valve Background: Four-dimensional (D) flow magnetic resonance imaging (MRI) is limited by time-consuming and nonstandardized data analysis. We aimed to test the efficiency and interobserver reproducibility of a dedicated 4D flow MRI analysis workflow. Materials and Methods: Thirty retrospectively identified patients with bicuspid aortic valve (BAV, age=47.8±11.8 y, 9 male) and 30 healthy controls (age=48.8±12.5 y, 21 male) underwent Aortic 4D flow MRI using 1.5 and 3 T MRI systems. Two independent readers performed 4D flow analysis on a dedicated workstation including preprocessing, aorta segmentation, and placement of four 2D planes throughout the aorta for quantification of net flow, peak velocity, and regurgitant fraction. 3D flow visualization using streamlines was used to grade aortic valve outflow jets and extent of helical flow. Results: 4D flow analysis workflow time for both observers: 5.0±1.4 minutes per case (range=3 to 10 min). Valve outflow jets and flow derangement was visible in all 30 BAV patients (both observers). Net flow, peak velocity, and regurgitant fraction was significantly elevated in BAV patients compared with controls except for regurgitant fraction in plane 4 (91.1±29.7 vs. 62.6±19.6 mL/s, 37.1% difference; 121.7±49.7 vs. 90.9±26.4 cm/s, 28.9% difference; 9.3±10.1% vs. 2.0±3.4%, 128.0% difference, respectively; P<0.001). Excellent intraclass correlation coefficient agreement for net flow: 0.979, peak velocity: 0.931, and regurgitant fraction: 0.928. Conclusion: Our study demonstrates the potential of an efficient data analysis workflow to perform standardized 4D flow MRI processing in under 10 minutes and with good-to-excellent reproducibility for flow and velocity quantification in the thoracic aorta. D.Z.G. and M.A.A. contributed equally. The authors declare no conflict of interest. Correspondence to: Muhannad A. Abbasi, MD, Department of Radiology, Northwestern University, 737 North Michigan Avenue, Suite 1600, Chicago, IL 60611 (e-mail: muhannadaboudabbasi@gmail.com). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

A Dose Simulation X-Ray Software: An Innovating Tool to Reduce Chest Radiograph Exposure in Children Purpose: Chest radiography is one of the most frequent x-ray examinations performed on children. Reducing the delivered dose is always a major task. The objective of our study was to determine the minimum dose to be delivered while maintaining the image quality of chest radiographs, using dose reduction simulation software. Materials and Methods: We included 60 children who had had a chest radiography in 5 groups established according to the diagnostic reference levels equitably represented by weight ranges. The software simulated for each radiograph 6 additional simulated photonic noise images corresponding to 100%, 80%, 64%, 50%, 40%, and 32% of the initial dose. The 360 radiographs were blindly scored by 2 radiologists, according to the 7 European quality criteria and a subjective criterion of interpretability, using a semiquantitative visual Lickert scale. Results: There was no significant difference in scoring between the reference radiograph (100%) and simulated radiographs at 80% of the dose in children between 5 and 20 kg, 50% of the dose in children between 20 and 30 kg, and between simulated radiographs at 40% of the dose in children over 30 kg. Interobserver reproducibility was moderate to excellent. Conclusion: Chest radiography dose might be reduced by 20% in children between 5 and 20 kg, 50% in children between 20 and 30 kg, and 60% in children over 30 kg, without any difference in the image quality appreciation. Software that produced simulated x-ray with decreasing delivered dose is an innovating tool for an optimization process. The local institutional review board approved this single multicentric prospective cohort study (2019-75). The authors declare no conflicts of interest. Correspondence to: Baptiste Morel, PhD, Department of Pediatric Radiology, Clocheville Hospital, 49 Boulevard Beranger, Tours 37000, France (e-mail: bamorel@univ-tours.fr). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Three-dimensional Ultrashort Echotime Magnetic Resonance Imaging for Combined Morphologic and Ventilation Imaging in Pediatric Patients With Pulmonary Disease Purpose: Ultrashort echotime (UTE) sequences aim to improve the signal yield in pulmonary magnetic resonance imaging (MRI). We demonstrate the initial results of spiral 3-dimensional (3D) UTE-MRI for combined morphologic and functional imaging in pediatric patients. Methods: Seven pediatric patients with pulmonary abnormalities were included in this observational, prospective, single-center study, with the patients having the following conditions: cystic fibrosis (CF) with middle lobe atelectasis, CF with allergic bronchopulmonary aspergillosis, primary ciliary dyskinesia, air trapping, congenital lobar overinflation, congenital pulmonary airway malformation, and pulmonary hamartoma. Patients were scanned during breath-hold in 5 breathing states on a 3-Tesla system using a prototypical 3D stack-of-spirals UTE sequence. Ventilation maps and signal intensity maps were calculated. Morphologic images, ventilation-weighted maps, and signal intensity maps of the lungs of each patient were assessed intraindividually and compared with reference examinations. Results: With a scan time of ∼15 seconds per breathing state, 3D UTE-MRI allowed for sufficient imaging of both “plus” pathologies (atelectasis, inflammatory consolidation, and pulmonary hamartoma) and “minus” pathologies (congenital lobar overinflation, congenital pulmonary airway malformation, and air trapping). Color-coded maps of normalized signal intensity and ventilation increased diagnostic confidence, particularly with regard to “minus” pathologies. UTE-MRI detected new atelectasis in an asymptomatic CF patient, allowing for rapid and successful therapy initiation, and it was able to reproduce atelectasis and hamartoma known from multidetector computed tomography and to monitor a patient with allergic bronchopulmonary aspergillosis. Conclusion: 3D UTE-MRI using a stack-of-spirals trajectory enables combined morphologic and functional imaging of the lungs within ~115 second acquisition time and might be suitable for monitoring a wide spectrum of pulmonary diseases. The project underlying this report was funded by the Deutsche Forschungsgemeinschaft (DFG), project number VE1008/1-1 and KO2938/5-1. The Department of Radiology receives a research grant from Siemens Healthcare GmbH. The grant is not specifically directed toward any of the authors. T.B. is an employee of Siemens Healthcare GmbH. The remaining authors declare no conflicts of interest. Correspondence to: Simon Veldhoen, MD, Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, Würzburg 97080, Germany (e-mail: veldhoen_s@ukw.de). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Computed Tomography Appearance of Unusual Nonaortic Thoracic Aneurysms and Pseudoaneurysms Although aneurysms of the thoracic aorta are easily recognized on computed tomography (CT), nonaortic intrathoracic aneurysms and pseudoaneurysms are unusual and not often encountered by radiologists. These lesions can result in complications such as hemorrhage or symptoms from mass effect. In some cases, patients may be asymptomatic and the aneurysms may represent incidental findings. Radiologists should be familiar with the CT appearances of these rare vascular abnormalities to enable prompt diagnosis. The goals of this pictorial essay are to: (1) illustrate and describe the CT appearances of various unusual intrathoracic nonaortic aneurysms and pseudoaneurysms; (2) discuss the etiology and clinical significance of these lesions; and (3) discuss management options where appropriate. The authors declare no conflict of interest. Correspondence to: Pierre D. Maldjian, MD, Department of Radiology, Rutgers New Jersey Medical School, 185 South Orange Avenue, MSB F-506B, Newark, NJ 07103 (e-mail: maldjipd@njms.rutgers.edu). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Effect of artificial saliva on the mechanical and tribological behavior of nano-/micro-filled biocomposite materials for biomedical applications Efe Çetin Yilmaz Journal of Dental Research and Review 2020 7(2):37-41 Aim: The purpose of this study is to investigate the effect of artificial saliva storage time of composite materials with different filler structure (micro/nanofiller) on the mechanical and tribological behavior. Material and Method: Mechanical and tribological behaviors of composite materials were investigated with storage in artificial saliva for the control group, 1 day, and 7 days. Composite materials were subjected to direct contact wear tests (80 N wear force, 100.000 wear cycles, 1.8 Hz wear frequency, and 37°C ambient temperature) with a computer-controlled dual-axis abrasion device. The surface hardness of composite materials after each artificial saliva test procedure was determined using the Vicker's Hardness method. Results: In this study, it was concluded that the waiting process in artificial saliva increases the tribological behavior of the composite material. Conclusion: However, for the composite test materials in this study considered, correlations between the contact-wear resistance and surface hardness were found to be statistically insignificant.

Knowledge, attitude, and practices toward oral hygiene among students of medhanealem high school, addis ababa, Ethiopia Bizuayehu Abate, Mahlet Ephrem, Miskir Gebremariam, Yodit Ayalew, Tariku Shimels Journal of Dental Research and Review 2020 7(2):42-49 Introduction: Poor oral health can affect a person's day today as well as overall quality of life. Discomforts from experience of pain, problems with eating and chewing, embarrassment about the shape, and missing, discolored, or damaged teeth can adversely affect peoples' daily lives and well-being. The aim of this study was to assess the knowledge, attitude, and practice (KAP) of oral hygiene among preparatory students of Medhanealem High School in Addis Ababa, Ethiopia. Methods: A cross-sectional study design was conducted using a self-administered questionnaire from June to September 2019 in Medhanealem High School, Addis Ababa. Data were analyzed using SPSS v. 20, and a descriptive statistics was employed to present results on KAPs of high school students toward oral hygiene. Results: A total of 320 students have participated in the study, of whom 207 (64.7%) were female. The study revealed that 201 (62.8%) of the respondents had a poor knowledge with regard to oral hygiene, about half (52.1%) of the students had a negative attitude toward oral hygiene, and their oral hygiene practices were still low that 193 (60.4%) of the students reported inadequate practice. The chewed stick (Mefakiya) is the most common oral hygiene aid used for cleaning teeth, which was adopted by 134 (51%) students. Conclusions: The study showed that oral hygiene KAP among the secondary school students in Medhanealem Preparatory School were not satisfactory. The findings of this study suggest that awareness on the importance of oral hygiene needs to be enhanced along with regular education.

Effects of stevia and xylitol chewing gums on salivary flow rate, pH, and taste acceptance Mitali R Shinde, Jasmin Winnier Journal of Dental Research and Review 2020 7(2):50-55 Context: Stevia is a natural sweetener which is used as a sugar substitute. There is limited research regarding the use of stevia chewing gum and its effect on salivary flow rate and pH. Aim: The aim of the study was to assess the effect of stevia and xylitol chewing gums on salivary flow rate, pH, and its taste acceptance. Setting and Design: A randomized, triple-blinded, clinical study with a crossover design was conducted. Subjects and Methods: Twenty children aged 8–13 years with decayed, missing, and filled teeth index score ≥3 were selected. Pretest unstimulated saliva was collected. The children were divided into two groups, and Stevia and Xylitol gums were provided to each group to chew for 15 min. Salivary samples were collected at 15 min and 1 h. Salivary flow rate and pH were measured at baseline, 15 min, and 1 h. Statistical Analysis: The collected data were subjected to statistical analysis using Wilcoxon signed-rank test, and P ≤ 0.05 was considered statistically significant. Results: There was an increase in the salivary flow rate from baseline to 15 min in children provided with stevia and Xylitol chewing gums with P = 0.003 and 0.001, respectively, in the trial. In the crossover trial, there was an increase in salivary flow rate from baseline to 15 min in children provided with stevia and Xylitol chewing gums with P = 0.020 and 0.001, respectively. There was a reduction in salivary pH from baseline to 15 min in children provided with Xylitol (P = 0.001) and 15 min to 1 h in stevia (P = 0.003) in the trial. In the crossover trial, there was a reduction in pH from baseline to 15 min (P = 0.020) and 15 min to 1 h (P = 0.003) in children provided with stevia and Xylitol chewing gums (P = 0.001). Conclusion: Stevia is equally effective to Xylitol chewing gum in increasing salivary flow rate and salivary pH. Stevia due to its bitter aftertaste is less accepted in children as compared to Xylitol.

Retention in fixed orthodontic treatment: An important aspect affecting success of treatment outcome – A questionnaire study Monika Mahajan Journal of Dental Research and Review 2020 7(2):56-63 Context: Postorthodontic treatment, retention is an important phase which can be decisive in determining the stability of the achieved result of functional occlusion and esthetic appearance of the patient. There are different types of retainers and different retention protocols followed among the orthodontists. Aims: The purpose of this study was to determine different factors which affect compliance of the patient with removable retainers. Materials and Methods: Thirty-eight patients, who had finished fixed orthodontic treatment and were in retention phase wearing Hawley removable retainers, were included in the study. They were given a questionnaire which dealt with factors affecting patient compliance with removable retainers and different reasons for not wearing removable retainers. Statistical Analysis Used: Categorical variables were reported as counts and percentages. Gender comparisons were made with the Chi-square test/Fisher's exact test. Conclusion: The most common reason for not wearing retainer was reported as patients forgetting to wear the retainer. The common reason for relapse may be associated with patients who think that responsibility of retention is only of orthodontist and not themselves or of both. Gender wise: it was found that the factors of level of satisfaction during the present retention phase, forgetting to wear it, and responsibility of retention showed statistically significant differences.

Surgical management of class 3 invasive cervical resorption Zehra Shavez, Shaikh Shahbaz, Sharique Alam Journal of Dental Research and Review 2020 7(2):64-66 Invasive cervical resorption (ICR) is a pathologic loss of dental hard tissue at the cervical region of tooth beneath the epithelial attachment. ICR is multifactorial in origin and has various predisposing factors such as orthodontic treatment, trauma, and internal bleaching. Thus, a multidisciplinary approach comprising of surgical repair with root canal treatment is required for its successful treatment outcome.

Cancellous osteoma of temporomandibular joint Rajdeep Singh, Sagar Bhure, B Pramod Krishna, Heena Mazhar, Amy Thomas, Sushant Kumar Soni Journal of Dental Research and Review 2020 7(2):67-69 Osteoma is a rare growth of bone, benign in nature, usually occurring in the craniofacial region. It usually results from the long-term deposition of compact and cancellous bone. The etiology of the tumor is not clear but can be linked with infections, inflammatory processes trauma, or/and abnormalities in growth. It manifests with symptoms of painful/painless swelling, dull pain in the preauricular region, clicking/popping and difficulty in mastication, trismus, gradual midline shift developing malocclusion, mandibular deviation of the contralateral side, and facial asymmetry. The diagnosis is mostly made by clinical and radiological imaging and is affirmed by histopathological examination. These condylar tumors have been usually treated by either resection through local excision or condylectomy with or without reconstruction. Therefore, we describe a rare case report of osteoma arising from the mandibular condylar neck of a 26-year-old female patient giving a chief complaint of difficulty in opening the mouth in the last 15 days along with pain. Radiographic images and computed tomography were suggestive of osteochondroma involving right condyle which, on excision and histopathological examination, was found to be cancellous osteoma.

Conservative treatment of traumatic crown fracture extending into cementum by glass post aided adhesive bonding of autogenous tooth fragment: A report of two cases Boris Saha, Sharique Alam, Surendra Kumar Mishra, Disha Mahore Journal of Dental Research and Review 2020 7(2):70-74 Advancement in the adhesive system has made fragment reattachment a viable treatment option for treating tooth fractures. It offers a simple and conservative technique to restore esthetics and function. Reattachment of a completely disjointed crown may need additional fiber post retention due to the greater functional load borne by the fragment. This article reports two cases of complicated crown root fracture managed by utilizing fiber post to reattach the disjointed crown fragment. The reattached fragment has shown reliable retentivity and periodontal health at 1-year follow-up.

Effect of additives to sodium hypochlorite on pulp tissue dissolution and physico-mechanical effects on root canal dentin: A systematic review Poorva Kurtarkar, Shalini D Aggarwal, Ishan Ahmed, Swapnil Khadtare, Rhea Digholkar Journal of Dental Research and Review 2020 7(2):75-85 Background: It is widely accepted now that; additives to sodium hypochlorite helps in better pulp tissue dissolution. However, due to proprietary concerns, the available literature is unable to clarify exactly how the modified NaOCl is better than unaltered NaOCl. This review evaluates the effect of additives on sodium hypochlorite on pulp tissue dissolution and physicomechanical effects on dentin. Methods: A systematic search was conducted using Medline PubMed, Ebscohost, Scopus, Google Scholar up to and including September 31, 2018, to identify relevant studies. All cross-reference lists of the selected studies were also screened. The inclusion criteria were articles in English or those having a detailed summary in English, published between January 2009 and September 2018. Articles were providing information about sodium hypochlorite, surfactants, and etidronic acid. Articles were providing information about in vitro studies, in which effect on root dentin was evaluated. Review, case reports, abstracts, letters to editors, and editorials were excluded. In vivo studies were excluded from this systematic review. Results: A total of 195 articles were examined, of which 11 articles were selected for the final synthesis. Most of the articles concluded that additives to sodium hypochlorite led to better pulp tissue dissolution and reduced the hardness of root canal dentin. Conclusion: This systematic review was able to garner adequate information stating that additives to sodium hypochlorite performed better pulp tissue dissolution. It was also able to evaluate successfully the physicomechanical effects of these solutions on root canal dentin.

Combating respiratory hazards in dentistry: A comprehensive review Shishir Singh, Sagar J Shah, Rajesh Podar, Roshan Shetty Journal of Dental Research and Review 2020 7(2):86-90 Oral healthcare settings are known to produce aerosols during dental procedures. With the outbreak of novel coronavirus, which has a definite droplet and possible aerosol transmission, a review of reducing bioburden due to aerosol generation in oral healthcare settings is warranted. Literature reporting characterization of aerosols in dental and medical settings, and potential for cross-infection in oral healthcare settings, was thoroughly reviewed. This was followed by reviewing studies and guidelines issued by various health organizations on methods of reducing the burden of aerosols in dental setting. Oral healthcare settings can serve as a potential site for cross-infection of diseases such as tuberculosis and severe acute respiratory syndrome. COVID-19 spreads principally by respiratory droplets and may spread through aerosols. Many dental procedures are associated with the generation of a high number of aerosols. Airborne contamination can be kept to a minimum by following the hierarchy of controls which includes triage, engineering, and workplace controls followed by personal protection equipment. The use of high-volume suction is highly recommended to reduce aerosols in the dental office. Preprocedural rinse with 0.2% povidone iodine is effective in reducing viral load against COVID-19.

A modification of ward's incision for management of mandibular angle fracture Uday Kiran Uppada Journal of Dental Research and Review 2020 7(2):91-93 It is a well-known fact that mandibular angle fracture is one of the most frequently encountered fractures in the facial skeleton. Lot of emphasis is given to the kind of fixation devices as well as number of fixation devices used in the management of these fractures. However, it is noteworthy that some of the distinguished complications are associated with the flap design and soft-tissue handling. This short communication highlights the fact that the Ward's incision without the distal release is a very valuable surgical approach in the management of these fractures.

Evaluation of the possible effect of magnetic resonance imaging noise on peripheral hearing organ with the otoacoustic emission
Cevahir Bulut Turay, Fulya Ozer, Tulin Yildirim, Seyra Erbek
In Press, Journal Pre-proof, Available online 20 June 2020
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Abstract
Abstract
Purpose
The aim of this study is to evaluate the effect of noise produced by magnetic resonance imaging (MRI) device on hearing by using objective and subjective audiological assessments.

Methods
A total of 38 patients between the ages of 18 and 50 without hearing loss, and had performed MRI for brain, head, neck or cervical imaging were included in this prospective clinical study. Pure tone audiometry, speech audiometry, high frequency audiometry, transient evoked otoacoustic emissions (TEOAE) and distortion product otoacoustic emission (DPOAE) were performed before and after MRI.

Results
There was no statistically significant difference in TEOAE, pure tone audiogram, high frequency audiogram and speech audiogram thresholds. In DPOAE, the median value before and after MRI at the frequency of the left ear at 4.0 kHz was 13.6 (8.5–19.9) and 15.7 (8.9–20.7) SNR respectively (p > .05). The median value before MRI at the right ear 4.0 kHz frequency was 14.1 (9.1–20.5) SNR, whereas the median value after MRI was 13.2 (8.8–19.8 SNR (p = 0,03). There was no statistically significant difference in other frequencies in DPOAE.

Conclusions
This is the first objective study that examines the MRI noise on speech audiometry and otoacoustic emission together. However, the effect of MRI noise on hearing pathway is still doubt. Based on the difference at 4 kHz frequency on DPOAE; on-earphones may not sufficiently protect the patients from the MRI noise and this issue should deserve further research.

select article Evaluation of the perioperative effects of dexmedetomidine on tympanoplasty operations
Research articleAbstract only
Evaluation of the perioperative effects of dexmedetomidine on tympanoplasty operations
Muge Kosucu, Ersagun Tugcugil, Bengu Cobanoglu, Erhan Arslan
In Press, Journal Pre-proof, Available online 20 June 2020
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Abstract
Abstract
Purpose
This randomized double-blind study aimed to evaluate the effects of dexmedetomidine on hemodynamic parameters and the quality of surgery and recovery criteria in tympanoplasty operations.

Materials and methods
A total of 75 patients 18–55 years undergoing tympanoplasty, who were graded as American Society of Anesthesiologists physical status I-II, were randomly divided into three groups. Group 1 included patients receiving remifentanil alone, Group 2 included patients receiving dexmedetomidine + remifentanil and Group 3 included patients receiving dexmedetomidine + ½ remifentanil. Anesthesia was induced with propofol and cisatracurium. For maintenance of anesthesia, a mixture of 2–2.5% sevoflurane, 40–60% oxygen/air was used. The groups were compared in terms of hemodynamic parameters, surgical area, recovery criteria, modified Aldrete, pain scores, additional analgesic requirements and adverse effects.

Results
Mean arterial pressure and heart rate values of Group 1 were higher at the time of intubation, incision, spontaneous breathing and extubation compared to Group 2 and Group 3. Surgical field satisfaction was higher in Group 2 and Group 3 than Group 1. Spontaneous breathing, eye opening and verbal cooperation times were shorter in Group 3 compared to Group 2. Eye opening and verbal cooperation times were longer in Group 2 compared to Group 1. The 30-minute modified Aldrete scores was higher in Group 3 compared to Group 1. There was no difference between the groups in terms of postoperative pain and adverse effects.

Conclusion
The use of dexmedetomidine during tympanoplasty operations may provide better hemodynamic control and surgical view, may provide faster recovery and may reduce remifentanil consumption.

select article Cervical necrotizing fasciitis affects only immunocompromized patients? Diagnostic challenges, treatment outcomes and clinical management of eleven immunocompetent adult patients with a still fatal disease
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Cervical necrotizing fasciitis affects only immunocompromized patients? Diagnostic challenges, treatment outcomes and clinical management of eleven immunocompetent adult patients with a still fatal disease
Giorgos Sideris, Thomas Nikolopoulos, Alexander Delides
In Press, Journal Pre-proof, Available online 20 June 2020
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Abstract
Abstract
Purpose
Cervical Necrotizing fasciitis (CNF) has been reported as an unusual rapidly progressive, life-threatening, inflammatory disease that is known to affect predominately immunocompromised patients. Few case reports have been sporadically published involving immunocompetent adults. This is the first study presents a series of immunocompetent CNF patients.

Materials and methods
A retrospective chart review study was performed on immunocompetent adults with CNF from January 2011 to December 2020. The diagnosis was histologically confirmed. We analyzed epidemiological, clinical, laboratory and imaging findings and discussed them along with the treatment plan.

Results
A total of eleven adult patients were included in the study. The average age was 43 years, ranging from 17 to 62 years. The average hospitalization time was 28 days, ranging from 10 to 129 days. All patients presented with cervical erythema and odynophagia. The causative factors are known in nine patients. Tissue cultures demonstrated mixed flora in six patients. Seven underwent a temporary tracheostomy. Wide neck exploration incisions were performed in all patients as the diagnosis was established after imaging findings. In nine cases the anterior-upper mediastinum was affected but only in two patients extension of the surgical planes to the mediastinum was performed. Four patients developed polyserositis. Nine patients survived and two developed multiorgan failure and died.

Conclusion
There seem to be no differences between immunocompetent and immunocompromised CNF patients, in regards to clinical, imaging and laboratory findings as well as their treatment plan.

select article Otolaryngology-related Google Search trends during the COVID-19 pandemic
Research articleFull text access
Otolaryngology-related Google Search trends during the COVID-19 pandemic
Matthew M. Pier, Luke J. Pasick, Daniel A. Benito, Ghiath Alnouri, Robert T. Sataloff
In Press, Journal Pre-proof, Available online 19 June 2020
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Abstract
Abstract
Objective
To assess trends of Google Search queries for symptoms and complaints encountered commonly in otolaryngology practices during the coronavirus disease 2019 (COVID-19) pandemic when in-person care has been limited.

Materials and methods
In this cross-sectional study, data on Google Search queries in the United States for 30 otolaryngology-related terms were obtained from Google Trends. The means of relative search volume from the COVID-19 period (March 29, 2020 through May 16, 2020) were compared to similar periods from 2016 to 2019 using a t-test of two independent samples.

Results
In total, 16.6% of search terms had significant increases in relative search volume during the COVID-19 period, with the largest percentage increase for “can't smell” (124.4%, p = .006), followed by “allergies” (30.3%, p = .03), “voice pain” (26.1%, p = .008), and “ears ringing” (19.0%, p < .001). Of all search terms, 26.7% had significant decreases in relative search volume, including the largest percentage decrease for “laryngitis” (59.8%, p < .001), followed by “thyroid nodule” (54.4%, p < .001), “thyroid cancer” (45.6%, p < .001), and “ENT” (34.9%, p < .001).

Conclusion
This study demonstrates that Google search activity for many otolaryngology-related terms during the COVID-19 pandemic has increased or decreased significantly as compared to previous years. With reduced access to in-office otolaryngology care in the United States during the COVID-19 pandemic, these are important considerations for otolaryngology practices to meet the needs of patients who lack access to care.

select article Are long-term auditory results following ossiculoplasty with bone cement as successful as early-middle period results?
Research articleAbstract only
Are long-term auditory results following ossiculoplasty with bone cement as successful as early-middle period results?
M. Tayyar Kalcioglu, Muhammed Zeki Yalcin, Osman Kilic, Ozan Tuysuz, ... Osman Ilkay Ozdamar
In Press, Journal Pre-proof, Available online 19 June 2020
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Abstract
Abstract
Purpose
Bone-cement (BC) ossiculoplasty is one of the options to solve ossicular chain problems. Many authors reported successful results in the early or mid-follow-up period; however, there is no long-term result in the literature. We aim to evaluate long term results of BC ossiculoplasty.

Materials and methods
Forty-eight patients who underwent BC ossiculoplasty as incudostapedial re-bridging by the same surgeon were invited to evaluation. Postoperative otomicroscopic examination was performed. Pre-operative and post-operative audiological results after longer follow up and graft success rate were noted.

Results
Fourteen patients came for control examination. The follow-up period was between 87 and 135 months (mean 102 months). None of the patients had graft failure. Ten patients had early postoperative follow-up results (between 10 and 52; mean 24 months). In the comparison of preoperative and early postoperative air-bone gap, there were significant differences in all frequencies while the comparison of preoperative and long-term postoperative results showed a significant difference only in 250 and 500 Hz. Early postoperative results were better than late with significant difference only in the 2000 and 4000 Hz.

Conclusions
As reported by many studies, bone cement application provides a significant auditory improvement in the early postoperative period. The results of the present study showed that this early auditory success may decrease over time with a long-term follow-up. Further studies should be conducted with larger patient groups to clarify the long-term benefits of this treatment and possible causes for its deterioration.

select article Correlation between effectual time and the curative effect in patients with all frequency descending sudden deafness after treatment
Review articleAbstract only
Correlation between effectual time and the curative effect in patients with all frequency descending sudden deafness after treatment
Jian-Ping Si
In Press, Journal Pre-proof, Available online 18 June 2020
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Abstract
Abstract
Objective
To discuss the correlation between effectual time and the curative effect in patients with all frequency descending sudden deafness.

Methods
According to effectual time, the subjects were divided into first week effectual group and second week effectual group and the curative effect of each group was compared.

Results
In patients with flat descent sudden deafness, the curative rate of the first week effectual group was higher than that of the second week effectual group, but there was no significant difference between the two groups (χ2 = 1.584, P = 0.208). Meanwhile, the total significant effective rate of the first week effectual group was higher than that of the second week effectual group, without obvious difference between the two groups (χ2 = 0.227, P = 0.634). Furthermore, in patients with total deafness type of sudden deafness, the curative rate of the first week effectual group was higher than that of the second week effectual group, showing no remarkable difference between the two groups (χ2 = 2.726, P = 0.099). Besides, there was no remarkable difference in the comparison of the total significant effective rate (χ2 = 2.933, P = 0.087), which was higher in the first week effectual group than that in the second week effectual group.

Conclusion
The course of treatment should be at least 2 weeks in patients with all frequency descending sudden deafness after onset.

select article Follow-up after failed newborn hearing screening: Parental and primary care provider awareness
Research articleAbstract only
Follow-up after failed newborn hearing screening: Parental and primary care provider awareness
Jose M. Juarez, Amber D. Shaffer, David H. Chi
In Press, Journal Pre-proof, Available online 18 June 2020
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Abstract
Abstract
Purpose
The current loss to follow-up rate after failed newborn hearing screening (NBHS) is 34.4%. Previous studies have found that lack of parental and primary care provider (PCP) awareness of NBHS results are significant contributors to loss to follow-up. The objective of this study was to identify factors associated with parental and PCP awareness of NBHS results.

Materials and methods
Retrospective cohort study. A survey asking about demographics and knowledge of NBHS testing and results was offered to parents in the waiting room of an urban pediatric primary care office. Included were biological parents ≥18 years of age of children ≤10 years of age born in Pennsylvania. Each child's chart was reviewed for PCP documentation of NBHS results. The odds of knowing NBHS results were evaluated using logistic regression.

Results
The survey was completed by 304 parents. 74.0% were aware of their child's NBHS results. Child age ≥1 year old (OR: 0.49, 95%CI[0.29, 0.82], P = 0.007) and Hispanic ethnicity (OR: 0.38, 95%CI[0.16, 0.89], P = 0.03) were associated with decreased odds of a parent knowing NBHS results. In addition, fewer fathers knew the results of their child's NBHS compared with mothers (OR: 0.33, 95%CI[0.18, 0.62], P < 0.001). However, parental awareness was not associated with birthing facility or insurance type. 222 charts were reviewed for NBHS documentation, revealing PCP awareness in 95.5% of cases and no associations with any of the factors examined.

Conclusions
Factors associated with parents not knowing NBHS results included being the parent of an older child, Hispanic, or the father.

select article Surgical management and outcomes of accessory parotid gland neoplasms: A systematic review
Review articleAbstract only
Surgical management and outcomes of accessory parotid gland neoplasms: A systematic review
Luke J. Pasick, Jane Y. Tong, Daniel A. Benito, Punam Thakkar, ... Arjun S. Joshi
In Press, Journal Pre-proof, Available online 16 June 2020
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Abstract
Abstract
Objective
To evaluate surgical approaches and outcomes associated with accessory parotid gland neoplasms.

Data sources
MEDLINE, SCOPUS, and the Cochrane Central Register of Controlled Trials.

Review methods
A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was performed. Studies were included if they reported surgical management and outcomes of patients with accessory parotid gland neoplasms.

Results
After screening 3532 records, 15 studies were included with a total of 187 patients. Benign tumors consisted of 61.5% of cases. External open, transoral, and preauricular endoscopic approaches were used for 82.3%, 11.3%, and 6.5% of cases, respectively. Accessory lobe resection alone, concurrent with partial parotidectomy, and concurrent with total parotidectomy were used in 54.8%, 43.0%, and 2.2% of cases, respectively. Complication rates were similar between histology groups (7.8% benign vs. 8.3% malignant, p = 0.82). Accessory lobe resection with concurrent partial parotidectomy had the lowest overall complication rate (6.3%). Resections limited to the accessory lobe were found to have an overall complication rate of 8.7%.

Conclusion
The results offer an overview of the surgical management and complications for accessory parotid gland tumors. Overall surgical complication rates found in these case series may be lower for management of accessory gland tumors than rates available in the literature for tumors within the main parotid gland.

select article Acceptance and commitment therapy combined with vestibular rehabilitation for persistent postural-perceptual dizziness: A pilot study
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Acceptance and commitment therapy combined with vestibular rehabilitation for persistent postural-perceptual dizziness: A pilot study
Junya Kuwabara, Masaki Kondo, Kayoko Kabaya, Wakako Watanabe, ... Tatsuo Akechi
In Press, Journal Pre-proof, Available online 11 June 2020
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Abstract
Abstract
Purpose
This study investigated the feasibility of acceptance and commitment therapy for persistent postural-perceptual dizziness and preliminarily verified the long-term effectiveness of the therapy.

Materials and methods
This study implemented the within-group pre–post comparison design. We enrolled 27 adult patients who met the criteria of persistent postural-perceptual dizziness. They underwent a treatment program including acceptance and commitment therapy combined with vestibular rehabilitation once a week for a total of six sessions. The primary outcome was changes in the Dizziness Handicap Inventory score 6 months posttreatment.

Results
All 27 patients completed the acceptance and commitment therapy + vestibular rehabilitation program, and 25 patients (92.6%) could be followed for 6 months posttreatment. For 27 participants, the scores from pretreatment to 6 months posttreatment significantly declined (P < .001), and the Dizziness Handicap Inventory effect size was 1.11 (95% confidence interval = 0.80–1.42). At 6 months posttreatment, 11 patients (40.7%) achieved remission (the score ≤ 14), 16 (59.3%) achieved treatment response (reduction in the score ≥ 18), and 20 (74.1%) achieved remission and/or treatment response.

Conclusions
Acceptance and commitment therapy is feasible for persistent postural-perceptual dizziness and might have long-term effectiveness. However, a randomized controlled trial is warranted.

select article The role of fine needle aspiration biopsy in deep lobe parotid tumors: Comparison of preoperative cytology and postoperative histopathologic results
Research articleAbstract only
The role of fine needle aspiration biopsy in deep lobe parotid tumors: Comparison of preoperative cytology and postoperative histopathologic results
Nurullah Seyhun, Uğur Doğan, Zeynep Aslı Batur Çalış, Mehmet Fatih Kaya, ... Suat Turgut
In Press, Journal Pre-proof, Available online 10 June 2020
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Abstract
Abstract
Purpose
Major salivary gland tumors constitute almost 3% of head and neck tumors. Tumors located exclusively in the deep lobe are not common and 20% of parotid gland tumors originate from deep lobe under the branches of the facial nerve. Accuracy of fine needle aspiration biopsy (FNAB) procedure in salivary gland tumors have been studied extensively, however there isn't any data regarding usefulness of FNAB in tumors located exclusively in deep lobe of parotid gland. In this study we aimed to assess the use of FNAB in deep lobe parotid tumors.

Materials and methods
We retrospectively analyzed 51 patients with deep lobe parotid tumors who underwent surgery in our clinic between January 2013–December 2018. Characteristics of patients were recorded. Preoperative FNAB results and postoperative final histopathologic diagnosis were compared. Statistical analysis was performed using SPSS 24.0 was used for statistical analysis.

Results
The number of patients that met the inclusion criteria was 51. The mean age of patients were 49.2(14–86). In 40 (78.4) of the patients, tumor was reported as benign and in 11 (21.6) patients FNAB diagnosis was suspicious for malignancy, malignant or non-diagnostic. In final histopathologic diagnosis, 42 of the tumors were benign and 9 were malignant. The most common benign tumor type was pleomorphic adenoma which constitutes 27 of the cases (52.9%). Regarding detection of malignant disease, the sensitivity of FNAB was 90.4%, specificity was 77.7%, positive predictive value was 95%, negative predictive value was 63.6%. There was a substantial agreement between FNAB and final histopathologic diagnosis(kappa = 0,628).

Conclusions
FNAB is a safe and reliable tool to evaluate deep lobe parotid tumors. It is an important part of preoperative surgical planning and can help the surgeon in patient counseling. FNAB with ultrasound guidance is recommended for deep lobe tumors.

select article Stapedectomy in patients with dehiscent and prolapsed facial nerve
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Stapedectomy in patients with dehiscent and prolapsed facial nerve
Erol Senturk, Sabri Baki Eren, Fadlullah Aksoy, Nurtaç Dagistanli, ... Orhan Ozturan
In Press, Corrected Proof, Available online 5 June 2020
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Abstract
Abstract
Objective
The aim of this study is to apply the modified stapedectomy technique in cases with dehiscent and prolapsed facial nerve canal, and to compare the postoperative results with those with normal facial nerve canal anatomy.

Material and method
28 patients who underwent primary stapedectomy were included. Of the patients, 17 were in the normal anatomical facial nerve group, and 11 were in the dehiscent and prolapsed facial nerve group. Facial nerve was retracted with micro elevator in dehiscent and prolapsed group. and Titanium-Teflon prosthesis was angled and used in accordance with facial nerve course at this group.

Result
No facial paresis or paralysis was observed in any patient postoperatively. In the first year, no significant difference was found in terms of air-bone gap.

Conclusion
It is safe to retract the facial nerve for a limited time in cases of stapedectomy in cases with dehiscent and prolapsed facial nerve canal. In these cases, modifying the stapedial prosthesis in accordance with the facial nerve course does not cause disadvantage in terms of hearing gain.

select article Incorporation of telemedicine by rhinologists: The COVID-19 pandemic and beyond
Research articleFull text access
Incorporation of telemedicine by rhinologists: The COVID-19 pandemic and beyond
Peter Svider, Michael Setzen, Randall Ow, Adam J. Folbe, ... Andrew P. Johnson
In Press, Journal Pre-proof, Available online 2 June 2020
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Abstract
Abstract
Objectives
The current analysis queries rhinologists' attitudes about the use of telemedicine, including the degree to which it has impacted practice patterns during the COVID-19 pandemic. Our objective was to survey rhinologists and understand the extent to which telemedicine serves as a rejoinder to in-person consultation: appreciation of relevant factors may be important in planning for present and future considerations.

Methods
A 14-question anonymous survey sent out to the American Rhinologic Society (ARS) membership in April 2020. It included demographic factors and detailed questions examining the extent of telemedicine use. Numerous topics including the degree of use, satisfaction with services, and utility of services were evaluated.

Results
There were 134 respondents. Most reported seeing ≤30% of typical in-person volume, with 14.8% not seeing any patients at all. 88.1% used telemedicine; 82.0% reported some level of satisfaction with telemedicine. The vast majority utilized platforms employing audio and video (83.3%), and a plurality reported spending 5–15 min on calls. Numerous reasons were cited for the use of telemedicine, including significant public health benefits amid the crisis (89.7%). Only 12.0% of respondents reported using telemedicine for hospital consultation.

Conclusion
Rhinologists have embraced telemedicine during the COVID-19 pandemic in an attempt to improve accessibility, patient satisfaction, and revenue stream. When utilized appropriately, this technology obviates the need for seeing at-risk patients and performing procedures such as nasal endoscopy. Only a minority of rhinologists was dissatisfied, viewing this as a temporary fix during the pandemic.

select article Transoral floor of mouth lipoma resection: A technical multimedia analysis
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Transoral floor of mouth lipoma resection: A technical multimedia analysis
Christopher L. Kalmar, Vijay A. Patel, Guy Slonimsky
In Press, Corrected Proof, Available online 2 June 2020
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Abstract
Abstract
Lipomas are common benign mesenchymal tumors that originate from mature adipocytes throughout the body, with 13–20% occurring in the head and neck region, however only 1–4.4% affect the oral cavity, where they are found predominately in the cheek, followed by the tongue, lips, palatal mucosa, gingiva, and floor of the mouth. Herein, we present a multimedia analysis of transoral floor of mouth lipoma resection in a 58-year-old female. Learning points include (1) Identification and stenting of Wharton's ducts in order to facilitate their functional preservation and to minimize risk of postoperative sialocele; (2) postoperative observation with airway monitoring due to expected floor of mouth edema; (3) utilization of a midline incision to minimize injury to Wharton's ducts and maximize bilateral access to the floor of mouth.

select article An open-label, multicentre, randomized comparative study of efficacy, safety and tolerability of the 5 plant - extract BNO 1012 in the Delayed Antibiotic Prescription Method in children, aged 6 to 11 years with acute viral and post-viral rhinosinusitis
Research articleOpen access
An open-label, multicentre, randomized comparative study of efficacy, safety and tolerability of the 5 plant - extract BNO 1012 in the Delayed Antibiotic Prescription Method in children, aged 6 to 11 years with acute viral and post-viral rhinosinusitis
Vasyl I. Popovych, Halyna V. Beketova, Ivana V. Koshel, Olha A. Tsodikova, ... Liudmyla I. Vakulenko
In Press, Journal Pre-proof, Available online 1 June 2020
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Abstract
Abstract
Acute rhinosinusitis (ARS) can be characterized as bacterial (ABRS) and require antibiotic therapy only in 0.5–5% of cases. In most cases, the disease is in a viral and post-viral form, which requires pathogenetic and symptomatic treatment.

The study objective was to determine the efficacy of BNO 1012 extract in the technology of delayed antibiotic prescribing in children with acute rhinosinusitis.

Methods
292 children aged 6 to 11 years with ARS were randomized in the multicenter, comparative study. They received an extract of five medicinal plants in addition to standard symptomatic therapy or standard therapy only.

Evaluation criteria
reduction of the sinusitis severity according to a 4-point medical assessment scale (nasal congestion, severity of anterior and posterior rhinorrhea) at each visit, dynamics of self-scoring of rhinorrhea and headache (according to a 10-point visual analogue scale), “therapeutic benefit” in days, frequency of antibiotic prescriptions due to the use of an extract of five plants.

Results
The use of the 5-plant extract BNO 1012 in addition to the standard symptomatic treatment of acute rhinosinusitis provides a clinically significant, adequate reduction in the severity of rhinorrhea, nasal congestion and post-nasal drip, assessed by a physician at V2 (p < 0.005). Significant differences are noted in the patient's self-scoring of rhinorrhea on the second or third day in viral RS, and from the fourth to the eighth day in post-viral RS. Symptoms of similar intensity in control group were observed at V3. Thus, in the first week of treatment, the treatment group compared to the control one showed a “therapeutic benefit” of three days. The use of BNO 1012 in patients with acute rhinosinusitis can 1.81-fold reduce the prescription of antibacterial drugs.

Conclusion
The combination of five medicinal plants is effective for the treatment of acute rhinosinusitis in children aged 6 to 11 years. Its use provides a significant “therapeutic benefit” when administered in addition to standard symptomatic therapy, reducing the need for antibiotic use.

select article 3D-printable headlight face shield adapter. Personal protective equipment in the COVID-19 era
Video articleFull text access
3D-printable headlight face shield adapter. Personal protective equipment in the COVID-19 era
Jaime Viera-Artiles, José J. Valdiande
In Press, Corrected Proof, Available online 1 June 2020
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Abstract
Abstract
The coronavirus SARS-CoV-2 (COVID19) pandemic has pushed health workers to find creative solutions to a global shortage of personal protection equipment (PPE). 3D-printing technology is having an essential role during the pandemic providing solutions for this problem, for instance, modifying full-face snorkel masks or creating low-cost face shields to use as PPE (Ishack and Lipner, 2020 [1]).

Otolaryngologists are at increased occupational risk to COVID19 infection due to the exposure to respiratory droplets and aerosols, especially during the routine nose and mouth examinations where coughing and sneezing happen regularly (Rna et al., 2017 [2]; Tysome and Bhutta, 2020 [3]). The use of a headlight is essential during these examinations. However, to our knowledge, none of the commercially available or 3D-printable face shields are compatible with a headlight. Hence, using a face shield and a headlight at the same time can be very uncomfortable and sometimes impossible.

To solve this problem, we have designed a 3D-printable adapter for medical headlights, which can hold a transparent sheet to create a face shield as an effective barrier protection that can be used comfortably with the headlight. The adapter can be printed in different materials with the most commonly used nowadays being the cost-efficient PLA (Polylactic Acid) used for this prototype. The resulting piece weighs only 7 g and has an estimated cost of $0.15 USD. The transparent sheets, typically made from polyester and used for laser printing, can be purchased in any office material store with a standard price of 0.4 USD per unit. After use, the transparent sheet can be easily removed.

We trialed the adapter in 7 different headlights. All of these headlights accommodated the printed blocks extremely well. The headlights were used in many different settings, including the ENT clinic, the operating room, the emergency room, the ENT ward and the COVID19 intensive care unit (ICU) for a two weeks period. All doctors using the headlight felt they were fully protected from respiratory droplets, blood, sputum and other fluids. The face shield with the headlight has been found very useful for treating epistaxis, changing tracheostomy cannulas and during routine nasal and oral examinations.

The headlight face shield adapter was designed to solve a specific problem among the ENT community; however other specialist can find it useful as well. Nonetheless, manufacturers should take care of specifics problems like this and provide commercially available products to protect the ENT workforce in this new era.

select article Auricular suppurative perichondritis secondary to exclusive endoscopic ear surgery for tympanoplasty: A case report and literature review
Review articleAbstract only
Auricular suppurative perichondritis secondary to exclusive endoscopic ear surgery for tympanoplasty: A case report and literature review
Lucheng Fang, Jiayuan Xu, Wen Wang, Yideng Huang
In Press, Journal Pre-proof, Available online 1 June 2020
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Abstract
Abstract
Endoscope is an innovative method for otologists in middle ear surgery. Many previous studies have confirmed the safety and efficiency of the endoscopic technique, as a reliable therapeutic option with very low complication rates, clearly supporting the use of endoscopy in ear surgery. Auricular suppurative perichondritis secondary to exclusive endoscopic ear surgery for tympanoplasty is an extremely rare type of those without any previously reported cases. In this report, we describe the course of auricular suppurative perichondritis of a 55-year-old woman. The patient was ultimately healed through surgical debridement and postoperative dressing with no evidence of recurrence at two months follow-up. There were no auricle deformity or external auditory canal stenosis with six months following-up.

select article Effect of late-onset blindness on cervical vestibular evoked myogenic potentials
Research articleAbstract only
Effect of late-onset blindness on cervical vestibular evoked myogenic potentials
Mansoureh Adel Ghahraman, Sahar Shomeil Shushtari, Mahin Sedaie, Shohreh Jalaie, Mojtaba Tavakkoli
In Press, Journal Pre-proof, Available online 1 June 2020
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Abstract
Abstract
Purpose
Approximately 1.3 billion people worldwide have vision impairment. The aim of the present study was to investigate the influence of Late-Onset blindness on cervical vestibular evoked myogenic potentials (cVEMP) responses. Accordingly, this study was performed to investigate and compare the parameters of the cVEMP test in sighted and late-onset blind individuals.

Materials and methods
In this cross-sectional- comparative study, cVEMP was recorded by presenting a tone burst stimulus of 500 Hz with an intensity of 95 dBnHL in 20 sighted and 20 late-onset blind individuals aged between 18 and 30 years old.

Results
cVEMP was observed in all the individuals (100%). The average latency of P13 and N23, amplitude, amplitude ratio, and VEMP threshold did not differ significantly between the two groups (p > 0.05).

Conclusion
The findings of the study revealed that the formation of the neural pathway and reflex arch of cVEMP is similar between late-onset blind and sighted individuals. Thus, cVEMP can be a suitable test for assessing the vestibular function of late-onset blind people.

select article The novel corona virus and rhinology: Impact on practice patterns and future directions
Research articleFull text access
The novel corona virus and rhinology: Impact on practice patterns and future directions
Michael Setzen, Peter Svider, Sean Setzen, Gavin Setzen, ... Andrew P. Johnson
In Press, Journal Pre-proof, Available online 1 June 2020
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Abstract
Abstract
Objectives
To evaluate the impact of the novel coronavirus pandemic on practice patterns, clinical behavior, personal health, and emotional/psychological concerns of rhinologists.

Methods
A 15-question survey was sent out to the American Rhinologic Society's (ARS) membership to determine the impact of COVID-19 during the crisis. Demographic factors and practice patterns were collected and evaluated.

Results
There were 224 total respondents out of 835 ARS members queried (26.8% response rate). Study queries were sent in April 2020. Notably, 17.8% reported illness in themselves or their staff and 74.4% noted a psychological/emotional impact. A plurality of rhinologists noted their practice volume and in-office procedure volume has become 20.0% and 0.0% of their prior volumes, respectively. In addition, 96.2% were noted to be using telemedicine in our subspecialty.

Conclusion
In addition to severely impacting volume and the perception of future decreases in patients and revenue, the COVID-19 pandemic has had a physical and emotional impact on rhinologists in ways that need to be further studied. These data include significantly novel and objective information. The COVID-19 crisis also reveals the important role of telemedicine in rhinology. Guidelines regarding personal protective equipment for in-office visits, nasal endoscopy, and other in-office and operating room procedures would be particularly helpful as future waves are expected.

select article Ultrasound dye-assisted parathyroidectomy (USDAP): Experience of a tertiary center
Research articleAbstract only
Ultrasound dye-assisted parathyroidectomy (USDAP): Experience of a tertiary center
Francesco Chu, Gioacchino Giugliano, Maria Silvia Lazio, Michele Proh, ... Mohssen Ansarin
In Press, Corrected Proof, Available online 29 May 2020
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Abstract
Abstract
Background
Primary hyperparathyroidism is primarily caused by parathyroid adenoma, followed by hyperplasia and parathyroid carcinoma. In the era of minimally invasive, targeted parathyroidectomy, the main challenge remains that of distinguishing intraoperatively pathological parathyroid from normal glands and peri-thyroid fat tissue. The aim of this study is to evaluate the surgical outcomes of a novel minimally invasive technique called ultrasound-guided dye-assisted parathyroidectomy (USDAP).

Methods
We perform a retrospective analysis of patients affected by parathyroid adenoma, treated with USDAP at our institution between 2014 and 2019. Data were collected on patient age and sex, tumor location and size, preoperative investigations, histopathology, perioperative complications and surgical outcomes.

Results
Between January 2014 and June 2019, 43 patients underwent parathyroidectomy in our Institute. Each case was discussed by the Institutional Multidisciplinary Board. All patients undergoing thyroidectomy together with USDAP or patients undergoing USDAP under endoscopic control were excluded from the present study. The final cohort, the largest to our knowledge, consisted of 29 patients. All patients were successfully treated with USDAP and remained disease-free during follow up. In all cases, pathological parathyroid was correctly identified and removed. There was no postoperative allergic reaction, nor were there neurotoxicity complications. USDAP permitted a shortening of operative and hospitalization time.

Conclusions
USDAP is an effective and safe procedure both as first line treatment and as a re-operative procedure after previous surgical failures in selected cases.

select article Treatment of patients with glomus jugulare tumours (GJT) and its subjective effect on quality of life (QoL) measures
Research articleAbstract only
Treatment of patients with glomus jugulare tumours (GJT) and its subjective effect on quality of life (QoL) measures
Andrea L.O. Hebb, Niki Erjavec, David P. Morris, Nael M. Shoman, ... Simon A. Walling
In Press, Corrected Proof, Available online 27 May 2020
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Abstract
Abstract
Cerebellopontine angle (CPA) tumours account for 6–10% of intracranial tumours. The most common CPA tumours are vestibular schwannomas (VS), also known as acoustic neuromas, benign tumours of the vestibulocochlear nerve. Less common but symptomatic skull base lesions are glomus jugulare tumours (GJT), of which approximately 40% are identified as CPA tumours. Initial symptoms for GJT may include hearing loss and tinnitus and progress to various cranial nerve dysfunctions. Three well-accepted treatment modalities for such tumours include surgical resection, radiotherapy and/or conservative management employing serial MR or CT imaging. Patients' quality of life may be impacted by different treatment methods, so treatment decisions should be client centered.

Transcultural Adaptation and Validation of the Korean Version of the Vocal Tract Discomfort Scale The present study translated the Vocal Tract Discomfort Scale (VTDS) into Korean (K-VTDS) and evaluated its reliability and validity.

The Challenge of Virtual Voice Therapy During the COVID-19 Pandemic Voice disorders are a significant public health issue; their lifetime prevalence is as high as 30% in the general population but much higher in professional voice users.1,2 Severe dysphonia is a very fatiguing condition with a negative impact on the social and professional life. In the era of the coronavirus disease 2019 (COVID-19) pandemic, lock-down and social restrictions have caused an abrupt interruption of voice therapy programs. This lack of care may impact the possibility of reestablishing a socially acceptable voice in a reasonable time, having a possible negative impact on professional careers and emotional life.

Differences on Voice Acoustic Parameters between Colombian College Professors with and without Vocal Fatigue To determine which acoustic parameters may be associated with vocal fatigue among college professors in Bogotá-Colombia.

Montgomery's Aperture: An External Anatomic Landmark for Surgical Identification of the Anterior Commissure This study evaluates the consistency of palpable identification of an external landmark for the anterior commissure (AC), termed Montgomery's aperture (MA), in cadaveric and surgical settings.

Predictors of Voice Therapy Initiation: A Cross-Sectional Cohort Study To determine predictors of voice therapy initiation.

Chilean's Self-Perception of Their Self-Regulatory Behaviors and Vocal Symptoms To compare vocal symptoms and self-regulatory behaviors between Chileans having behavioral dysphonia and those who were vocally healthy; and to correlate their vocal symptoms and self-regulatory behaviors.

Voiced High-Frequency Oscillation or Lax Vox Technique? Immediate Effects in Dysphonic Individuals To analyze the immediate effects of voiced high-frequency oscillation (VHFO) and Lax Vox technique on vocal quality and self-reported intensity of vocal and laryngeal symptoms in individuals with behavioral dysphonia.

Patient Experience Contributing to Outcomes of Laryngeal Botulinum Toxin Injection Laryngeal Botulinum Toxin injection (LBTX) in the adductor musculature is the current therapy for Adductor Spasmodic Dysphonia. This study explores nonbiological factors that can affect the patient experience during this procedure and their association with better or worse self-reported effectiveness.

Struggling to Breathe: Inspiratory Muscle Training in Adolescent Athletes Dyspnea is a primary characteristic of exercise-induced laryngeal obstruction and prevents individuals from inhaling and exhaling without effort. This single subject research study investigated the effects of inspiratory muscle training (IMT) on exercise-induced symptoms characteristic of exercise-induced laryngeal obstruction in adolescent athletes.

Reflux Symptom Index (RSI) and Singing Voice Handicap Index (SVHI) in Singing Students: A Pilot Study To correlate, RSI with SVHI, in a group of singing students, by means of a specific anamnestic questionnaire which analyzes the physical, social, emotional, and economic impacts of voice problems on their lives. This study is a cross-sectional single-center observational study.