ENT Consultation Research Articles

Facial Palsy, Hypoacusis and Vertigo as Inaugural Symptoms of Neuroborreliosis - Case Report

Introduction: Facial Palsy (FP) is the most common acute mononeuropathy and consists of a decrease in facial muscle strength due to facial nerve damage. Peripheral FP (PFP) can result from a wide variety of disorders and aetiologies, with Lyme Disease (LD) being considered one of the most common causes of FP. LD is an infectious disease that affects the central nervous system, causing Neuroborreliosis (NB) in 15% of cases. Cranial neuropathy is the most common form of presentation of NB, as uni or bilateral PFP. We describe a case of PFP with hypoacusis and vertigo as the inaugural presentation of neuroborreliosis. Case Report: We present a case report of a 75-year-old female patient, referred to ENT consultation due to a 3-day course of a grade 4 right PFP, moderate right sensorineural hearing loss and right vestibular hypofunction. The patient underwent cranioencephalic Computed Tomography (CT-CE) which excluded a central event and was treated with 2 cycles of oral corticosteroids, without any clinical improvement. A Magnetic Resonance Imaging (MRI) was performed, which showed an abnormal inflammatory uptake of the right facial nerve. An analytical positivity for Borrelia IgM was found and the diagnosis of polyneuropathic NB with involvement of the VII and VIII right cranial pairs was assumed. The patient completed 28 days of doxycycline, with FP and vertigo improvement and normalization of hearing acuity. Discussion/Conclusion: In the presented case, the absence of the classical migratory erythema or painful meningopolyneuritis didn’t exclude the diagnosis of NB. FP associated to signs of other cranial nerves involvement raised the hypothesis of a systemic polyneuropathic disease, which motivated the etiological investigation carried out.

Urgent pediatric consultation for otologic conditions

Introduction: Pediatric otologic disorders are one of the most frequent reasons for urgent pediatric consultation, thus demanding important medical resources. Objective: The aim of the present study was to give quantitative description of the overall otologic pediatric pathology, presenting to an emergency ENT consultations office in the city of Sofia, Bulgaria. Patients and method: The records of all pediatric patients presented with urgent otorhinolaryngologic symptoms during one calendar year were retrospectively reviewed. Results: Consultations for otologic conditions in children account for 23.7% of all cases and for 55.3% of all pediatric consultations. The leading symptoms were from the external in 14.5% of the cases, form ihe middie ear - in 85.2% and form ihe inner ear in 0.3%. The most frequent etiologies include trauma for the auricle and infections for the external auditory canal and the middle ear. During the different year seasons there is significant variation in the relative incidence of otitis media and otitis externa. Much larger variations show the incidences of different pathologic otologic conditions in the different age groups. Otologic symptoms present an average of 52.8±9.4% of all emergency ENT consultations with an age peak in the age group 3-12 years, reaching up to 66%, followed by a gradual decline. Conclusion: The observed high proportion of children with otologic symptoms seen at an emergency ENT office underlines the importance of this pathology. The data reported could be used as reference when planing the facilities needed to provide adequate specialised medical help in urban areas.

An Unusual Presentation of Parathyroid and Micro Papillary Thyroid Carcinoma

Abstract Background: Parathyroid carcinoma is a rare endocrine malignancy, that usually presents with parathyroid hormone elevations five to ten times higher than normal. It is rarely diagnosed in cases with a normal or mildly elevated PTH. Clinical Case: 68 yo female with history of Hypertension, Spontaneous Vocal Cord Paralysis, Multinodular Goiter, Breast cancer s/p right radical mastectomy/chemotherapy, and Osteoporosis who presented to outpatient Endocrine clinic for hypercalcemia. Medications include Coreg 12.5 mg BID. Patient was asymptomatic. Labs showed BUN 21 mg/dL [8 mg/dL - 27 mg/dL], Creatinine 0.82 mg/dL [0.57 mg/dL - 1 mg/dL], eGFR 74 ml/min/1.73 m2 [nl>59 ml/min/1.73 m2], Calcium 10.8 mg/dL [8.7 mg/dL - 10.3 mg/dL], Phosphorus 3 mg/dL [3 mg/dL - 4.3 mg/dL], Magnesium 2.2 mg/dL [1.6 mg/dL - 2.3 mg/dL], PTH 77 pg/mL [15 pg/mL - 65 pg/mL], Albumin 4.2 g/dL [3.8 g/dL - 4.8 g/dL], Vitamin D 1,25 Dihydroxy 47.2 pg/mL [19.9 pg/mL - 79.3 pg/mL], Vitamin D 25-OH 18.2 ng/mL Low [30 ng/mL - 100 ng/mL], TSH 1.599 uIU/mL (.450-5.330 uIU/mL), Hgb 13.4 g /dL (12.0 -16.0 g/dL). Most recent FNA in 2019 of a dominant thyroid nodule was benign. Bone Density Scan June 2020 showed a T score of -3.4 in the lumbar spine and -3.1 in the left hip. Sestamibi Scan showed a right inferior parathyroid adenoma. Following ENT consultation, patient underwent surgical exploration. Pathology showed parathyroid tissue with extensive fibrosis, consistent with Parathyroid Carcinoma (1.8 x 1 x .7cm), probable positive margins, nodular growth pattern with individual nodules separated by fibrous bands, capsular invasion, focally, into adjacent adipose tissue invading through the thyroid capsule, positive for perineural invasion and PTH. Ki67 approximately six percent. Right thyroid lobe excision should a micro focus of papillary thyroid carcinoma (.2 x .2 cm), capsulated, negative margins, pT1a. Conclusion: This case demonstrated an unusual presentation of Parathyroid carcinoma causing a mild elevation of PTH level that in pathology after excision unexpectedly revealed a right parathyroid carcinoma along with micro papillary thyroid carcinoma.

Different Grafts used In Closure of Central Small Tympanic Membrane Perforations

Background: Large number of patient seek ENT consultation for central perforation of tympanic membrane. A significant portion of these cases are often found with very small central perforation. Minimyringoplasty is a very simple procedure to close such small perforations. Objective: the aim of the present study is to compare the surgical and audiological results of temporalis fascia versus more simple methods ( fat graft, fat graft wih hyaluronic acid and platelet rich plasma)in myringoplasty. Patient and Methods: a randomized prospective study concerned with 80 patients for whom myringoplasty was done. Patients were randomly assigned into four groups; in the first group fat graft was used (20patient) and fat graft with hyaluronic acid was used in the second group (20 patients).and platelet rich plasma was used in third group (20 patients) and temporalis fascia was used in fourth group (20 patients). Results: our study included 80 patients, 45 males and 35 females with a range from 18- 55 years. Surgical success rates75% , 80%, 75%and 75%for fat graft, fat graft with hyaluronic acid, platelet rich plasma and temporalis fascia respectively. There was 6.5 dB, 7db , 6 db and 5.5 db mean hearing improvement improvement in fat graft, fat graft with hyaluronic acid, platelet rich plasma and temporalis fascia respectively. Conclusions: The myringoplasty with fat graft,fat graft with hyaluronic acid and PRP is a minimally invasive effective procedure in management of the small central tympanic membrane perforations . Also it is safe and feasible procedure In this study we have achieved High success rate of repair of tympanic membrane perforation.

Otolarygological Manifestations of Patients with Confirmed Covid-19 Infection

Background: the coronavirus leads to upper respiratory tract-associated manifestations like nasal congestion, sore throat, and smell disorder
 Objectives: To reveal the impact of COVID-19 pandemic on otolaryngology symptoms using our daily medical practice.
 Subject and Methods: A cross-sectional study that was carried on in the isolation wards at Al-Kindy and Al-Nu’man Teaching Hospitals during three months from the 1st of Jun. till the end of Aug. 2020. It included 1270 patients who were diagnosed with COVID-19 infection seen in the ENT consultation clinic and admitted to the isolation wards.
 Results: Otolaryngological manifestations were shown as 15.7% complained of sore throat, the headache was presented in 11%. Non-otolaryngological manifestations were more common than otolaryngological manifestations as fever presented in 63% of cases and cough in 56.1%.
 Conclusion: Otolaryngological symptoms are not uncommon but less than fever or cough. Otolaryngological manifestation with a history of contact with COVID-19 patients should be considered in the diagnosis.

A systematic review of outcomes of remote consultation in ENT.

Remote or tele-consultation has become an emerging modality of consultation in many specialities, including ENT. Advantages include increasing accessibility, potential to reduce costs and, during the COVID-19 pandemic, reduced risk of infection transmission. Here, we systematically collate and synthesise the evidence base on outcomes from remote consultation in adult and paediatric ENT services. We performed a review in accordance with PRISMA guidelines. We searched Medline and Embase for relevant articles. Outcomes include specific patient pathway efficiency measures (including number of healthcare visits, lead time, touch time and handoff), patient/clinician satisfaction, cost analysis and safety implications. From 6325 articles screened, 53 met inclusion criteria. Publications included studies on remote consultation for initial, preoperative and follow-up assessment (including postoperative). In most instances, remote consultation reduced costs and time from referral to assessment and was associated with high patient satisfaction. However, a face-to-face follow-up appointment was required in 13%-72% of initial consultations, suggesting that remote consultation is only appropriate in selected cases. Remote consultation is appropriate and preferable for ENT consultation in specific conditions and circumstances. Future research should look to better define those conditions and circumstances, and report using recognised quality standards and outcome measures.

Management of the ENT Consultation During the COVID-19 Pandemic Alert. Are ENT Telephone Consultations Useful?

ObjectiveTo describe how the ENT and Head and Neck departments of the HMM and HVC hospitals were managed during the COVID-19 state of alert and to analyse the results obtained to assess the usefulness of telephone consultations in our specialty. Material and methodsFrom March 16, the ENT and Head and Neck departments of the HMM and HVC Hospitals began telephone consultations. Due to the disparity in the actions of the different department members, the decision was made to create a protocol to manage these consultations which started to be implemented March 23. ResultsDuring the study period, 1054 patients were attended in the consultations of both departments; 663 (62.9%) were first visits and 391 (37.10%) were successive visits. Twenty-one percent (229) of the consultations could be resolved by telephone, 10.82% (114) required face-to-face care, 57.40% (605) were indicated for an on-demand check-up depending on their disease course, and 10.05% (106) of the patients could not be reached by telephone. DiscussionThe state of alarm caused by COVID-19 has been a determining factor in how we undertake our care work. In the ENT and Head and Neck departments of the HMM and HVC Hospitals we decided to carry out consultations by telephone as an alternative to the traditional consultation. During this period, we have observed that up to 21.73% of the consultations could be dealt with by telephone. ConclusionThe telephone consultation seems to be a very useful tool to attend our patients avoiding the risk of COVID-19 infection during the state of alarm. Furthermore, according to the data analysed and the different studies, it seems a good alternative to the traditional consultation in selected patients.

ENT Referral From Emergency Department During COVID-19: A Single-Center Experience.

COVID-19 pandemic transformed the health system response worldwide. The aim of this study is to report changes about numbers and reason for ENT consultations in emergency department (ED) during COVID-19 pandemic comparing with those occurred the previous year (2019). Data about patients admitted to adult and pediatric ED were collected from March 1 to May 31, 2019 and 2020. Patients referred for urgency from general practitioners were excluded from the study. Global ED admission (except for dyspnea or COVID-19-related symptoms) dramatically decreased during pandemic (-50.9% among adults and -71.4% among pediatrics). At the same time, ENT consultancy significantly reduced too, by 71.5% (P < .01) among adults and 45.1% (P < .01) for pediatrics. Among adults, it was reported a statistically significant decrease in consultation for ear problems (-88.5%, P = .0146). Reduction in ENT referral for bone fracture (-40%, P = .059), vertigo (-77.8%, P = .637), and tonsillitis (-87.5%, P = .688) was consistent, but not significant. Among pediatric patients, it was observed an increase by 25% about foreign bodies (12 vs 15, P < .01). A reduction in numbers of consults for ear problem (-90.8%; P = .045), epistaxis (-80%; P = .196), and nasal fracture (-70%; P = .36) was also observed. Fear of infection and the forced lock down caused a significant decrease in the number of ED accesses and in ENT consultancy. These data may suggest that some ED referral usually could be deferred, but on the other hand, pandemic will cause a great diagnostic delay.

Knowledge, attitudes and practices of adult patients seen in ENT consultation facing COVID-19 in Lomé, Togo

Introduction: The objective of this study was to verify the knowledge, attitudes and practices of patients received in an ENT consultation in Lome in the face of COVID-19 in order to better guide information, education and communication campaigns. Methods: This was a descriptive and analytical cross-sectional study that took place from May 4 to June 5, 2020, in the ENT department of the Sylvanus Olympio University Hospital in Lome, the country´s leading reference hospital center. An anonymous questionnaire with open and closed questions was given during the first 5-10 minutes of a regulatory ENT consultation. Only patients 15 years of age and older who gave their consent were included in the study. The consent of patients aged 15 to 18 was confirmed by their parent or guardian accompanying them. Results: A total of 166 patients were enrolled in the study and one interviewee was not aware of the presence of COVID-19 on Togolese territory. Radio and TV programs and newspapers were the main source of information for the respondents (86.14%). Patients´ overall knowledge of COVID-19 in terms of symptoms, routes of transmission and barrier measures was rated as good. More than 79% of respondents reported being afraid of COVID-19. The attitudes and practices of those surveyed were diverse and varied. Respondents who thought they had been infected tended to take preventive self-medication (p = 0.0003). Low education was been associated with fear of COVID-19 (p = 0.0112).Conclusion: Further awareness-raising and with the right explanations, is still necessary to ensure what has been learned and avoid fear, stigma and bad practice when faced with COVID-19.

Knowledge, attitudes and practices of adult patients seen in ENT consultation facing COVID-19 in Lomé, Togo

Introduction: The objective of this study was to verify the knowledge, attitudes and practices of patients received in an ENT consultation in Lom´ in the face of COVID-19 in order to better guide information, education and communication campaigns.

Tolerability and usability of 0.5% PVP-I gargles and nasal drops in 6692 patients: Observational study

Objectives1.To assess the feasibility and usability of 0.5% PVP-I gargles and nasal drops in patients attending ENT consultations for a period of 5 months as a pre requisite prior to ENT examination.2.To assess the tolerance of 0.5% PVP-I in these patients for regular use for a period of 8 days. Study designObservational study. SettingSecondary care ENT Centre. MethodsAll patients attending the hospital for office ENT consultations from 15th April 2020 to 15th September 2020 were included in the study. A total of 6692 office patients were evaluated for feasibility, usability and tolerability of the 0.5% PVP-I gargles and nasal drops. ResultsOverall practicability of using 0.5% PVP-I gargles and nasal drops at office level was assessed in terms of feasibility and usability. Feasibility and usability was considered in terms of the ease of the dispensing method of the 0.5% PVP-I gargles and nasal drops by the health care workers to the patients prior to ENT examination. Tolerance was assessed in terms of altered taste, staining of teeth or nasal skin or irritation in the nose. None reported any serious reactions or adverse effects following use of 0.5% PVP-I. ConclusionThe study reports the successful feasibility and usability of 0.5% PVP-I gargles and nasal drops and bears the potential to provide benefits in preventing transmission from the patients to the health care workers and vice versa. Level of evidence4.

An Assessment of Management Strategies for Adult Patients with Foreign-Body Sensation in the Neck.

Objectives:Patients come to the emergency department (ED) for the evaluation of foreign-body sensation in the neck. Given the dearth of clinical studies for this complaint, these patients are treated subjectively by different providers. We aim to propose a treatment approach that results in the timely diagnosis and removal of foreign bodies by comparing the common radiologic studies used in the ED for this complaint, determining the utility of consults, and providing an approach that minimizes length of stay.Methods:We conducted a retrospective cohort study of adults between January 2014 and December 2015 presenting to LIJ and NSUH EDs with a chief complaint of foreign-body sensation in the pharynx, larynx, or esophagus. Fifty unique cases were studied. Consultations with ear, nose, and throat (ENT) and/or gastrointestinal, any imaging studies used, and time until discharge from the hospital were the primary exposures studied. The time for each diagnostic path for successful removal of a foreign body was compared for each case.Results:Three common diagnostic approaches were identified. The most common pathway (six cases) had an ENT consult for removal of the foreign body, with an average time to discharge of 188 min. Another common pathway (four cases) began with a neck X-ray followed by an ENT consult, with an average time of 327 min. The third common approach (6 cases) involved no imaging studies or consults, with an average time of 166 min. Neck X-ray (20 cases) was found to have a sensitivity of 43% and a specificity of 83%. The sensitivity of neck computed tomography (CT) (15 cases) had a sensitivity of 91% and a specificity of 50%. Chest X-ray (15 cases) was found to have a sensitivity of just 17%. Chest CT (3 cases) had a sensitivity of 67%.Conclusion:Based on our data, we recommend that an attempt to localize the foreign body be completed by the emergency physician. If an initial attempt does not resolve the sensation, an ENT consult to remove the possible object should be initiated. Only after failure by ENT should radiological imaging be considered.

Child Deafness in Sub-Saharan Africa: Experience of Two ENT Services in Casamance, South of Senegal

Introduction: Hearing impairment is the most common sensory deficit at birth. It is a public health problem because of the repercussions on the communication development, on the education and subsequent social integration of the child. The objective of this study was to determine the epidemiological, clinical, audiometric and etiological profiles of child deafness in Casamance, South of Senegal. Materials and Methods: This was a retrospective multicenter study, which extended a period of 7 years from January 1st, 2012 to December 31st, 2019. All children aged between 1 to 18 years old and received during their first ENT consultations at the regional and PEACE hospital in Ziguinchor were included. Results: One hundred and seventy-eight records of children were collected during this period, that is a prevalence of 1.30%. The average age was 9 years old. Conductive hearing loss was found in 68% of patients, followed by reception hearing deafness in 24%. The deafness was acquired in the majority of cases (93%) and the predominant etiology was infectious. However, the cause was unknown in 7.51% of cases. Conclusion: Child deafness is common in Casamance and is most often underdiagnosed. The acquired forms are the most common, hence the importance of early detection after a rigorous family investigation.

Prevalence of ENT Diseases in the Mental Deficient Patients

Introduction: Patients with mental deficiency have increased health needs. They develop certain ailments more than the rest of the general population. ENT pathology includes all the ailments concerning the nose, throat and ear and is a frequent reason for consultation in our health facilities. The aim of this study was to report the prevalence of ENT diseases in mental deficient. Material and Methods: This was a prospective, longitudinal study on a population of patients received in ENT consultation, during the days of October 15, 2019 and February 18, 2020 on the occasion of health campaigns organized by the Senegal Special Olympics Association. All admitted patients were mental deficient. Results: Out of a total of 334 patients received in general consultation (all specialties combined), 61 patients underwent an ENT consultation, i.e. a prevalence of 18.26%. There were more men (N = 39) than women (N = 32). The average age of the patients was 20 years. A past history of chronic otitis media was reported in 9.83% of patients (N = 6). Functional signs were dominated by hypoacusis (N = 16). Seventy point forty-nine patients (N = 43) had otologic conditions. Thirty-four patients had trisomy 21 (64.15%). Conclusion: The prevalence of ENT diseases among the mental deficient is considerable. This study is the first of its type in Senegal which superimposes the ENT on mental deficiency.

Lacrimal Duct Obstruction in Adults

The tearing eye (epiphora) is the guiding symptome of nasolacrimal duct obstruction. Depending on the localization of stenosis, mucopurulent lacrimal discharge occurs additionally. These symptoms induce alterations of the optical system and can cause severe complications such as acute phlegmonous dacryocystitis. The grade of suffering in these patients is very high. For the diagnosis, patient's history, ocular surface conditions and inspection (macro-/microscopically) as well as palpation of the lacrimal region are essential examinations. Moreover, functional and anatomical tests enable a classification of nasolacrimal duct obstruction regarding grade of stenosis (incomplete vs. complete), type (functional vs. mechanical), and localization (pre-, intra-, postsaccal). ENT consultation prior to lacrimal surgery is obligate. Through this, a purposeful therapeutic intervention is warranted. Surgical methods consist of minimally invasive transcanalicular procedures or anastomosing surgeries. Dependent on the clinical findings, these treatment options can be applied in a patient centered therapeutic concept.

Hearing Efficiency in Oral Submucous Fibrosis: A Clinical Study

Oral Submucous fibrosis (OSMF) is a chronic insidious disease of oral mucosa that occurs due to areca-nut chewing, consumption of chillies, autoimmunity and genetic predisposition. The disease starts with burning sensation and inability to tolerate spicy foods with gradual reduction in mouth opening due to fibrosis of the oral mucosa. The extension of fibrosis into the naso pharynx leads to reduction in hearing efficiency. As very few studies had been done to evaluate the hearing disability in OSMF patients, this study had been undertaken to prove the same. To evaluate hearing efficiency in patients with Oral Submucous Fibrosis of various grades of severity. Presentation includes 30 patients of osmf with various grades and evaluated for hearing efficacy by audiometry. Hearing threshold was compared in different grades of osmf. The present study revealed a significant association between OSMF and hearing deficit. Involvement of the palatal muscles with OSMF may decrease the patency of the Eustachian tube, leading to conductive hearing loss. Therefore, the protocol for managing OSMF patients should include ENT consultation and treatment for hearing deficit in order to increase the success rate of treatment.

Prevalence of Foreign Bodies in the Ear, Nose and Throat in Alramadi City

Background: Foreign body in ENT refers to an object which settles within head orifices which includes theear, nose, or throat.Aim: Compare the incidence of various Foreign Bodies in the Ear, Nose and Throat and the type of anesthesiarequired for removal in alramadi teaching hospital.Method: This cross-sectional study was conducted on 100 patients who presented with complaints of foreignbody insertion/impactionor ingestion in ear or nose or throat in alramadi teaching hospital.Results: These cases comprised of 64 (64%) males &amp; 36 (36%) females having male: female ratio= 1.77:1. Out of all patients 56 (56%) presented with ear foreign bodies, 33 patients (33%) presented with nasalcavity foreign bodies, 11 patients (11%) presented with the throat (oropharyngeal/hypopharyngeal) foreignbodies. General anesthesia was required in 8 cases (8%) while the rest removed by senior house officersunder supervision by ENT specialists or Consultants without GA.Conclusion: Foreign bodies considered an important challenge to otolaryngologist especially in childrenwho represented the most commonly affected age.

General characteristics of otorhinolaryngology consultations: 3-year analysis

Aim: Nowadays, with the rapid development and change of knowledge in the scientific field, the number of specialty branches in medicine has increased. Therefore, the rate of consultation requests in different specialties during the patient evaluation process gradually escalates. This study aims to evaluate the characteristics of the diagnostic and therapeutic consultations requested from the Otorhinolaryngology (ENT) branch in a university hospital. Methods: In this cross-sectional study, the data of patients consulted to the ENT clinic of Kutahya University of Health Sciences Evliya Celebi Training and Research Hospital between January 1st, 2017 and December 31st, 2019 were retrospectively scanned. Apart from demographic findings such as age and gender, departments requesting the consultation, post-consultation diagnoses and surgical treatments performed by an ENT physician were noted. Results: The total number of patients with an ENT consultation was 2340. The mean age of the patients was 45.95 (25.09) years. Most consultation requests were made from the emergency department (n=877, 37.5%), which was followed by 278 requests (11.9%) by the neurology and neurology ICU departments, and 193 (8.2%) requests by the anesthesiology and intensive care unit (ICU) departments. Although varying among age groups, epistaxis (10%) and vertigo (dizziness) (10%) were the most common diagnoses. A total of 146 patients received surgical treatment. The most common surgical operations were tracheotomy and nasal bone fracture reduction. Conclusion: Determining the characteristics of patients for whom ENT consultation is required will be beneficial in shaping the training programs for other clinics, reducing unnecessary consultation requests, thus reducing the workload of ENT physicians.

IT’S ALL IN THE STORY: A MISLEADING CHEST CT

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: An abnormal chest CT is a common reason for pulmonary consultation. There is a wide differential and a thorough history is important in helping to hone in on a diagnosis. Here, we present a case where the floridly abnormal chest CT was misleading. CASE PRESENTATION: The pulmonary team was consulted for an abnormal chest CT with request for bronchoscopy. A 32 yo woman without major past medical history presented to the ED short of breath - she described running for the bus and suddenly not being able to breathe. Labs on arrival significant for lactic and respiratory acidosis, suggesting near respiratory arrest. She improved rapidly with nebulizers, rest, and oxygen, and quickly weaned back to room air; her labs also improved rapidly. Her CXR showed patchy opacities so a chest CT was obtained showing diffuse ground glass opacities (Figure 1). She denied a wide range of exposures. Part of the thyroid obtained on the chest CT looked enlarged; she reported having been told several months ago that her thyroid was enlarged, and on exam it was noticeably large. A CT of the neck showed enlarged thyroid causing compression of the upper airway (Figure 2). We suspected the cause of her abnormal CT to be negative pressure pulmonary edema in the setting of likely upper airway obstruction caused by her enlarged thyroid. The initial ENT consult team did not feel this was related, however a secondary consult with endocrine surgery agreed with immediate resection of the thyroid. The patient was monitored in the MICU with heliox at the bedside, and underwent the resection without complication; she was surprisingly able to be intubated easily. She recovered fully and is now doing well; repeat CXR showed improvement. DISCUSSION: Negative pressure pulmonary edema (NPPE) is most commonly reported in the post-operative period from laryngospasm causing deep inspiration against a closed upper airway.1 This intense negative pressure pulls fluid into the alveolar space. Treatment involves addressing the underlying issue, whether it be laryngospasm or upper airway obstruction, with which the edema should rapidly resolve. Other cases have reported large thyroid masses causing similar presentations.2 Heliox can be used in cases of respiratory distress from narrowed airways, as its properties provide much less turbulent flow.3 It has been used to decrease intubation rates in children with croup, patients with subglottic stenosis, and even in severe asthma exacerbations. CONCLUSIONS: NPPE can cause an extremely abnormal chest CT, though the history and rapid improvement will help rule out other causes and rapidly narrow the differential. Heliox can be used to help improve oxygenation and ventilation in the setting of a narrowed upper airway. Patients improve with treatment of underlying obstruction or laryngopasm. Reference #1: Bhattacharya, M., Kallet, R. H., Ware, L. B. & Matthay, M. A. Negative-Pressure Pulmonary Edema. Chest 150, 927–933 (2016). Reference #2: Goh, K. J., Koh, M. S. & Tay, C. K. The Aftermath of Relieving an Upper Airway Obstruction. A Case of Postobstructive Pulmonary Edema. Am. J. Respir. Crit. Care Med. 198, e106–e108 (2018). Reference #3: Hashemian, S. M. & Fallahian, F. The use of heliox in critical care. Int. J. Crit. Illn. Inj. Sci. 4, 138–142 (2014). DISCLOSURES: No relevant relationships by Catherine Gao, source=Web Response No relevant relationships by Lisa Wolfe, source=Web Response

An Empowerment Model for Individuals with Chronic Tinnitus.

This qualitative study sought to construct a model of empowerment for clinical implementation, based on the first-hand experience of a sample of individuals with chronic tinnitus. The study was conducted in accordance with the inductive approach to data in classic grounded theory (GT). GT aims to build a model of behavior that accounts for the main concern of individuals and how they strive to resolve it. Twenty-one participants with chronic tinnitus (10 females, 11 males, age 31-85, mean: 57.6 years, mean duration of tinnitus: 12 years) were recruited through the patient association France Acouphènes and ENT consultations. Open-ended, tape-recorded interviews addressed the variation in the intrusiveness of tinnitus in daily life. A constant comparison analysis was undertaken to identify a core category and to distinguish stages in behavioral changes toward the tolerance of tinnitus. Participants' main concern was to limit the intrusiveness of tinnitus day in, day out. They continuously had to handle tinnitus-induced frustration, which was found to be the core category of the analysis accounting for how all the participants tried to deal with the condition. The more they managed to handle their frustration, the better they coped with the condition. Three behavior patterns were identified as facilitating the ongoing management of tinnitus-induced frustration: (1) searching for perspective upon tinnitus; (2) maintaining order in perception despite its interference; and (3) alleviating conflict arising from social interactions. A model of empowerment is presented that is based on four stages toward tolerance of tinnitus. They are dominated by lack of perspective upon tinnitus (circuit 1), preservation of energy through attempts to control its intrusiveness (circuit 2), attempts to detach oneself from the interference of tinnitus through constant activities (circuit 3), and self-induced relief through the fulfillment of meaningful goals (circuit 4). Tolerance of tinnitus requires finding balance between limiting one's social participation and spontaneity in carrying out meaningful activities. Tolerance can be enhanced by the preservation of one's energy and the mediating role of enjoyment through the fulfillment of gratifying goals. In patient counseling, it is essential to address the individual's desire for direct relief from tinnitus through its elimination. Individuals should be made aware that such a desire will likely be thwarted, resulting in the worsening of intrusiveness. Improvement in tolerance is accompanied by the attenuation of niggling self-awareness, a change that is typical of full commitment with valued goals and that helps in alleviating the interference of tinnitus. By understanding the role of frustration, individuals may develop a sense of responsibility in dealing with disabling tinnitus.