Revista Arquivos 17(3) - ingles.pmd - Internationalarchivesent.org

• Tympanomastoidectomy: Comparison between canal wall-down and canal wall-up techniques in surgery 

for chronic otitis media 

• Endoscopic surgery in the treatment of crista galli pneumatization evolving with localizated frontal 

headaches 

• Velopharyngeal dysfunction: a systematic review of major instrumental and auditory-perceptual 

assessments 

• Results obtained with a low cost software-based audiometer for hearing screening 

• Comparison of videonasoendoscopy and auditory-perceptual evaluation of speech in individuals with 

cleft lip/palate 

• Clinical and fiberoptic endoscopic assessment of swallowing in patients with chronic obstructive 

pulmonary disease 

• Characteristics of polypoid lesions in patients undergoing microsurgery of the larynx 

• Audiological outcomes of cochlear implantation in Waardenburg Syndrome 

• Performance analysis of ten brands of batteries for hearing aids 

• Contribution of audiovestibular tests to the topographic diagnosis of sudden deafness 

• Diffusion of aniline blue injected into the thyroarytenoid muscle as a proxy for botulinum toxin injection: 

an experimental study in cadaver larynges 

• Correlation of cephalometric and anthropometric measures with obstructive sleep apnea severity 

• Use of surface electromyography in phonation studies: an integrative review 

• Middle ear adenoma with neuroendocrine differentiation: relate of two cases and literature review 

• Bullous Systemic Lupus Erythematosus: Case report 

• Eagle’s Syndrome 

• Retrolabyrinthine approach for cochlear nerve preservation in neurofibromatosis type 2 and simultaneous 

cochlear implantation

234

ISSN 1809-9777 

Official Publication of the Otorhinolaryngology Foundation and 

Societa Oto-Rhino-Laryngologica Latina 

First Electronic Journal of ENT 

INDEXATIONS 

DOAJ - Diretory of Open Access Journals. 

FUNPEC-RP (Foundation for Scientific Research 

of Ribeirão Preto). 

Latindex - Regional Cooperative Online 

Information System for Scholarly Journals from 

Latin America, the Caribbean, Spain and 

Portugal. 

LILACS and LILACS-Express Latin-American 

and Caribbean Center on Health Sciencies 

Information. 

SciELO - Scientific Electronic Library Online. 

SCOPUS - SciVerse (Elsevier). 

AFFILIATION 

Vol. 17 nº 3 - Jul/Aug/September- 2013 

The whole edition has 4 issues published: March, 

June, September and December. 

Periodicity: threemonthly 

Number printed: 5,500 issues 

Address for correspondence: 

Rua Teodoro Sampaio, 483 

São Paulo - SP - Brazil 

Zip code: 05405-000 

Phone: (+55 11) 3068.9855 

Fax: (+55 11) 3079.6769 

E-mail: 

archives@internationalarchivesent.org 

Home page: 

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Creation, publishing and printing 

H. Máxima 

V.R. Galizia Produtora Editora e Gráfica 

Rua Antonio Tavares, 207 A - Sala 4 

São Paulo - SP - Brazil 

Zip code: 01542-010 

Phone/Fax: (+55 11) 2372-5061 

E-mail: hmaxima@terra.com.br 

Design: Vagner Bertaco Severino 

SUPPORT 

EDITOR 

Geraldo Pereira Jotz – UFRGS – Porto Alegre – Brazil 

CO-EDITOR 

Aline Gomes Bittencourt – USP – São Paulo – Brazil 

ASSOCIATED EDITORS 

Alergy and Olfact: ................................ João Ferreira de Mello Junior ........... USP – São Paulo / Brazil 

Audiology: ........................................... Marcelo M. Hueb ........................... UFTM – Uberaba / Brazil 

Skull Base: ........................................... Ricardo L. Carrau ........................... Ohio State University – OH / USA 

Head and Neck: ................................... Luiz Paulo Kowalski ....................... H. AC Camargo – São Paulo / Brazil 

Stomatology: ........................................ Michiel W. M. Van den Brekel ......... Netherlands Cancer Institute – Amsterdam / Netherlands 

Pharyngology: ...................................... Marcus Miranda Lessa .................... UFBA – Salvador / Brazil 

Laryngology: .......................................... Robert T. Sataloff ............................. Drexel University College of Medicine – Philadelphia / USA 

Neurotology: ........................................ Ricardo Ferreira Bento ................... USP– São Paulo / Brazil 

Otology: ............................................... Priscila Bogar Rapoport .................. FMABC – Santo André / Brazil 

Facial Plastic and Reconstructive: ............. Marcos Mocelin .............................. UFPR – Curitiba / Brazil 

Rhinosinusology: .................................. Richard Voegels ............................. USP – São Paulo / Brazil 

EDITORIAL BOARD 

Adriana Brondani da Rocha – ULBRA - Canoas - Brazil; Adriane Teixeira - UFRGS - Porto Alegre - Brazil; Agrício Crespo - UNICAMP - Campinas - Brazil; 

Agustin del Canizo - Universidad de Salamanca - Salamanca - Spain; Alberto Alencar Nuldelmann - PUC - Porto Alegre - Brazil; Alejandro Rivas - 

Vanderbilt University Medical Center - Tennessee - USA; Alexandre Felippu Neto - Instituto Felippu - São Paulo - Brazil; Alfio Ferlito - Udine School 

of Medicine - Unide - Italy; Ana Cristina H. Hoshino - USP - São Paulo - Brazil; André Luiz Lopes Sampaio - UNB - Brasília - Brazil; Antonio Celso Nassif 

Filho - PUC - Curitiba - Brazil; Badr Eldin Mostafa - Ain-Shams University - Cairo - Egypt; Bernard Fraysse - Hôpital PURPAN - Toulouse - France; 

Carlos Augusto Pires de Oliveira - UNB - Brasília - Brazil; Carlos Curet - Universidad Nacional de Córdoba - Córdoba - Argentina; Carlos Diógenes 

Pinheiro Neto - Albany Medical College - New York - USA; Ciríaco Cristóvão Tavares Atherino - UERJ - Rio de Janeiro -Brazil; Desiderio Passáli - 

University Hospital - Siena - Italy; Domenico Cuda - Guglielmo da Saliceto Hospital – Piacenza - Italy; Domingos Hiroshi Tsuji - USP - São Paulo - 

Brazil; Eduardo Crema - UFTM – Uberaba - Brazil; Eliane Schochat - USP - São Paulo - Brazil; Elisabeth Carrara de Angelis - Hospital AC Camargo 

- São Paulo – Brazil; Fabrizio Ricci Romano - USP - São Paulo - Brazil; Filipe Matuba -Agostinho Neto University - Luanda - Angola; Fernando Luis 

Dias - INCA - Rio de Janeiro - Brazil; Francini Grecco de Melo Pádua - UNIFESP - São Paulo - Brazil; Francisco Verissimo de Mello Filho - USP-RP - 

Ribeirão Preto - Brazil; Gerson Schulz Maahs - UFRGS - Porto Alegre - Brazil; Giovanni Danesi - Ospedali Riuniti di Bergamo - Bergamo - Italy; Héctor 

Rondón Cardoso - Universidad Nacional de San Agustín - Arequipa - Perú; Heinz Stammberger - Graz University - Graz - Austria; Hélio Lessa - UFBA 

- Salvador - Brazil; Jacques Magnan - Université dAix-Marseille - Marseille - France; Jair Cortez Mantovani - UNESP - Botucatu - Brazil; Jeferson 

S. D’Avila - UFSE - Aracajú - Brazil; Jesús Algaba Guimera - Hospital Donostia de San Sebastián -San Sebastián - Spain; José Faibes Lubianca Neto 

- UFCSPA - Porto Alegre - Brazil; Jose N. Fayad - Keck School of Medicine, USC - California - USA; Lídio Granato - FCMSCSP - São Paulo - Brazil; Lilian 

Muniz - Universidade Federal de Recife - Recife – Brazil - Luciana Miwa Nita – UNB - Brasília - Brazil; Luiz Antonio Guerra Bernd - UFRS - Porto 

Alegre – Brazil; Luiz Lavinsky - UFRGS - Porto Alegre - Brazil; Luiz Ubirajara Sennes - USP - São Paulo - Brazil; Maira Rozenfeld Olchik -UFRGS 

- Porto Alegre - Brazil; Manuel Manrique Rodríguez - Universidad de Navarra - Navarra - España; Marcelo Lazzaron Lamers - UFRGS - Porto Alegre 

- Brazil; Marcelo Ribeiro de Toledo Piza - Associação Paparella - Ribeirão Preto - Brazil; Márcio Abrahão - UNIFESP - São Paulo - Brazil; Márcio 

Nakanishi - UNB - Brasília – Brazil; Marcos Vial Goycoolea - Clinic of Las Condes -Santiago – Chile; Maria Valéria Schimidt Goffi Gómez - USP - São 

Paulo – Brazil; Mario Andréa -Lisboa University - Lisboa – Portugal; Mario Svirsky - New York University - New York - USA; Maurizio Barbara - 

Sapienza University, SantAndrea Hospital - Rome - Italy; Minoru Hirano -Kurume University - Kurume – Japan; Nédio Steffen - PUC - Porto Alegre 

– Brazil; Nelson Rosário - UF do Paraná - Curitiba – Brazil; O. Nuri Özgirgin - Ba_kent University Faculty of Medicine - Ankara – Turkey; Olivier 

Sterkers - Université Paris Diderot - Paris – France; Onivaldo Cervantes - UNIFESP - São Paulo – Brazil; Otávio Bejzman Piltcher - UFRGS - Porto 

Alegre - Brazil; Paulo Sérgio Lins Perazzo - UNEB - Salvador – Brazil; Pedro L. Coser - UFSM -Santa Maria – Brazil; Pedro Luís Mangabeira Albernaz 

- UNIFESP - São Paulo – Brazil; Regina Helena Garcia Martins - UNESP - Botucatu – Brazil; Richard Harvey - University of New South Wales - New 

South Wales – Australia; Robert Sweet - McGill University - Montreal – Canada; Robert Vincent - Causse Ear Clinic - Colombiers – France; Roberto 

Campos Meirelles - UERJ -Rio de Janeiro – Brazil; Roberto Dihl Angeli - UFRGS - Porto Alegre -Brazil; Roberto Filipo - Sapienza Università di Roma 

- Roma – Italy; Rodrigo de Paula Santos - UNIFESP - São Paulo – Brazil; Ronaldo Frizzarini - USP - São Paulo – Brazil; Sady Selaimen da Costa 

– UFRGS – Porto Alegre – Brazil; Salvatore Conticello - Università degli Studi di Torino - Turin – Italy; Samir Cahali - HSPE -São Paulo – Brazil; 

Shiro Tomita - UFRJ - Rio de Janeiro - Brazil; Silvia Dornelles - UFRGS - Porto Alegre - Brazil; Silvio Antonio Monteiro Marone - PUCCAMP - Campinas 

– Brazil; Silvio da Silva Caldas Neto - UFPE - Recife – Brazil; Tania Maria Sih - FMUSP - São Paulo – Brazil; Thomas Linder - Luzerner Kantonsspital 

- Luzern – Switzerland; Ugo Fisch - University Hospital - Zürich –Switzerland; Wytske Fokkens - Academic Medical Cente - Amsterdam – Netherlands; 

Zelita Ferreira Guedes - UNIFESP - São Paulo - Brazil. 

Librarian: Adilson Montefusco 

Int. Arch. Otorhinolaryngol., São Paulo - Brazil, v.17, n.3, Jul/Aug/September - 2013. 

235

Int. Arch. Otorhinolaryngol. 2013;17(3):236. 

DOI: 10.7162/S1809-97772013000300001 

Editorial 

International Archives of Otorhinolaryngology 

Editorial 

17 th Volume (3) – Jul/Aug/September - 2013 

International Archives of Otorhinolaryngology and Thieme Medical Publishers 

On 16 April 2013, the Otorhinolaryngology Foundation signed a partnership with Thieme Medical Publishers for the 

publication of the International Archives of Otorhinolaryngology, beginning with this year’s 4th edition. 

Thieme, a German publishing company based in Stuttgart with a 125-year history, is one of the most important publishers 

of medical books and journals in the world. It publishes 130 diversified medical journals and 70 new books a year. 

The International Archives of Otorhinolaryngology is a journal sponsored by the Otorhinolaryngology Foundation and the 

Societas Oto-Rhino-Laryngologica Latina, a medical society founded in 1924. It has been continuously published for the last 

17 years and is the first electronic journal of otorhinolaryngology in the world. This scientific journal is reviewed by an 

international editorial board and independent peer reviewers and is currently supported by FAPESP (Foundation for 

Research Support of the State of Sao Paulo). 

This partnership is a major breakthrough for Brazilian science, since our journal, as part of Thieme’s portfolio, will partake 

of the publisher’s quality standards and achieve more international visibility. 

With this partnership, the International Archives of Otorhinolaryngology will be added to the most important indexations 

of medicine in the medium term, thus supplementing its already established academic presence. It will also increase the 

contributions from all around the world. This way, we hope the journal will become, soon, the major vehicle for research in the 

field of otorhinolaryngology, speech therapy, and related sciences in Latin America. The authors who publish in our journal 

will thus have an international impact comparable to researchers whose work appears in other renowned periodicals. 

Congratulations to all who have published in our journal and who have induced Thieme, which took notice of the quality 

of its contents and its importance among Brazilian experts, to choose it as its starter in Brazil. 

Finally, this partnership was made possible by the visionary mission of Professor Ricardo Bento, President of the Board of 

Trustees of the Otorhinolaryngology Foundation; the perseverance and encouragement of Professor Richard Voegels; the 

institutional and quality commitment of Professor Geraldo Pereira Jotz, Editor-in-Chief; and of Dr. Aline Bittencourt, 

Co-Editor; together with the professional dedication of Adilson Montefusco, librarian in charge. This partnership was signed 

in Sao Paulo in the presence of Mr. Daniel Schiff, Senior Vice President of Thieme Publishers, and Mrs. Michele Aranha, 

representative in Brazil of Thieme Publishers. 

For future issues, we will be changing the system of online manuscript submission and review, which will be managed by 

ScholarOne (http://mc.manuscriptcentral.com/iaorl) 

Best regards, 

Geraldo Pereira Jotz 

Editor-in-Chief 


Aline Bittencourt 

Co-Editor 


Index in LILACS and LILACS-Express – Latindex – DOAJ – FUNPEC-RP – 

SciELO – SCOPUS 


236

ISSN 1809-9777 

Contents 

Int. Arch. Otorhinolaryngol., 17 (3) 

Original Article 

242 Tympanomastoidectomy: Comparison between canal wall-down and canal wall-up techniques in 

surgery for chronic otitis media 

Azevedo AF, Soares ABC, Garchet HQC, Sousa NJA. 

246 Endoscopic surgery in the treatment of crista galli pneumatization evolving with localizated frontal 

headaches 

Socher JA, Santos PG, Correa VC, Silva LCB. 

251 Velopharyngeal dysfunction: a systematic review of major instrumental and auditory-perceptual 

assessments 

Paniagua LM, Signorini AV, Costa SS, Collares MVM, Dornelles S. 

257 Results obtained with a low cost software-based audiometer for hearing screening 

Ferrari DV, Lopez EA, Lopes AC, Aiello CP, Jokura PR. 

265 Comparison of videonasoendoscopy and auditory-perceptual evaluation of speech in individuals with 

cleft lip/palate 

Paniagua LM, Signorini AV, Costa SS, Collares MVM, Dornelles S. 

274 Clinical and fiberoptic endoscopic assessment of swallowing in patients with chronic obstructive 

pulmonary disease 

Macri MRB, Marques JM, Santos RS, Furkim AM, Melek I, Rispoli D, Nunes MCA. 

279 Characteristics of polypoid lesions in patients undergoing microsurgery of the larynx 

Ido Filho JM, Carvalho B, Mizoguchi FM, Catani GSA, Macedo Filho ED, Malafaia O,Stahlke Jr. HJ. 

285 Audiological outcomes of cochlear implantation in Waardenburg Syndrome 

Magalhães ATM, Samuel PA, Gomez MVSG, Tsuji RK, Brito B, Bento RF. 

291 Performance analysis of ten brands of batteries for hearing aids 

Penteado SP, Bento RF. 

305 Contribution of audiovestibular tests to the topographic diagnosis of sudden deafness 

Oiticica J, Bittar RSM, Castro CC, Grasel S, Pereira LV, Bastos SL, Ramos ACM, Beck R. 

315 Diffusion of aniline blue injected into the thyroarytenoid muscle as a proxy for botulinum toxin injection: 

an experimental study in cadaver larynges 

Alonso VMO, Chagury AA, Hachiya A, Imamura R, Tsuji DH, Sennes LU. 

321 Correlation of cephalometric and anthropometric measures with obstructive sleep apnea severity 

Borges PTM, Ferreira Filho ES, Araujo TME, Moita Neto JM, Borges NES, Melo Neto B, Campelo V, Paschoal JR, Li LM. 

Review Article 

329 Use of surface electromyography in phonation studies: an integrative review 

Balata PMM, Silva HJ, Moraes KJR, Pernambuco LA, Moraes SRA. 

340 Middle ear adenoma with neuroendocrine differentiation: relate of two cases and literature review 

Bittencourt AG, Tsuji RK, Cabral Junior F, Pereira LV, Fonseca ACO, Alves V, Bento RF. 

Case Report 

344 Bullous Systemic Lupus Erythematosus: Case report 

Miziara ID, Mahmoud A, Chagury AA, Alves RD. 

347 Eagle’s Syndrome 

Pinheiro TG, Soares VYR, Ferreira DBL, Raymundo IT, Nascimento LA, Oliveira CACP. 

351 Retrolabyrinthine approach for cochlear nerve preservation in neurofibromatosis type 2 and simultaneous 

cochlear implantation 

Bento RF, Monteiro TA, Bittencourt AG, Gomez MVSG, Brito R. 


237

AUTHOR GUIDELINES 

INTERNATIONAL ARCHIVES OF 

OTORHINOLARYNGOLOGY 

Editor-in-Chief - Geraldo Pereira Jotz, M.D. Ph.D. 

Co- Editor - Aline Bittencourt, M.D. 

Editorial Office: 

Rua Teodoro Sampaio 483 

Zip code 05405-000 

São Paulo – SP – Brazil 

Phone/FAX: +55 (11) 3085-9943 

archives@internationalarchivesent.org 

International Archives of Otorhinolaryngology (IAO) 

is an international peer-reviewed journal dedicated to the 

otolaryngology–head and neck surgery, audiology and speech 

therapy. 

IAO is published every three months and supports the 

World Health Organization (WHO) and of the International 

Committee of Medical Journal Editors (ICMJE) politics regarding 

registration of clinical trials. Therefore from now on we will 

only accept for publication articles of clinical trials that have 

been given a number of identification from one of the Clinical 

Essay Registry validated by the criteria established by the 

WHO and the ICMJE, which links are available at the ICMJE 

(http://www.icmje.org/). The identification number should 

be informed at the end of the abstract. 

IAO reserves the right to exclusive publication of all 

accepted manuscripts. We will not consider any manuscript 

previously published nor under review by another publication. 

Once accepted for review, the manuscript must not be 

submitted elsewhere. Transfer of copyright to IAO is a 

prerequisite of publication. All authors must sign a copyright 

transfer form. 

Authors must disclose any financial relationship(s) at 

the time of submission, and any disclosures must be updated 

by the authors prior to publication. Information that could be 

perceived as potential conflict(s) of interest must be stated. 

This information includes, but is not limited to, grants or 

funding, employment, affiliations, patents, inventions, 

honoraria, consultancies, royalties, stock options/ownership, 

or expert testimony. 

Article Categories 

The journal publishes the types of articles defined 

below. When submitting your manuscript, please follow the 

instructions relevant to the applicable article category. 

Original Research: Original, in-depth, clinical or 

basic science investigations that aim to change clinical 

practice or the understanding of a disease process. Article 

types include, but are not limited to, clinical trials, before-andafter 

studies, cohort studies, case-control studies, crosssectional 

surveys, and diagnostic test assessments. Components 

of original research are: 

• A title page, including the manuscript title and all authors’ 

full names, academic degrees (no more than three), 

institutional affiliations, and locations. Designate one 

author as the corresponding author. Also indicate where 

the paper was presented, if applicable. 

• A structured Abstract of up to 250 words with the headings: 

Introduction, Objective, Methods, Results, and Conclusion. 

• The Manuscript body should be divided as: introduction 

with objective(s); method; result; discussion; conclusion; 

references. 

• Manuscript length of no more than 24 pages (exclusive of 

the title page and abstract). There is no limit on references. 

• Studies involving human beings and animals should 

include the approval protocol number of the respective 

Ethics Committee on Research of the institution from 

which the research is affiliated. 

Systematic Reviews (including Meta-analyses): 

Critical assessments of literature and data sources on 

important clinical topics in otolaryngology-head and neck 

surgery. Systematic reviews that reduce bias with explicit 

procedures to select, appraise, and analyze studies are 

highly preferred over traditional narrative reviews. The 

review may include a meta-analysis, or statistical synthesis 

of data from separate, but similar, studies leading to a 

quantitative summary of the pooled results. The components 

of a systematic review are: 


full names, academic degrees, institutional affiliations, 

and locations. Designate one author as the corresponding 

author. Also indicate where the paper was presented, if 

applicable. 


Introduction, Objectives, Data Synthesis and Conclusion. 

• The Manuscript body should be divided as: introduction; 

review of literature; discussion; final comments; references. 



Case Reports: Report of a truly unique, highly relevant, 

and educationally valuable case. 


238





applicable. 


Introduction, Objectives, Resumed Report and Conclusion. 


review of literature with differential diagnosis; case report; 

discussion; final comments; references. 

• Manuscript length: no more 2 pages. 

• The Manuscript should include the approval protocol 

number of the respective Ethics Committee on Research of 

the institution from which the research is affiliated. 

In accordance with double-blind review, author/ 

institutional information should be omitted or blinded from 

the following submission files: Manuscript, Figure(s), Table(s), 

Response to Reviewers. 

The Abstract should be followed by three to six 

keywords in English, selected from the list of Descriptors 

(Mesh) created by National Library of Medicine and available 

on http://www.nlm.nih.gov/mesh/2013/mesh_browser/ 

MBrowser.html. 

Abbreviations: Do not use abbreviations in the title or 

abstract. When using abbreviations in the text, indicate the 

abbreviation parenthetically after the first occurrence and use 

the abbreviation alone for all subsequent occurrences. 

Update Manuscripts: The manuscript is an update 

that explores a particular subject, developed from current 

data, based on recently published works. 





applicable. 


Introduction, Objectives, Data Synthesis and Conclusion. 


review of a particular subject; discussion; final comments; 

references. 



Letters to the Editor and Opinion articles: Only by 

invitation from the Editorial Board. Manuscript length: no 

more 2 pages. 

Manuscript Preparation 

Correct preparation of the manuscript will expedite the 

review and publishing process. Manuscripts must conform to 

acceptable English usage. 

Necessary Files for Submission (each topic should start 

in a new page): 

• Title Page 

• Abstract 

• Manuscript (main text, references and figure legends) 

• Figure(s) (when appropriate) 

• Table(s) (when appropriate) 

Authorship: Authorship credit should be based on 

criteria established by the International Committee of Medical 

Journal Editors: 1) substantial contributions to conception 

and design, acquisition of data, or analysis and interpretation 

of data; 2) drafting the article or revising it critically for 

important intellectual content; and 3) final approval of the 

version to be published. 

References: Authors are responsible for the 

completeness, accuracy, and format of their references. 

References should be numbered consecutively as they are 

cited in Arabic numbers the text between parentheses. All 

authors shall be listed in full up to the total number of six; for 

seven or more authors, list the first six authors and add “et al.”. 

There should be no more than 90 references for Original 

Articles, 120 for Literature review or update articles and 15 for 

Case Report articles. Refer to the List of Journals Indexed in 

Index Medicus for abbreviations of journal names, or access 

the list at http://www.nlm.nih.gov/tsd/serials/lji.html. 

Sample references are given below. For more information, 

please check: http://www.ncbi.nlm.nih.gov/books/NBK7256. 

Examples: 

- Journals: Author | Article Title | Journal Title | 

Date of Publication | Volume Number | Issue Number | 

Pagination. 

Huttenhower C, Gevers D, Knight R, et al. Structure, 

function and diversity of the healthy human microbiome. 

Nature. 2012;486(7402):207-14. 

- Dissertations and Theses: Author | Title | Content 

Type | Place of Publication | Publisher | Date of Publication 

| Pagination. 

Baldwin KB. An exploratory method of data retrieval 


239

from the electronic medical record for the evaluation of 

quality in healthcare [dissertation]. Chicago: University of 

Illinois at Chicago, Health Sciences Center; 2004. 116 p. 

- Books: Author/Editor | Title | Edition | Place of 

Publication | Publisher | Date of Publication. 

Valente M, Hosford-Dunn H, Roeser RJ. Audiology 

treatment. 2nd ed. New York: Thieme; 2008. 

- Book chapters: Author of the chapter | Title of 

chapter | In: Editor(s) of book | Title of chapter | Place of 

Publication | Publisher | Date of Publication | Pagination. 

Vilkman, E. A survey on the occupational safety and 

health arrangements for voice and speech professionals in 

Europe. In: Dejonckere PH, editor. Occupational voice: Care 

and cure. Hague: Kugler Publications; 2001. p. 129-37. 

- Electronic material: for articles taken entirely from 

the Internet, please follow the rules above mentioned and add 

at the end the site address. 

Ex: AMA: helping doctors help patients [Internet]. 

Chicago: American Medical Association; c1995-2007 [cited 

2007 Feb 22]. Available from: http://www.ama-assn.org/. 

Figures: Figures must be uploaded separately. Include 

the number of the figure in the description box. 

Figure Legends: Provide a legend for each figure. List 

the legends (double-spaced) on a separate text page, after the 

reference page. Up to 8 pictures will be published at no cost 

to the authors; color pictures will be published at the editor’s 

discretion. Acceptable submissions include the following: 

JPG, GIF, PNG, PSD or TIF. The Publication Management 

System accepts only high definition images with the following 

features: 

· Width up to 1000 px and DPI equals or higher to 300; 

· The image formats should be preferentially TIF or JPG; 

· The maximum image size should be 8 MB; 

· If figures have multiple parts (e.g., A, B, C, D), each part must 

be counted as a separate image in the total number allowed. 

Tables and Graphs: tables should be numbered in 

Arabic numbers consecutively as they appear in the text, with 

a concise but self explicative title, without underlined elements 

or lines inside it. When tables bring too many data, prefer to 

present graphics (in black and white). If there are abbreviations, 

an explicative text should be provided on the lower margin of 

the table or graph. 

Appendices: Appendices will only be published 

online, not in the print journal, and may include additional 

figures or tables that enhance the value of the manuscript. 

Appendices must be submitted online with the rest of the 

manuscript and labeled as such. Questionnaires will be 

considered as Appendices. 

Online Manuscript Submission 

All the submission process should be done through 

the internet address http:// 

www.internationalarchivesent.org/sgp which gives access 

to our Manager Publication System (MPS), where the submission 

of the article is done by the authors and the evaluation process 

is done by the revisors of our editorial board in a process 

where the names of the authors are not displayed in any 

instance. When linked the system will ask for your user name 

and password in case you have already registered. On the 

contrary click on the link “Register” and make your registration. 

In case you have forgotten your password, click on the 

appropriate link and the system will generate an automatic e- 

mail with the information. 

The author(s)should keep a copy of all submitted 

material for publication, as the editor cannot be held responsible 

for any lost material. 

The submission is an eight steps process as listed 

below: 

1st Informing article classification 

2nd Sending images for your article 

3rd Registering co-authors 

4th Informing title and keywords 

5th Informing abstract and comments 

6th Preparing Manuscript 

7th Filling, signing and sending the Copyright and Conflicts 

of Interest form 

8th Author approval 

After submission, the system offers the option of 

saving a copy of your manuscript in PDF format for your 

control. 

The journal strongly recommends that the authors 

submit their electronic manuscripts written in Microsoft Word 

or Word Perfect. In the “Preparing Manuscript” step a screen 

that simulates the word processor will be displayed, where it 

is possible to “copy and paste”, including tables. 


240

Mandatory Author Forms 

Ethics, Financial Disclosure and Copyright Transfer 

Agreement: The manuscript will be assigned to an Editor for 

solicitation of peer review and editorial evaluation ONLY after 

this form has been submitted by the corresponding author. 

Patient Confidentiality 

For manuscripts containing photographs of a person, 

submit a written release from the person or guardian, or 

submit a photograph that will not reveal the person’s identity 

(eye covers are inadequate to protect patient identity). The 

journal has no standard patient consent form. 

Using Previously Published Material and 

Illustrations 

For manuscripts containing illustrations and/or material 

reproduced from another source, permission from the 

copyright holder, medical illustrator, or original publication 

source must be obtained and submitted to the editorial office. 

The journal has no standard permission form. 

Revised manuscripts must follow the same instructions 

and should be submitted within 30 days of the revision letter 

date. 

Accepted manuscripts sent to the publisher will be 

typeset and proofs will then be sent electronically to the 

corresponding author. If proofs are not approved and received 

within 2 business days, the article will not be published. 

The reviewers should send their comments within 20 

days. 

English Language Assistance 

Appropriate use of the English language is a requirement 

for publication in IAO. Authors who wish to improve the 

grammar and spelling in their articles may wish to consult a 

professional service. Many companies provide substantive 

editing via the web. A few examples are: 

· www.journalexperts.com 

· www.editage.com 

Please note that IAO has no affiliation with these 

companies and use of the service does not guarantee your 

manuscript will be accepted. 

IRB Policy and Animal Studies 

For all manuscripts reporting data from studies involving 

human participants, formal review and approval, or formal 

review and waiver (exemption), by an appropriate institutional 

review board (IRB) or ethics committee is required and should 

be described in the Methods section with the full name of the 

reviewing entity. All clinical research requires formal review, 

including case reports, case series, medical record reviews, 

and other observational studies. For experiments involving 

animals, state the animal-handling protocol in the Methods 

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Int. Arch. Otorhinolaryngol. 2013;17(3):242-245. 

DOI: 10.7162/S1809-97772013000300002 

Tympanomastoidectomy: Comparison between canal wall-down and canal 

wall-up techniques in surgery for chronic otitis media 

Alexandre Fernandes de Azevedo 1 , Anna Bárbara de Castro Soares 2 , Henrique Queiroz Correa Garchet 3 , 

Nicodemos José Alves de Sousa 4 . 

1) MD in Infectology at the Federal University of Minas Gerais. Assistant Doctor - Otolaryngology Clinic of Santa Casa B.H. 

2) Resident of Plastic Surgery at the Hospital Mater Dei. 

3) Resident of Otolaryingology at the Santa Casa B.H. 

4) M.D. in Otolaryngology at the Federal University of São Paulo. Honorary Chief of the Otolaryngology Clinic of Santa Casa B.H. 

Institution: Santa Casa of Belo Horizonte 

Belo Horizonte / MG - Brazil. 

Mailing address: Clínica de Otorrinolaringologia da Santa Casa de Belo Horizonte - Alexandre Fernandes de Azevedo - Rua Perdigão Malheiro, 195/ 501 - Cidade Jardim 

- Belo Horizonte / MG - Brazil - Zip code: 30380-050 - Telephone: (+55 31) 8863-8548 - E-mail: xandefa@hotmail.com 

Article received on September 2 nd , 2012. Article accepted on April 15 th , 2013. 

SUMMARY 

Introduction: Chronic otitis media (COM) is an inflammatory condition associated with otorrhea as well as large and persistent 

perforations of the tympanic membrane in some cases. COM can also lead to cholesteatoma. Surgical treatment with canal walldown 

and canal wall-up tympanomastoidectomy is considered for both types of illness. The choice of technique is controversial 

and is dependent on several factors, including the extent of disease. 

Objective: We aimed to evaluate surgical outcomes in COM patients with and without cholesteatoma treated with canal walldown 

and canal wall-up tympanomastoidectomy. Disease eradication and post-operative auditory thresholds were assessed. 

Method: Patient records from the otorhinolaryngology department of a tertiary hospital were assessed retrospectively. 

Results: Patients who underwent canal wall-up tympanomastoidectomy had a higher rate of revision surgery, especially those 

with cholesteatoma. However, there were no statistically significant differences in post-operative hearing thresholds between 

the two techniques. 

Conclusion: The canal wall-down technique is superior to the canal wall-up technique, especially for patients with cholesteatoma. 

Keywords: Chronic Disease; Otitis Media; Hearing Loss; Cholesteatoma, Middle Ear; Reoperation. 

INTRODUCTION 

Otitis media is defined as an inflammatory disease 

of the middle ear that may be infectious or not and focal 

or generalized. The course of disease may be acute with 

a tendency towards total resolution and a return to the 

integrity of the regions affected, or it may be chronic with 

permanent sequelae (1,2,3). 

Chronic otitis media (COM) is clinically characterized 

as an inflammatory condition associated with otorrhea and 

tympanic membrane perforation in some cases. The 

disease course is more than 3 months in duration and 

histopathologically it is associated with irreversible tissue 

changes. 

The incidence of COM is higher in less developed 

countries. Malnutrition, poor hygiene, poor quality 

housing, and high population density are factors that are 

associated with a higher incidence of middle ear infections 

(3,4). 

COM can be subdivided into two groups: 

cholesteatomatous chronic otitis media (CCOM) and 

chronic otitis media without cholesteatoma (COMWC). A 

central or marginal perforation may be present. The 

inflammatory process in the middle ear mucosa may show 

different stages of evolution. 

CCOM is characterized by epithelial accumulation 

with keratin production in the middle ear. Cholesteatoma 

may be classified as congenital or acquired, and is further 

categorized as primary or secondary cholesteatoma. Clinical 

and surgical treatments are available for COM. The first is 

reserved for COMWC when patient follow-up is possible. 

The surgical approach is suitable for both CCOM and 

COMWC and encompasses tympanoplasty, canal wall-up 

(CWU) and canal wall-down (CWD) mastoidectomy (1,5,6) 

and its variations, including modified radical mastoidectomy 

or Bondy’s procedure. The choice of technique remains 

controversial and is usually decided based on the presence 

or absence of cholesteatoma, its location, the state of the 

middle ear mucosa, and auditory thresholds. Recurrence and 

post-operative functional status vary between techniques. 

Int. Arch. Otorhinolaryngol., São Paulo - Brazil, v.17, n.3, p. 242-245, Jul/Aug/September - 2013. 

242

Tympanomastoidectomy: Comparison between canal wall-down and canal wall-up techniques in surgery for chronic otitis media. 

Azevedo et al. 

The aim of this study was to clarify which surgical 

technique provides the best outcomes in terms of disease 

control and improved hearing thresholds. 

METHOD 

This was a retrospective study of an historical 

cohort. The medical records of patients with COM who 

underwent a CWU or CWD mastoidectomy at the 

otorhinolaryngology department of a tertiary hospital 

between 1997 and 2005 were evaluated. 

Postoperative outcomes for the 2 techniques 

mentioned above were compared using control of the 

disease, absence of otorrhea, and cholesteatoma recurrence 

during the follow-up period, which was at least 24 months, 

as criteria. Pure tone average hearing thresholds at 500 Hz, 

1000 Hz, and 2000 Hz were also compared before and 

after surgery for both techniques. 

Statistical analyses were performed using the Chi 

square test, and p values



DISCUSSION 

Among the patients with COMWC, the disease 

control rate was 91.9%, regardless of the technique used, 

which is similar to the rates reported in other studies, which 

have ranged from 63% to 96% (7,8,9,10). Among the 

patients with CCOM, the disease control rate was 64.1%, 

which is slightly lower than previous reports, which have 

ranged from 75% to 90% (7,11,12,13). 

When the CWU technique was used, the disease 

control rate for the first surgery was 76.6%. In contrast, 

when the CWD technique was used, the disease control 

rate was 85.7%, regardless of the presence of cholesteatoma. 

Data in the literature are similar with reported values 

ranging from 71% to 95% for the CWU technique 

(9,11,14,15,16) and from 71% to 96% for the CWD 

technique (9,11,13,14,15,16). 

In the COMWC group, a higher rate of revision 

surgery was found among patients who underwent a CWD 

mastoidectomy (25%) compared with a CWU 

mastoidectomy (12.2%). This can be explained by the fact 

that patients with more severe disease were selected for 

CWD mastoidectomy. 

Of the patients with CCOM who underwent a CWU 

mastoidectomy, 57.9% required revision surgery whereas 

only 15% of those who underwent a CWD mastoidectomy 

required revision surgery. The current literature also shows 

higher recurrence rates when patients with cholesteatoma 

undergo a CWU mastoidectomy. Cruz et al. (2001) reported 

surgical revision rates of 37.5% and 26.08% when using the 

CWU and CWD techniques, respectively. We believe that 

in our study the higher rate of reoperation observed when 

preserving the canal wall is related to the longer follow-up 

(median 7.5 years), and suggests late complications of the 

disease, which are not uncommon when the CWU technique 

is used. 

The choice of technique remains controversial but 

this study, in agreement with the literature, has shown that 

cholesteatoma can be treated with the CWU technique. 

However, Bento et al. and Cruz et al. (14,5) suggest that 

criteria such as cholesteatoma restricted to the attic, good 

condition of the middle ear mucosa, and the possibility of 

good postoperative follow-up are required before the 

CWU technique is used. 

In this study, no statistically significant difference in 

pure tone average thresholds before and after surgery with 

either of the techniques. Because patients with less than 2 

years follow-up were excluded from the study, there was 

a considerable decrease in the number of individuals 

available for analysis, which hindered any robust analysis of 

this variable. In the literature we found many studies that 

reported better audiometric results when the CWU technique 

was used rather than the CWD technique (7,8,10,11,15,17). 

However, other studies have reported no significant 

differences in hearing outcomes in association with the two 

techniques (16). 

CONCLUSION 

The CWD technique and its various modifications 

results in better outcomes, especially when it comes to 

surgery to control CCOM. Some precautions facilitate a 

satisfactory functional outcome with better control of 

persistent otorrhea and greater certainty as to the 

eradication of cholesteatoma compared to CWU 

mastoidectomy. 

REFERENCES 

1. Costa SS, Dornelles CC, Netto LFS, Braga MEL. Aspectos 

gerais das otites médias. In: Costa SS, Cruz OLM, Oliveira 

JAA. Otorrinolaringologia Princípios e Prática. 2nd ed. São 

Paulo: Artmed; 2006. p. 254-73. 

2. Bluestone CD. Epidemiology and pathogenesis of 

chronicsuppurative otitismedia: implications for prevention 

and treatment. Int J Pediatr Otorhinolaryngol. 1998 

Jan;420:207-23. 

3. Azevedo AF, Pinto DCG, Souza NJA, Greco DB, Gonçalves 

DU. Perda auditiva sensório-neural na otite média crônica 

supurativa em pacientes com e sem colesteatoma. Braz J 

Otorhinolaryngol. 2007 Sep-Oct;73(5):671-4. 

4. Godinho RN, Goncalves TM, Nunes FB, et al. Prevalence 

and impact of chronicotitismedia in school age children in 

Brazil. First epidemiologic study concerning 

chronicotitismedia in Latin America. Int J Pediatr 

Otorhinolaryngol. 2001 Dec;61(3):223-32. 

5. Cruz OLM, Campos CAH. Cirurgia para a otite média 

crônica. Acta Otorrinolaringol. 2005;23(1):33-8. 

6. Roland PS, Isaacson B, Kutz JW. Office management of 

tympanic membrane perforation and the draining ear. In: 

Brackmann DE, Shelton C, Arriaga MA. Otologic Surgery. 

3rd ed. Philadelphia: Saunders Elsevier; 2010. p. 107-18. 

7. Segalla DK, Nakao LH, Anjos MF, Penido NO. Resultados 

cirúrgicos e audiológicos pós mastoidectomia em um serviço 

de Residência Médica. Acta Otorrinolaringol. 

2008;26(3):178-81. 


244



8. Vartianinen E, Nuutinen J. Long term hearing results of 

one stage tympanoplasty for chronic otitis media. Eur Arch 

Otorhinolaryngol. 1992;249(6):329-31. 

9. Veldman JE, Braunius WW. Revision surgery for chronic 

otitis media: a learning experience. Report on 389 cases 

with a long-term follow-up. Ann Otol Rhinol Laryngol. 1998 

Jun;107(6):486-91. 

10. Cruz OL, Kasse CA, Leonhart FD. Efficacy of surgical 

treatment of chronic otitis media. Otolaryngol Head Neck 

Surg. 2003 Feb;128(2):263-6. 

11. Cruz OLM, Kasse CA, Leonhardt FD. Eficácia do tratamento 

cirurgico da otite média crônica colesteatomatosa. Braz J 

Otorhinolaryngol. 2001 Mar-Apr;67(2):142-6. 

12. Cook JA, Krishnan S, Fagan PA. Hearing results following 

modified radical versus canalup mastoidectomy. Ann Otol 

Rhinol Laryngol. 1996 May;105(5):379-83. 

13. Chang CC, Chen MK. Canal-wall-down tympanoplasty 

with mastoidectomy for advanced cholesteatoma. J 

Otolaryngol. 2000 Oct;29(5):270-3. 

14. Bento RF, Rezende VA, Soares IP. Mastoidectomia: Estado 

atual da indicação cirúrgica do ponto de vista infeccioso. 

Braz J of Otorhinolaryngol. 2004 Apr-Jun;60(2):98-102. 

15. Harkness P, Brown P, Fowler S, Grant H, Ryan R, Topham 

J. Mastoidectomy audit: results of the Royal College of 

Surgeons of England comparative audit of ENT surgery. Clin 

Otolaryngol Allied Sci. 1995 Feb;20(1):89-94. 

16.Zhang X, Chen Y, Liu Q, Han Z, Xu A, Ding Y. Long-term 

results analysis of mastoidectomy for chronic otitis media. Lin 

Chuang Er Bi Yan Hou Ke Za Zhi. 2005 Oct;19(19):870-2. 

17. Murphy TP, Wallis DL. Hearing results in pediatric patients 

after canal-wall-up and canal-wall-down mastoid surgery. 

Otolaryngol Head Neck Surg. 1998 Nov;119(5):439-43. 


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DOI: 10.7162/S1809-97772013000300003 

Endoscopic surgery in the treatment of crista galli pneumatization evolving 

with localizated frontal headaches 

Jan Alessandro Socher 1 , Pedro Geisel Santos 2 , Vinicius Cidral Correa 3 , Leandro Caetano de Barros e Silva 3 . 

1) Doctor of Otolaryngology Faculty of Medicine, University of Sao Paulo. Professor of Otorhinolaryngology in FURB - Regional University of Blumenau. 

2) Otolaryngologist. 

3) Student of Medicine in FURB - Regional University of Blumenau. 

Institution: FURB - Regional University of Blumenau. 

Blumenau / SC – Brazil. 

Mailing address: Jan Alessandro Socher - Alameda Duque de Caxias, 145 - sala 306 - Bairro Centro – Zip code: 89015-010 - Blumenau / SC – Brazil - E-mail: 

jan_socher@yahoo.com.br 

Article received on November 19 th , 2012. Article accepted on March 19 th , 2013. 

SUMMARY 

Introduction: The crista galli is part of the ethmoid bone and thus may suffer from the process of pneumatization. Pneumatization 

occurs in between 3% and 14% of patients, resulting from air cells in the frontal or ethmoid sinuses. 

Aim: To describe 3 cases of crista galli pneumatization in which the patients developed infection and were treated surgically 

by endoscopic techniques. 

Method: We present 3 case studies of patients complaining of severe frontal headaches. The patients underwent ENT evaluation, 

examination by video-endoscopy, and computed tomography, which identified crista galli pneumatization with mucosal thickening 

and the presence of fluid. Patients underwent treatment with antibiotics and corticosteroids; however, they showed no symptomatic 

improvement, displayed recurrence of symptoms, and maintained radiographic changes. Thus, patients then underwent drainage 

through the crista galli via an endoscopic procedure. 

Discussion: During surgery, mucopurulence and/or mucosal thickening and edema were identified in the pneumatized crista 

galli. There were no complications during or after surgery. Postoperatively, headache was improved in patients after a minimum 

follow-up of 6 months. 

Conclusion: Crista galli pneumatization can result in infection, simulating rhinosinusitis. When there is little response to drug 

therapy, endoscopic surgical treatment is required; the current cases demonstrate that this technique is safe and effective. 

Keywords: Natural Orifice Endoscopic Surgery; Video-Assisted Surgery; Headache. 

INTRODUCTION 

The crista galli lies on the midline of the cribriform 

plate. The falx cerebri attaches anteriorly tothis bone 

formation a thin posterior border and slightly curve , and 

the anterior border is attached to the frontal bone completing 

the margin of the foramen cecum. The crista galli is 

embryologically derived from the ethmoid bone (1). 

Regarding pneumatization of the crista galli, 2 theories are 

valid: pneumatization can originate from the ethmoid sinus 

or the frontal sinus. The oldest theory in which the 

pneumatization result from the ethmoid sinus is based on 

the embryological origin of the crista galli, the ethmoid 

bone, and states that the displacement of ethmoidal air 

cells would lead to increased aeration of the crista galli 2 . In 

the theory explaining pneumatization by the frontal sinus, 

sinus extension is likely to cause increased aeration beyond 

the normal margin of the frontal bone (3). The incidence 

of crista galli pneumatization has been reported to be 

between 2.8% and 14.1%, depending on the population 

studied (2,4,5). The possibility of involvement of 

inflammatory and/or infectious processes in pneumatization 

of the crista galli is a noteworthy finding; however, such 

involvement is very rare since there are no reports of it in 

the literature. 

AIM 

The aim of this study was to describe 3 cases where 

crista galli pneumatization evolved into inflammation and 

infection and was treated surgically by endoscopic 

techniques. 

CASE STUDY #1 

A 57-year-old female patient sought advice from 

the Specialized Service in Otolaryngology in June 2008, 

complaining of a frontal headache that had been present 

for the last year. The patient reported previous drug 

treatments for sinusitis including azithromycin for 5 days, 

amoxicillin for 10 days, and a combination of amoxicillin 


246

Endoscopic surgery in the treatment of crista galli pneumatization evolving with localizated frontal headaches. 

Socher et al. 

Figure 1. Preoperative coronal section CT scan showing crista 

galli pneumatization with mucosal thickening. 

Figure 2. Video-endoscopic visualization of the left nasal 

cavity showing the septal incision site and opening of the 

bone wall of the pneumatized crista galli. SEPTO = nasal 

septum; CM = middle turbinate; CI = inferior turbinate. 

and clavulanate potassium for 10 days. However, she 

always experienced recurrence and progressive worsening 

of her symptoms. Examination with video-endoscopy 

showed hypertrophy of the lower and middle turbinates 

bilaterally associated with septal deviation in the left nasal 

cavity. A computed tomography (CT) scan of the paranasal 

sinuses and nasal cavity in the axial, coronal, and sagittal 

planes with a bone window of 2500–3500 rads was 

requested, which identified pneumatization of the crista 

galli with mild mucosal thickening in the interior (Figure 1). 

This finding indicated endoscopic surgery through the 

transseptal approach in the left nasal cavity for drainage 

and cleaning of the pneumatized crista galli (Figure 2). 

CASE STUDY #2 

A 35-year-old female patient sought advice from 

the Specialized Service in Otolaryngology in August 2010, 

complaining of a localized headache, cacosmia, and nasal 

obstruction with progressive worsening of her symptoms 

during the previous 6 months. Her symptoms had remained 

after drug treatment with amoxicillin and clavulanate 

potassium for 10 days. Video-endoscopy showed a deviated 

septum and inferior turbinate hypertrophy. A CT scan of 

the paranasal sinuses and nasal cavity in the axial, coronal, 

and sagittal planes with a bone window of 2500–3500 rads 

was requested, which identified pneumatization of the 

crista galli apophysis with signs of mucosal thickening and 

obliteration interiorly. We introduced antibiotic treatment 

(levofloxacin at a dose of 500 mg/day) for 14 days, 

corticosteroids (prednisone at a dose of 40 mg/day) for 7 

days, and symptomatic analgesia. The patient’s symptoms 

Figure 3. Coronal CT section showing mucosal thickening 

and obliteration of the pneumatized crista galli. 

improved temporarily, but 5 days after treatment with 

antibiotics was stopped, recurrence of her symptoms 

occurred. A second CT scan of the paranasal sinuses and 

nasal cavity showed the maintenance of mucosal thickening 

and obliteration within the crista galli (Figure 3). Endoscopic 

surgery by a transseptal approach through the right nostril 

was indicated for drainage and cleaning of the pneumatized 

crista galli (Figures 4-7). 


247


Socher et al. 

Figure 4. Intraoperative endoscopic visualization of the right 

nasal cavity showing septal incision and detachment. 

SEPTO = nasal septum; CM = middle turbinate. 


nasal cavity demonstrating septal resection to allow approach 

to the bone wall of the pneumatized crista galli. 



nasal cavity showing transseptal opening of the bone wall of 

the pneumatized crista galli. 



nasal cavity demonstrating the detail of opening of the 

pneumatized crista galli, the lining of which shows mucosal 

thickening and edema. 

CASE STUDY #3 

A 31-year-old male patient sought advice from the 

Specialized Service in Otolaryngology in April 2012, with 

the complaint of chronic nasal obstruction that had been 

present since childhood and was associated with the 

symptoms of congestion, rhinorrhea, and facial pain 

localized in the frontal region for the last 3 months. He had 

shown no improvement after 2 previous episodes of 

treatment with antibiotics (levofloxin and amoxicillin 

lasting 10 days and 14 days, respectively). He also 

reported a history of adenoidectomy surgery prior to the 

age of 5. Video-endoscopic examination identified the 

presence of septal deviation in the left nasal cavity 

associated with mild inferior and right middle turbinate 

hypertrophy as well as hypertrophy of lymphoid tissue in 

the nasopharynx. A sinus and nasal cavity CT scan in the 

axial, coronal, and sagittal planes was requested, which 

identified septal deviation with bone spur formation, 

prominence of the soft parts of the cavum, and 

pneumatization of the crista galli with significant mucosal 

thickening and fluid present within (Figure 8). The 

patient underwent surgical resection of the lymphoid 

tissue present in the nasopharynx and transseptal 

endoscopic drainage of the pneumatized crista galli. 


248


Socher et al. 

another 6 months thereafter. These follow-ups ensured 

maintenance of the patency of the crista galli through 

video-endoscopic examinations. After 6 months, the patients 

were advised to return annually or if there was a need. 

The collected material was sent for bacterial and 

fungal culture, but the results were inconclusive, which can 

be explained by use of antibiotics prior to surgery. The use 

of different antibiotics prescribed based on clinical criteria 

for sinusitis was common in the history of all the patients 

prior to surgery. However, the use of antimicrobial agents 

was apparently unsuccessful in treating this condition, in 

view of the maintenance or recurrence of symptoms in all 

patients. 

Figure 8. Coronal CT section showing mucosal thickening 

and fluid within the pneumatized crista galli. 

DISCUSSION 

Most studies on the crista galli in the literature are 

anatomical descriptions from surveys of series of CT scans 

or findings obtained during access to the anterior skull base 

using endoscopic surgery (1-5). There is a predominance 

in the study of pneumatization of the crista galli in females, 

with a ratio of 2 females:1 male between the ages of 31 and 

57 years. However, reports on pneumatization of the crista 

galli related to the complaint of headache were not found 

in the literature, and neither was evidence of the possibility 

of infection from such pneumatization. 

In the present study, it was possible to access 

pneumatization of the crista galli and confirm the findings 

of CT scans showing signs of inflammation and/or infection 

in all 3 cases by using a transseptal endoscopic approach. 

In the first patient, mucosal thickening and edema was 

identified, while the second and third cases were associated 

with purulent drainage and identification of mucosal 

thickening and edema within the pneumatized crista galli. 

There were no transoperative or postoperative 

complications. However, it is important to note that good 

knowledge of the field of endoscopic technique and the 

anatomy of this region is essential, especially areas near the 

crista galli such as the cribriform plate and other structures 

of the anterior skull base. Patients were discharged on the 

same day as surgery, about 8 hours after operation. 

Antibiotics (oral levofloxacin at a dose of 500 mg/day for 

10 days in the first case and oral clindamycin at a dose of 

900 mg/day for 10 days in the other cases) plus 

corticosteroids (oral prednisone at a dose of 40 mg/day for 

7 days) were administered. Postoperative follow-ups were 

performed weekly during the first month and monthly for 

The findings of video-endoscopy examinations were 

nonspecific and did not contribute significantly to the 

diagnosis of these cases. The suspected inflammation and/ 

or infection within the pneumatized crista galli were only 

confirmed by CT scan. 

In all cases, pathological results confirmed the 

presence of fragments of upper airway tract mucosa that 

were lined by pseudostratified ciliated epithelium resting 

on corium and contained a discrete amount of mononuclear 

inflammatory cells and eosinophils, which is characteristic 

of chronic inflammation of the respiratory mucosa contained 

inside the crista galli. Furthermore, pathological examination 

in the third patient confirmed the presence of lymphoid 

tissue in the nasopharynx that had no signs of malignancy 

and was compatible with pharyngeal tonsil. 

The patients complained of transient postoperative 

nasal obstruction and hyposmia/anosmia, but showed 

improvement of symptoms and had no recurrence during 

a clinical monitoring period of 3 years in the first patient, 

1 year and 6 months in the second patient, and 6 months 

in the third patient. 

CONCLUSION 

Pneumatization of the crista galli may be complicated 

by inflammatory and/or infectious processes simulating 

rhinosinusitis and shows little response to drug therapy, 

thus requiring endoscopic surgical treatment. In the current 

cases, such treatment was demonstrated to be safe and 

effective. 

REFERENCES 

1. Som PM, Park EE, Naidich TP, Lawson W. Crista Galli 

Pneumatization Is an Extension of the Adjacent Frontal 

Sinuses. AJNR Am J Neuroradiol. 2009;30:31–3. 


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Socher et al. 

2. Hajiioannou J, Owens D, Whittet HB. Evaluation of 

anatomical variation of the crista galli using computed 

tomography. Clin Anat. 2010;23(4):370-3. 

3. Miranda CMNR, Maranhão COM, Arraes FMNR, Padilha 

IG, Farias LPG, Jatobá MAS, Andrade ACM, Padilha BG. 

Variações anatômicas das cavidades paranasais à tomografia 

computadorizada multislice: o que procurar? Radiol Bras. 

2011;44(4):256-62. 

4. Dutra LD, Marchiori E. Tomografia computadorizada 

helicoidal dos seios paranasais na criança: avalização das 

sinusopatias inflamatórias. Radiol Bras. 2002;35(3):161–9. 

5. Lee JM, Ransom E, Lee JYK, Palmer JN, Chiu AG. 

Endoscopic Anterior Skull Base Surgery: Intraoperative 

Considerations of the Crista Galli. Skull Base. 2011;21(2):83- 

6. 


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DOI: 10.7162/S1809-97772013000300004 

Velopharyngeal dysfunction: a systematic review of major instrumental 

and auditory-perceptual assessments 

Lauren Medeiros Paniagua 1 , Alana Verza Signorini 2 , Sady Selaimen da Costa 3 , Marcus Vinicius Martins Collares 4 , 

Sílvia Dornelles 5 . 

1) Speech Language Pathologist. Doctor of Science in Children’s and Teenager’s Health- Universidade Federal do Rio Grande do Sul-UFRGS. Professor of Speech-Language 

Pathology at Fatima College (RS). 

2) Undergraduate Speech Pathology Fellow - Universidade Federal do Rio Grande do Sul - UFRGS. Undergraduate fellow of CNPq. 

3) MD; MSc; PhD. Associate Professor - Department of Otolaryngology & Head and Neck Surgery/School of Medicine Universidade Federal do Rio Grande do Sul. 

4) MD; PhD. Associate Professor - Department of Surgery; Head, Plastic Surgery Section - School of Medicine /Universidade Federal do Rio Grande do Sul. 

5) Speech Pathology, MSc, PhD. Professor - Department of Speech Pathology/ Universidade Federal do Rio Grande do Sul. 

Institution: Universidade Federal do Rio Grande do Sul (UFRGS). 

Porto Alegre / RS - Brazil. 

Mailing address: Lauren Medeiros Paniagua - Universidade Federal do Rio Grande do Sul (UFRGS) - Avenida João Wallig 1705/627 – Porto Alegre / RS - Brazil - Zip Code: 

91340-001 - E-mail: lmedeirospaniagua@yahoo.com.br 

Article received on December 2 nd , 2012. Article accepted on April 15 th , 2013. 

SUMMARY 

Introduction: Velopharyngeal dysfunction may cause impaired verbal communication skills in individuals with cleft lip and 

palate; thus, patients with this disorder need to undergo both instrumental and auditory-perceptual assessments. 

Objective: To investigate the main methods used to evaluate velopharyngeal function in individuals with cleft lip and palate 

and to determine whether there is an association between videonasoendoscopy results and auditory-perceptual assessments. 

Method: We conducted a systematic review of the literature on instrumental and auditory-perceptual assessments. We searched 

the PubMed, Medline, Lilacs, Cochrane, and SciELO databases from October to November 2012. 

Summary of findings: We found 1,300 studies about the topic of interest published between 1990 and 2012. Of these, 56 studies 

focused on velopharyngeal physiology; 29 studies presented data on velopharyngeal physiology using at least 1 instrumental 

assessment and/or 1 auditory-perceptual assessment, and 12 studies associated the results of both types of assessments. Only 

3 studies described in detail the analysis of both methods of evaluating velopharyngeal function; however, associations between 

these findings were not analyzed. 

Conclusion: We found few studies clearly addressing the criteria chosen to investigate velopharyngeal dysfunction and associations 

between videonasoendoscopy results and auditory-perceptual assessments. 

Keywords: Cleft Palate; Communication Disorders; Velopharyngeal Sphincter 

INTRODUCTION 

The velopharyngeal mechanism relies on the action 

of the velopharyngeal sphincter to control the distribution 

of voiced and voiceless airstream in both the oral cavity and 

the nasal cavity. Individuals with an impaired velopharyngeal 

mechanism will develop velopharyngeal dysfunction 

(VPD), which may compromise the verbal communication 

skills of patients with an intact velopharyngeal sphincter 

(VPS). One of the consequences of such dysfunction is 

hypernasality, which has a great impact on the individuals 

with this condition. 

Hypernasality induces nasal resonance in sounds 

that should not have this characteristic in articulate speech. 

This is caused by excessive nasal air emissions and weak 

intraoral pressure for some sounds. Nasal air escape and 

hypernasality are typical of VPD. Hypernasality is a 

resonance alteration that affects the emission of vowel 

sounds, whereas nasal air escape is a change in speech 

articulation that hinders the production of high pressure 

consonants such as plosives and fricatives (1). 

Several methods for evaluating the VPS have been 

designed. The choice of a specific evaluation method is 

directly related to the focus of interest of a clinical 

investigation and its need for accuracy. The use of 1 

auditory-perceptual assessment and at least 1 instrumental 

assessment is recommended for the analysis of 

velopharyngeal function (2, 3). 

Auditory-perceptual assessment is the main method 

for detecting possible changes in speech nasality, and 

provides data on the function of velopharyngeal structures 

during speech production. That is, this evaluation method 

makes it possible to detect specific symptoms of cleft 

palate that may or may not be associated with VPD (4, 5, 

6, 7). Because auditory-perceptual assessment is easily 

performed, it is the most commonly used evaluation 


251

Velopharyngeal dysfunction: a systematic review of major instrumental and auditory-perceptual assessments. 

Paniagua et al. 

method in clinical practice (8, 9). Analysis of the test results 

has been widely discussed in the literature because of a 

lack of uniformity in the protocols used by researchers and 

institutions, which makes it difficult to compare study 

results (2). 

Videonasoendoscopy shows dynamic, direct, and 

natural images of the anatomical structures of the nasal 

cavity, pharynx, and larynx; this imaging method is thus 

one of the most appropriate tools for assessment of the VPS 

(10). Velopharyngeal closure patterns and the presence of 

a velopharyngeal gap (i.e., a residual opening during 

maximum contraction of the VPS) can be detected during 

performance of the test. Such patterns can also be identified 

during speech production, including the characteristics and 

degree of movement of the soft palate and pharyngeal 

walls (11, 12, 13). 

Based on both the literature and clinical practice, it 

is possible to state that the anatomy and physiology of the 

velopharyngeal mechanism are complex. Velopharyngeal 

dysfunctions that impair oral communication skills because 

of hypernasality, nasal air escape, and other disorders can 

be detected in individuals with cleft lip and palate. Therefore, 

the objective of the present review was to investigate the 

main methods used to evaluate the velopharyngeal function 

in individuals with cleft lip and palate, and to determine 

whether there is an association between 

videonasoendoscopy results and auditory-perceptual 

assessments. 

METHOD 

A systematic review of the literature is aimed at 

providing answers to specific questions and is based on 

clear and systematic methods in order to identify, select, 

and critically evaluate studies that may meet the proposed 

objective (14, 15). In order to perform the present systematic 

review of the literature, we searched studies conducted in 

different countries addressing the types of assessments 

used to describe the velopharyngeal function in individuals 

with surgically repaired cleft lip and palate. The following 

research questions were proposed: What are the main 

methods of velopharyngeal function assessment used in 

individuals with cleft lip and palate and how are the 

findings analyzed by the examiner? Is there an association 

between videonasoendoscopy results and auditoryperceptual 

assessments? 

We searched the PubMed, Medline, Lilacs, Cochrane, 

and SciELO databases from October to November 2012. 

The same search strategy was used for all databases. Our 

search strategy included only manuscripts published 

between 1990 and 2012. This period was selected based 

on the fact that videonasoendoscopy first appeared in the 

literature in 1990. First, we selected the keywords to search 

the databases considering our research questions. The 

following keywords were used alone and in combination 

with the other terms: “cleft palate,” “velopharyngeal closure,” 

“velopharyngeal insufficiency,” “velopharyngeal 

dysfunction,” “compensatory articulation,” 

“videonasoendoscopy,” “assessment and hypernasality,” 

“velopharyngeal mechanism,” “hypernasality,” and 

“speech.” 

The abstracts and titles of the manuscripts were 

selected by 2 researchers who worked independently. A 

reviewer resolved potential discrepancies of opinion. The 

full text of all potentially relevant manuscripts was obtained 

and analyzed separately by 2 reviewers based on the 

following inclusion criteria: (1) involved adults or children 

with cleft lip and palate; (2) included at least 1 

videonasoendoscopy and 1 auditory-perceptual assessment 

for screening of VPD; (3) described the methods and 

criteria used for the analysis of the velopharyngeal functional 

assessment results. Studies on cleft lip and palate focused 

on audiological findings, classification of different cleft 

types, and surgical interventions were excluded. Finally, 2 

researchers who specialize in the area of interest in the 

present study revised the selection of manuscripts with the 

purpose of refining the results. 

RESULTS AND DISCUSSION 

Considering the objective of the present review of 

the literature, our search of the previously mentioned 

scientific databases retrieved 1,300 manuscripts on 

velopharyngeal dysfunction in individuals with cleft lip and 

palate. Of these, 56 studies addressing velopharyngeal 

physiology were selected. Among these studies, there 

were 29 studies including data about auditory-perceptual 

assessment, some of which were associated with other 

instrumental assessments. We selected 12 studies that 

found an association between instrumental assessments 

(videonasoendoscopy and other tests) and auditoryperceptual 

assessment. Of these, 6 studies used 

videonasoendoscopy and auditory-perceptual assessment 

to evaluate velopharyngeal function. We refined our search 

in accordance with the objective of the present review and 

found only 3 studies that included an explanatory description 

of the analysis of both types of assessments. 

The characteristics of each study included in this 

review are shown in Table 1. The 12 studies selected were 

conducted in 4 different countries, including Brazil. These 

studies involved patients with different types of cleft lip 

and palate, including submucous cleft. Their age ranged 

from 3 to 76 years (Table 1). 


252



Table 1. Characteristics of the study. 

Author Country Type of cleft Age group 

Araújo Netto & Cervantes, 2011 Brazil CLP, CP 4–19 years old 

Trindade et al., 2004 Brazil CLP, SCP NA 

Chanchareonsook et al., 2007 China CP 12–18 years old 

Kao et al., 2008 United States CP, SCP 7–11 years old 

Marsh, 2009 India CP, CLP NA 

Miguel et al., 2004 Brazil SCP, SCLP 6–46 years old 

Nagarajan et al., 2009 India CLP, CP NA 

Penido et al., 2007 Brazil CP 8–34 years old 

Qui Chen et al., 2011 United States SCP, CP 1–34 years old 

Camargo et al., 2001 Brazil NA 6–76 years old 

Shprintzen and Marrinan, 2009 United States NA NA 

Shyammohan et al., 2010 India NA NA 

Source: The authors 

CLP = cleft lip and palate 

CP = cleft palate 

SCP = submucuous cleft palate 

SCLP = submucous cleft lip and palate 

NA = not available 

Table 2. Tools used in the study. 

Authors Direct instrumental Indirect instrumental Clinical evaluation 

assessment 

assessment 

Araújo Netto & Cervantes, 2011 videonasoendoscopy Not used Auditory-perceptual assessmentl 

Trindade et al., 2004 Not used Not used Auditory-perceptual assessment 

Chanchareonsook et al., 2007 nasoendoscopy nasometry Auditory-perceptual assessment 

Kao et al., 2008 nasoendoscopy Not used Auditory-perceptual assessment 

Marsh, 2009 videonasoendoscopy Not used Auditory-perceptual assessment 

Miguel et al., 2004 videonasoendoscopy nasometry/PERCI-SARS Auditory-perceptual assessment 

Nagarajan et al., 2009 Videonasoendoscopy and nasometry Auditory-perceptual assessment 

videofluoroscopy 

Penido et al., 2007 nasopharyngoscopy Not used Nasal air emission test 

Qui Chen et al., 2011 lateral cephalogram of Not used Auditory-perceptual assessment 

nasopharyngography and 

nasopharyngeal fiberscope 

Camargo et al, 2001 nasoendoscopy Not used Auditory-perceptual assessment 

focused on nasal air emission 

Shprintzen e Marrinan, 2009 Nasopharyngoscopy and MRI nasometry Not used 

Shyammohan et al, 2010 Not used Not used Auditory-perceptual assessment 

Source: The authors. 

Detailed descriptions of both types of assessment 

and the parameters used for the analysis of the results of 

these 12 studies are shown in Table 2. The direct instrumental 

assessments used in these studies included 

videofluoroscopy, magnetic resonance imaging (MRI), 

nasopharyngeal fibroscopy, videonasoendoscopy, 

nasopharyngoscopy, and nasoendoscopy. Despite the 

different terms used, the last 4 assessments consisted of the 

same type of test performed with the purpose of viewing 

the velopharyngeal mechanism. The indirect instrumental 

assessments mentioned in these studies were nasometry 

and the PERCI-SARS system. The methods of clinical 

evaluation used in most studies were auditory-perceptual 

assessments and nasal airflow measurements. Such tests 

were analyzed according to the specific protocols of each 

institution. The analysis parameters for each type of 

instrumental assessment and auditory-perceptual 

assessment differed for each study (Table 2). 

Our decision to conduct a systematic review with 

the previously mentioned objective was prompted by a 

problem faced by health professionals who provide clinical 

care to patients with cleft lip and palate, that is, the impact 

of VPD on these patients’ verbal communication skills. 


253



Discrepancies in findings relating to speech nasality and 

the degree of velopharyngeal closure are common in 

clinical practice. Clinical reports of verbal communication 

based on auditory-perceptual assessments reveal situations 

where the examiners detect severe hypernasality and, 

conversely, videonasoendoscopy shows a small 

velopharyngeal gap. Inversely proportional situations also 

occur when a large gap has little impact on nasality. Thus, 

the association between the clinical and instrumental 

evaluations is very important for achieving a clinical 

conclusion as to the real condition of the velopharyngeal 

mechanism. Even though we are aware that the 

pathophysiology of the velopharyngeal sphincter is 

complex and involves a variety of biases produced by the 

patient or the examiner, we searched for studies addressing 

this issue (i.e., the association between the size of the gap 

and the impact on nasality) in a straightforward manner. 

Therefore, the 3 studies selected are discussed further in an 

attempt to determine significant aspects related to the 

velopharyngeal mechanism and nasality. It is noteworthy 

that the specific association of interest in the present 

review was not explained by any of these studies, revealing 

the scarcity of scientific literature on the topic (Figure 1). 

While investigating this topic, Marsh (2009) addressed 

the velopharyngeal closure and provided a description of 

videonasoendoscopy and auditory-perceptual assessment 

in a study involving patients with cleft palate. Marsh suggested 

a classification of the residual gap in the VPS closure using 

different closure patterns during speech production, and 

considers investigation of the VPS closure pattern and 

analysis of lateral pharyngeal wall movement essential for 

establishing the diagnosis of VPD. Although there is no direct 

association between findings of nasality, audible nasal air 

emission, and the classification proposed, analysis of these 

findings does facilitate clinical surgical intervention. 

Qi Chen et al. (2011) used analysis of the lateral 

pharyngeal wall movement as a diagnostic criterion for 

VPS, considering that most patients without nasality and 

audible nasal air emission have sagittal closure. This study 

included 276 individuals aged 6 to 12 years. Despite 

considering factors such as surgical age and technique, Qi 

Chen et al. and Marsh both highlight the role played by 

lateral wall movement in satisfactory functioning of the 

VPS, and the consequences and impact on nasality. 

With the purpose of demonstrating an association 

between audible nasal air emission and VPS closure pattern 

shown by videonasoendoscopy, Penido et al. (2007) found 

a valid association between these aspects by means of 

comparison. These authors described the reliability of the 

correlation between the Glatzel mirror test using nasal air 

escape and VPS closure pattern in 21 individuals with cleft 

lip and palate whose mean age was 17 years. Based on 

Figure 1. Logistics associated with the systematic review. 

videonasoendoscopy, the size of the gap was categorized 

as small, medium, or large. This study demonstrated that 

the nasal air emission test is useful for evaluating the 

function of the velopharyngeal mechanism, and for 

establishing a direct relationship between the size of the 

gap and the area of condensation on the mirror. It is worth 

noting that these authors found divergent behaviors of the 

velopharyngeal mechanism considering the nasal air escape 

expected in an individual from this sample. 

CONCLUSIONS 

In the present systematic review of the literature we 

identified different evaluation methods used for determining 


254



velopharyngeal function. However, we found few studies 

that showed both the detailed criteria chosen to analyze 

the results of the assessments and the association between 

videonasoendoscopy results and auditory-perceptual 

assessments. Only 1 study demonstrated an association 

between findings of VPD assessed using 

videonasoendoscopy and the severity of audible nasal air 

escape evaluated by auditory-perceptual assessment. 

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DOI: 10.7162/S1809-97772013000300005 

Results obtained with a low cost software-based audiometer for hearing 

screening 

Deborah Viviane Ferrari 1 , Esteban Alejandro Lopez 2 , Andrea Cintra Lopes 3 , Camila Piccini Aiello 4 , Pricila Reis Jokura 5 . 

1) PhD in Neuroscience and Behavior - Institute of Psychology, University of São Paulo. Professor, Department of Speech Language Pathology and Audiology. Dentistry 

School of Bauru - University of São Paulo. 

2) Clinical Engineer. Master in Biomedical Engineering - Favaloro University, Buenos Aires, Argentina. Favaloro University, Buenos Aires, Argentina. 

3) PhD in Communication Disorders - University of São Paulo. Associate Professor, Department of Speech Language Pathology and Audiology. Dentistry School of Bauru 

- University of São Paulo. 

4) Speech Language Pathologist and Audiologist. Graduate Student - Master in Speech Language Pathology and Audiology. Dentistry School of Bauru - University of 

São Paulo. 

5) Speech Language Pathologist and Audiologist. Graduate Student - Master in Speech Language Pathology and Audiology. Dentistry School of Bauru - University of 

São Paulo. 

Institution: Departamento de Fonoaudiologia. Faculdade de Odontologia de Bauru - USP. 

Bauru / SP - Brazil. 

Mailing address: Faculdade de Odontologia de Bauru – USP. Deborah Viviane Ferrari Al. Octávio Pinheiro Brisola 9-75. Vila Universitária - Bauru / SP – Brazil - Zip code: 

17012-901. E-mail: deborahferrari@usp.br 

Article received on December 10 th , 2012. Article accepted on April 7 th , 2013. 

SUMMARY 

Introduction: The implementation of hearing screening programs can be facilitated by reducing operating costs, including the 

cost of equipment. The Telessaúde (TS) audiometer is a low-cost, software-based, and easy-to-use piece of equipment for 

conducting audiometric screening. 

Aim: To evaluate the TS audiometer for conducting audiometric screening. 

Methods: A prospective randomized study was performed. Sixty subjects, divided into those who did not have (group A, n 

= 30) and those who had otologic complaints (group B, n = 30), underwent audiometric screening with conventional and TS 

audiometers in a randomized order. Pure tones at 25 dB HL were presented at frequencies of 500, 1000, 2000, and 4000 Hz. 

A “fail” result was considered when the individual failed to respond to at least one of the stimuli. Pure-tone audiometry was 

also performed on all participants. The concordance of the results of screening with both audiometers was evaluated. The 

sensitivity, specificity, and positive and negative predictive values of screening with the TS audiometer were calculated. 

Results: For group A, 100% of the ears tested passed the screening. For group B, “pass” results were obtained in 34.2% (TS) 

and 38.3% (conventional) of the ears tested. The agreement between procedures (TS vs. conventional) ranged from 93% to 98%. 

For group B, screening with the TS audiometer showed 95.5% sensitivity, 90.4% sensitivity, and positive and negative predictive 

values equal to 94.9% and 91.5%, respectively. 

Conclusions: The results of the TS audiometer were similar to those obtained with the conventional audiometer, indicating 

that the TS audiometer can be used for audiometric screening. 

Keywords: Hearing; Hearing Loss; Hearing Tests. 

INTRODUCTION 

Hearing loss is among the three most prevalent 

conditions worldwide, with around 636.5 million people 

suffering from a certain degree of hearing loss (1). It is 

estimated that in Brazil, 6.8% of the population suffers from 

disabling hearing loss, i.e., a hearing threshold level for the 

better ear of 41 dB HL or greater, averaged at frequencies 

of 0.5, 1, 2, and 4 kHz. Of these individuals, 5.3% are 

children between 4 and 9 years old, 36.2% are elderly, and 

19.5% are adults between 20 and 59 years old (2). In the 

state of São Paulo, a population-based study showed that 

the prevalence of hearing loss was 44%, being higher for 

elderly male individuals (3). A population-based crosssectional 

study performed in Rio de Janeiro showed that, 

for the elderly, the prevalence of hearing loss in the better 

ear was 42.9% (4). 

Hearing loss can hinder or even impede acquisition 

and development of oral language, as well as academic and 

social development in children. In addition, it can decrease 

the quality of life and work and educational opportunities of 

adult individuals. This condition also has an impact on society 

in terms of loss of productivity of affected individuals as well 

as costs of treatment, education, and rehabilitation of people 

with special needs. Thus, healthcare actions focused on 

prevention, early identification, and treatment of hearing 

problems also have social and economic implications. 

The Brazilian National Health System (Sistema Único 

de Saúde, SUS) has incorporated the treatment of the 


257

Results obtained with a low cost software-based audiometer for hearing screening. 

Ferrari et al. 

hearing impaired in previous decades. Such action was 

supplemented by the establishment of the National Hearing 

Healthcare Policy in 2004 (5) and, more recently, by the 

Care Network for People with Disabilities within the SUS 

(6). This network is organized into the components of 

primary care, specialized rehabilitation care, and emergency 

hospital care. Primary care services are provided through 

Healthcare Basic Units (UBS), which prioritize certain 

strategic actions intended to enhance access for and 

attention to people with disabilities, including the promotion 

of early identification services. 

In Brazil, newborn universal hearing screening has 

been enforced by law since 2010 (7). However, progressive 

or late onset hearing losses are not detected at birth. It is 

estimated that 9–10 out of 1000 school aged children have 

permanent hearing loss in at least one ear (8). The Health 

in School Program (PSE), initiated in 2007 as a joint action 

between the Ministries of Health and Education, aims to 

incorporate the school community into projects and 

programs that make use of healthcare and education in 

order to comprehensively deal with the issues that 

compromise the development of Brazilian children and 

teenagers. The primary task of the PSE is the assessment 

of the health condition of students, including hearing status. 

In order to do so, audiometric procedures, among others, 

are recommended (9). 

For adults and the elderly, hearing loss onset is often 

insidious, complicating self-perception of the problem 

and, consequently, the request for treatment. Performing 

hearing screening in this population would enable timely 

identification and corresponding referral to rehabilitation 

services, in order to minimize secondary consequences 

such as functional decline, depression, and social isolation. 

In Brazil, there are still no large scale hearing 

screening programs targeting school aged children, adults, 

and the elderly. When screenings are conducted in this 

population, they are isolated events. The reasons for this 

scenario are multifactorial and include the costs of the 

procedure. The related costs can be attributed to the cost 

of the professional performing the procedure, the necessary 

time to perform it, and the cost of the necessary equipment. 

In order to decrease screening costs, a simple, fast, and 

effective method using low cost equipment that can be 

easily operated by a primary care professional must be 

utilized (10). 

It is also necessary to emphasize the difficulty of 

access to hearing health for populations living far from 

urban centers. Thus, a relevant aspect of this scenario is the 

development of computer-based systems that can be used 

in telehealth models. Different low cost systems for 

conducting audiometric screening (11-13) or audiological 

assessment at distance (14-15) have been published in the 

literature. Such systems use TDH-39 supra-aural headphones 

or ER3A insert phones, which can increase device cost. 

One study was found on the use of a software-based 

screening audiometer that utilized a conventional 

circumaural phone with a 3.5 mm plug. However, this 

system was automatic and hearing responses were queried 

with 3 dB increments, making the test relatively lengthy 

with a duration of about 15 minutes (10). 

The Telessaúde (TS) audiometer was developed to 

perform audiometric screening using off-the-shelf USB 

interface headphones. This characteristic has a relevant 

impact on acquisition and replacement costs (the prototype 

costs less than 50 USD) and also facilitates access of the 

user to the TS audiometer. A wide variety of USB headphones 

are available and the user can chose a model that is 

considered more convenient, once that set of headphones 

has been calibrated for use with the TS audiometer. The 

fact that only off-the-shelf electronic devices are used also 

facilitates the availability of the TS audiometer, as the 

eventual manufacturer will not require a specific 

infrastructure for manufacturing and distribution. The aim 

of this study was to evaluate the TS audiometer for use 

during audiometric screening. 

METHOD 

This randomized prospective study was conducted 

in the Speech Language Pathology and Audiology Clinic of 

the X School, University X, and was approved by the 

relevant research ethics committee (process number 021/ 

2010). This clinic is currently accredited by the SUS as a 

tertiary hearing healthcare service. 

Once an informed consent form was signed by 60 

individuals, aged 18 years or older, they were voluntarily 

enrolled in the study and segregated into 2 groups (Table 

1): 

• Group A: for this group, employees and graduate 

students of the Bauru School of Dentistry were invited 

to participate in the study. This group was composed 

of 30 adults with age varying from 18 to 41 years old. 

None of these individuals presented a hearing complaint. 

• Group B: for this group, individuals who had ENT or 

audiological complaints and were referred to the clinic 

were invited to participate in the study. This group was 

comprised of 30 individuals with age ranging from 23 

to 85 years old. There were 12 adults and 18 elderly 

subjects (aged 60 years or older). None of these 

individual had had their hearing assessed previously. 

The TS audiometer is integrated by software 

developed in Visual Basic.NET 2005 (Net Framework 2.0) 


258



Table 1. Demographic data of the participants. 

Group Number of Age in years Gender Complaint 

ears tested (mean ± SD) 

Male Female Tinnitus Dizziness Hearing difficulty 

A (n = 30) 60 23.2 ± 5.6 26 4 —- —- —- 

B (n = 30) 60 59 ± 18.2 16 14 11 3 18 

for Windows XP and a set of USB headphones. It is 

supported by a multiuser database system managed by an 

administrator. The system can store the registration 

information of the location where screening is performed, 

the information of the healthcare professionals (users) and 

screened populations, as well as the corresponding 

evaluation results. Figure 1 shows an example of a TS 

audiometer user interface. 

With regards to hardware, the audiometer uses a 

Microsoft LifeChat LX-3000 headset with the following 

specifications: (a) bilateral earphones (20 Hz–20 kHz); (b) 

embedded microphone (100 Hz–10 kHz); (c) embedded 

USB sound board with 16 bit precision; (d) plug and play, 

i.e., no other software installation is needed for normal use; 

and (e) incorporated volume control. As for every USB 

device, the headset is identified by the host computer by 

its Vendor ID and Product ID, therefore allowing the 

software to apply the corresponding calibration parameter 

or impede the performance of the audiometric procedure 

if the corresponding parameters are not available. 

Following FDA recommendations for signature of 

electronic records (16), the identity and electronic signature 

of the healthcare professional are protected by a password 

only known and modifiable by the healthcare professional. 

Additionally, a change control, or audit trail, is not deemed 

necessary, as once they are electronically signed, the 

assessment results can no longer be modified. 

In this study, the TS audiometer was installed and 

tested in an ASUS EeePc900 laptop, given its relatively 

low cost and portability. This laptop has a 8.9" screen, a 

Celeron M353 processor, a 4 GB hard drive, 1 GB of DDR 

II RAM, an Intel UMA video board, a 1.3 megapixel 

webcam, a Windows ® XP operating system, 802.11b/g 

WLAN, USB/VGA/Earphone/Mic/Network inputs/outputs, 

embedded loudspeakers, a battery autonomy of 

approximately 2.5 hours, dimensions of 22.5x17x2 cm, 

and a weight of 0.99 kg. 

The TS audiometer includes a calibration user 

interface. This interface is only accessible for the testing 

prototype. Through this interface, the calibration parameters 

of a certain headset model can be determined and stored. 

These values are stored in the system parameters database 

Figure 1. TS audiometer user interface. 

and they are used every time an audiometric screening is 

performed. The device (computer and headphones) was 

calibrated by an engineer with experience in conventional 

audiometer calibration according to the applicable 

requirements of the standard project ABNT/CB 03/CE- 

03:029.01-022/1. The frequencies 250–8000 Hz were 

used to calibrate the left and right earphones of the 

Microsoft LifeChat LX-3000 headset. During calibration, the 

TS audiometer software was used to provide acoustic 

stimulation. With regard to the calibration, it must be noted 

that the USB headset included its own sound board, i.e., its 

own analog and digital input/output stages. Therefore, the 

calibration parameters were characteristic of the headset 

model and independent of the host computer model or 

type. The frequencies 250, 500, 1000, 2000, 3000, 4000, 

6000, and 8000 Hz were calibrated ranging from 10 dB HL 

(minimum stimulation level) to 70 dB HL (maximum 

stimulation level) in 5 dB steps for both the right and left 

channels. 

Another feature contemplated during development 

of the TS audiometer was the real-time estimation of 

ambient noise levels during performance of the screening 

procedure. As audiometric screening is not necessarily 

conducted in an audiometric booth or an acoustically prepared 

room, the TS audiometer uses the microphone embedded 

in the headset, placed in the upright position, to determine 

the ambient noise level. The software application converts 

the sampled noise level into a dB scale in order to assess if 


259



the real-time ambient noise level allows screening to be 

performed. The system will automatically display a message 

to the evaluator when the ambient noise level is greater than 

60 dB SPL to make him/her aware that minimization of noise 

level is desirable. The system user interface will flag the 

responses obtained under an ambient noise level greater 

than 60 dB SPL and also stores the average ambient noise 

level measured during an evaluation on its database. This is 

intended to minimize the occurrence of false positives 

induced by the lack of an appropriate acoustic environment. 

As the screenings were conducted in a sound booth, this 

feature of the TS audiometer was not evaluated in the 

present study. 

Audiometric screening was conducted in groups A 

and B with 2 different pieces of equipment: the SD 50 

audiometer (Siemens) coupled with supra-aural THD-39 

headphones and the TS audiometer. The screenings were 

conducted on the same day by 2 different audiologists, 

each one operating one audiometer. The audiologists did 

not share the results obtained with each other and they 

were not aware of the patients’ hearing complaints. The 

procedures were conducted in a randomized order. 

Audiometric screening was based on the ASHA 

protocol 17 . Pure tones at frequencies of 500, 1000, 2000, 

and 4000 Hz were presented at a 25 dB HL level. The 

participant was instructed to raise his/her hand each time 

the acoustic stimuli were heard. In the audiometric screening, 

a “pass” result was considered when the subject responded 

to the stimuli presented. The result was considered “fail” 

when the subject did not respond to one or more stimuli 

presented in one or both ears. 

Following audiometric screening, and regardless of 

the result (pass or fail), all participants underwent otologic 

inspection, pure-tone threshold audiometry, and speech 

audiometry procedures. For such purposes, SD 50 

(Siemens) or Midimate 622 (Madsen) audiometers were 

used. Air conduction hearing thresholds were obtained 

with TDH-39 earphones for the inter-octaves of the 

frequencies between 250 and 8000 Hz, for both ears. 

When the air conduction hearing thresholds were greater 

than 20 dB HL, bone conduction audiometry was also 

performed for the frequencies 500, 1000, 2000, 3000, and 

4000 Hz. 

Hearing thresholds were determined by applying 

the ascendant-descendant strategy. At each pure-tone 

detection response, the presentation level was reduced by 

10 dB until the individual no longer responded to the 

stimuli. Then, the presentation level was increased in 5 dB 

steps until a response was detected. The hearing threshold, 

at each frequency, was the lowest level at which the 

individual could detect 50% of the stimuli presented. 

All procedures were performed in a sound booth, 

where the noise levels were within the specified ranges of 

the ANSI 1999 standard (18). 

Concordance analysis and Cohen’s kappa coefficient 

were used to analyze the screening results between the 

conventional and TS audiometers for groups A and B. 

The precision of the TS audiometer screening 

instrument was evaluated through specificity, sensitivity, 

positive predictive value, and negative predictive value 

analysis. The sensitivity was defined as the percentage of 

ears that failed screening with the TS audiometer among 

those in which hearing loss was observed with pure-tone 

threshold audiometry. The specificity was defined as the 

percentage of ears that passed screening among those 

with normal hearing results. In this study, air conduction 

audiometric thresholds less than or equal to 20 dB HL were 

considered as normal hearing. The positive and negative 

predictive values were defined as the probability of a 

patient having hearing loss if they failed screening and the 

probability of a patient having normal hearing if they 

passing screening, respectively. 

RESULTS 

With regard to group B, the number of individuals 

that failed the screening was 27 with the TS audiometer 

and 26 with the conventional audiometer. 

Within group B, 4 participants presented normal 

hearing at all frequencies. The other 26 participants 

presented different degrees of sensorineural hearing loss 

(Figure 2), as per the pure-tone and speech audiometry 

results. 

Figure 2. Mean and standard deviation of audiometric thresholds 

for participants who presented hearing loss (n = 26). 


260



Table 2. Audiometric screening and concordance results for group A (n = 60 ears). 

Frequency (Hz) TS audiometer Conventional audiometer Concordance (%) 

Pass Fail Pass Fail 

500 60 0 60 0 100 

1000 60 0 60 0 100 

2000 60 0 60 0 100 

4000 60 0 60 0 100 

Total (%) 240 (100) 0 (100) 240 (100) 0 (100) 100 

Table 3. Audiometric screening and concordance results for group B (n = 60 ears). 

Frequency (Hz) TS audiometer Conventional audiometer Concordance (%) Kappa coefficient 

Pass Fail Pass Fail 

500 32 28 32 28 98.31 0.97 

1000 24 36 28 32 93.33 0.86 

2000 20 40 22 38 96.67 0.93 

4000 06 54 10 50 96.33 0.71 

Total (%) 82 (34.2) 158 (65.8) 92 (38.3) 148 (61.4) 96.67 0.84 

DISCUSION 

In group A (Table 2), all tested ears passed the 

screening. Although the sample size was limited, this 

observation is supported by the fact that the participants 

were predominantly young females, a population for 

which the prevalence of hearing loss is smaller (2-3). The 

concordance between the screening results obtained with 

the conventional and TS audiometers was excellent. 

In group B (Table 3), most ears failed the screening 

with both audiometers. It is worth noting that this group of 

participants had some kind of otologic complaint, with 18 

of them reporting hearing difficulties. This group was also 

mostly composed of elderly subjects, for whom a greater 

prevalence of hearing loss is observed (2-4). Thus, a 

considerable number of failures were expected. 

The number of failures at the frequency of 500 Hz 

was less than that for the other frequencies, which contradicts 

results reported in the literature (10). This can be explained 

by the fact that the screening was conducted in a sound 

booth, this being a limitation for the generalization of the 

data from the current study. In fact, hearing screening is 

generally conducted in a non-acoustically isolated room. 

Consequently, ambient noise can exert a masking effect 

over emitted signals, which is more significant at low 

frequencies, thus affecting screening results at these 

frequencies. For this reason, several screening protocols 

exclude the 500 Hz test, although this frequency is 

relevant for the assessment of the impact of middle ear 

condition on hearing sensitivity. 

In Table 3, the kappa coefficients show an excellent 

concordance between the evaluators for the screening 

results obtained with the conventional and TS audiometers 

at the frequencies of 500 Hz to 3000 Hz, and substantial 

concordance for the frequency of 4000 Hz (19). The interevaluator 

reliability allows verification of the degree of 

correspondence between the independent evaluations of 

2 or more evaluators classifying the same phenomena. 

Therefore, it is a relevant indicator of the quality of the 

screening procedure with the TS audiometer. Previously, 

kappa coefficients of 0.79–0.93 were observed when 

evaluating the concordance between audiometric 

screenings conducted with a portable audiometer and a 

conventional audiometer 20 . Another study 10 indicated a 

kappa coefficient of 0.20 between screening performed 

with a software-based audiometer and a conventional one. 

The fact that this result is lower than the one obtained in 

the current study could be related to the population 

characteristics (school aged children) and the impact of 

ambient noise at the frequency of 500 Hz, since when this 

was excluded from the analysis, a kappa value of 0.62 was 

obtained. Another important difference is that an automatic 

screening procedure was employed in the previous study, 

in contrast with the conventional procedure utilized in the 

current study. 

In Table 4, it can be observed that audiometric 

thresholds for group A were within normal values. 

Audiometric thresholds greater than 25 dB HL were found 

for at least one frequency in 65.4% of the ears tested in 

group B. For this group, 26 participants (86.6%) presented 

sensorineural hearing loss, with a greater involvement of 

the high frequencies (Figure 2). This high incidence of 


261



Table 4. Distribution of the number of ears with normal thresholds and 

hearing loss in both groups. 

Frequency (Hz) Group A (n = 60 ears) Group B (n = 60 ears) 

Normal Hearing loss Normal Hearing loss 

500 60 0 29 31 

1000 60 0 29 31 

2000 60 0 19 41 

4000 60 0 6 54 

Total (%) 240 (100) 0 (0) 83 (34.6) 157 (65.4) 

Table 5. Specificity, sensitivity, positive predictive value, and negative predictive 

value for TS and conventional audiometers. 

Audiometer Group Predictive value 

Sensitivity Specificity Positive Negative 

TS A —— 100% —— 100% 

B 95.5% 90.4% 94.9% 91.5% 

Conventional A —— 100% —— 100% 

B 91.1% 94% 96.6% 84.8% 

hearing loss is due to the fact that the participants of this 

group were recruited from a specialized hearing healthcare 

clinic. It is relevant to note that all of the subjects who 

presented hearing loss underwent a complete audiological 

assessment and received corresponding treatment, including 

fitting of hearing aids. 

Pure-tone audiometry is currently the gold standard 

for assessment of hearing sensitivity. Therefore, the 

sensitivity and specificity of the screening procedures 

with the conventional and TS audiometers (Table 5) were 

calculated using the results obtained with pure-tone 

threshold audiometry as a reference. It was not possible 

to calculate the sensitivity of the procedures for group A 

due to the fact that none of the participants failed the 

screening or presented hearing loss with pure-tone 

audiometry. The specificity of this group equaled 100% 

for both procedures. For group B, the sensitivity and 

specificity values of the TS audiometer were similar to 

those of the conventional audiometer (Table 5). Elevated 

sensitivity and specificity values avoid the occurrence of 

false negatives and false positives, respectively. However, 

it must be remembered that no procedure is entirely 

accurate, i.e., no procedure has a sensitivity and specificity 

equal to 100%. 

The sensitivity and specificity values of the TS 

audiometer were similar to those found in the literature. 

The sensitivity and specificity of a portable screening 

audiometer were reported to be 91.8–98.5% and 88.0– 

96.3%, respectively (20). Studies involving the Audioscope 

device with pure-tone sweep (500 to 4000 Hz) for hearing 

screening demonstrated a sensitivity of 94–97% and a 

specificity of 69–80% (11). With regards to affordable 

audiometers, the TS audiometer presented higher sensitivity 

and specificity values than those found in the literature. 

Sensitivity and specificity values of 86.7% and 75.9% were 

verified with a remote automatic audiometric screening 

method (20 dB HL pure-tone sweep), based on the use of 

a computer and TDH-39 earphones (13). Automatic hearing 

screening conducted with a low cost audiometer and a 

circumaural phone showed a sensitivity of 100% and a 

specificity of 49% (10). The differences observed between 

the literature and the present study can be related to the 

stimuli loudness level applied in the current study (25 dB 

HL), attenuation differences in the earphones utilized, and, 

mainly, the screening method (automatic vs. manual) and 

screening room acoustics (non-acoustically isolated room 

vs. audiometric booth) used. 

Under operational conditions (field application), the 

performance indicators of a test procedure are modified by 

the frequency of occurrence of a medical condition within 

the population (prevalence). Therefore, the predictive 

value of the procedure has a significant relevance, i.e., the 

probability of occurrence of a medical condition given a 

positive or negative result. In the current study, the 

positive and negative predictive values of the TS audiometer 

were equal to 94.9% and 91.5%, respectively, being similar 

to those obtained with a conventional audiometer (Table 

5). This means that if a subject fails screening with the TS 

audiometer, there is a 94.9% chance of them actually 

suffering from hearing loss and a 5.1% (100 - 94.9) chance 

of them having normal hearing. If the subject passes 


262



screening, there is 91.5% chance of them having normal 

hearing and an 8.5% (100 - 91.5) chance of them having 

hearing loss. 

For group B, the observed predictive values of the 

TS audiometer were greater than those found in the 

literature for other affordable audiometers, which 

presented positive and negative predictive values of 

48.1% and 95.7% 13 and 56% and 43% 10 , respectively. 

These findings are justified by the differences observed 

in the sensitivity and specificity of the TS audiometer 

when compared to other audiometers, and the fact that 

the screened population was from a specialized hearing 

healthcare clinic, where a higher number of subjects with 

hearing loss were registered. 

Screening programs are justified if there is evidence 

that sustains 3 standard criteria: (a) negative consequences 

of the medical condition must be sufficiently significant in 

order to justify the screening effort; (b) an effective 

treatment for the detected medical condition is available; 

and (c) an accurate, practical, and convenient screening 

test is available 11 . Although this study is limited by the 

number of participants, the results obtained suggest that 

the TS audiometer meets the necessary criteria for a 

screening procedure. 

CONCLUSION 

The specificity, sensitivity, and positive and negative 

predictive values of audiometric screening conducted with 

the TS audiometer were high and similar to those obtained 

with a conventional audiometer. 

ACKNOWLEDGEMENTS 

The authors would like to thank Audiologist X for her 

support during data collection and Engineer X for performing 

the calibration of the TS audiometer. 

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DOI: 10.7162/S1809-97772013000300006 

Comparison of videonasoendoscopy and auditory-perceptual evaluation 

of speech in individuals with cleft lip/palate 

Lauren Medeiros Paniagua 1 , Alana Verza Signorini 2 , Sady Selaimen da Costa 3 , Marcus Vinicius Martins Collares 4 , 

Sílvia Dornelles 5 . 

1) Speech Language Pathologist. Doctor of Science in Children’s and Teenager’s Health- Universidade Federal do Rio Grande do Sul-UFRGS. Professor of Speech-Language 

Pathology at Fatima College (RS). 

2) Undergraduated Speech pathology - Universidade Federal do Rio Grande do Sul - UFRGS (fellow undergraduated of CNPq). 

3) MD; MSc; PhD.Associate Professor - Department Of Otolaryngology & Head And Neck Surgery School Of Medicine - Universidade Federal do Rio Grande do Sul. 

4) MD; PhD. Associate Professor Department of Surgery; Head, Plastic Surgery Section - School of Medicine/Universidade Federal do Rio Grande do Sul. 

5) Speech Pathology, MSc, PhD. Professor Department of Speech Pathology - Universidade Federal do Rio Grande do Sul. 

Institution: Universidade Federal do Rio Grande do Sul (UFRGS). 

Porto Alegre / RS - Brazil. 

Mailing address: Lauren Medeiros Paniagua - Universidade Federal do Rio Grande do Sul (UFRGS) - Avenida João Wallig 1705/627 – Porto Alegre / RS - Brazil - Zip Code: 

91340-001 - E-mail: lmedeirospaniagua@yahoo.com.br 

Article received on December 17 th , 2012. Article accepted on April 7 th , 2013. 

SUMMARY 

Introduction: The velopharyngeal sphincter (VPS) is a muscle belt located between the oropharynx and the nasopharynx. 

Investigations of velopharyngeal function should include an auditory-perceptual evaluation and at least 1 instrument-based 

evaluation such as videonasoendoscopy. 

Aim: To compare the findings of auditory-perceptual evaluation (hypernasality) and videonasoendoscopy (gap size) in individuals 

with cleft lip/palate. 

Method: This was a retrospective, cross-sectional study assessing 49 subjects, of both sexes, with cleft lip/palate followed up 

at the Otorhinolaryngology Service and the Speech Therapy outpatient clinic of Hospital de Clínicas de Porto Alegre (HCPA). 

The results from the auditory-perceptual evaluation and the videonasoendoscopy test were compared with respect to the VPS 

gap size. 

Results: Subjects with moderate/severe hypernasality had more severe velopharyngeal closure impairment than those with a 

less severe condition. The interaction between hypernasality severity and the presence of other speech disorders (p = 0.035), 

whether compensatory and/or obligatory, increased the likelihood of having a moderate-to-large gap in the velopharyngeal 

closure. 

Conclusions: We observed an association between the findings of these 2 evaluation methods. 

Keywords: Cleft Palate; Velopharyngeal Sphincter; Communication Disorders; Evaluation. 

INTRODUCTION 

The velopharyngeal sphincter (VPS) is a muscle belt 

located between the oropharynx and the nasopharynx and 

includes the muscles of the soft palate (anterior wall of the 

VPS) and the lateral and posterior pharyngeal walls. The 

VPS comprises the levator veli palatini, tensor veli palatini, 

muscle of uvula, superior pharyngeal constrictor, 

palatopharingeus, palatoglossus, and salpingopharyngeus 

(1). Among these muscles, those of the soft palate, 

especially the tensor veli palatine, have an important role 

in the physiological function of the region. While the VPS 

is not a sphincter by strict definition (a circular muscle band 

in a hollow viscera), its physiological function is that of a 

sphincter, as it works like a valve, contracting and occluding 

itself (2). 

The VPS plays an extremely important role in 

allowing alternation between the respiratory and digestive 

paths of the pharynx during swallowing (3). Velopharyngeal 

closure, performed by the VPS, is essential in motor actions 

of the region such as speaking, whistling, blowing, sucking, 

and swallowing (4). Several studies have described intersubject 

variability in velopharyngeal closure (1, 5) and 

have identified 4 types of closure based on structure 

movement (6, 7, 1, 5). In the coronal type of closure, there 

is more participation of the soft palate. Sagittal closure 

predominantly involves the lateral pharyngeal walls. In the 

circular type of closure, the soft palate and lateral pharyngeal 

walls are involved. Finally, the circular type closure with a 

Passavant ridge, is similar to the circular closure except that 

a Passavant ridge is present on the posterior pharyngeal 

wall. 

The configuration of the velopharyngeal region 

depends on the specific motor actions performed. The 

raising of the soft palate and, concomitantly, the medial 

approximation of the lateral pharyngeal walls promotes 

the partial or complete separation of the nasal and oral 


265

Comparison of videonasoendoscopy and auditory-perceptual evaluation of speech in individuals with cleft lip/palate. 


portions of the pharynx. The velopharyngeal structures are 

thus important for the production of speech, as they 

distribute and direct airflow to the oral cavity to produce 

oral sounds and to the nasal cavity for the emission of nasal 

sounds (1, 8, 9). 

Investigators have several types of tools to choose 

from when assessing VPS function (10, 11, 12). A detailed 

description of the velopharyngeal mechanism was obtained 

only after the availability of both direct and indirect 

assessment methods. Direct methods enable the investigator 

to visualize the structures involved in velopharyngeal 

closure and to observe how these structures move during 

different types of motor actions. Indirect methods provide 

information on the functional repercussions of 

velopharyngeal action (13, 12, 14). 

Videonasoendoscopy is one of the most widely 

used methods for studying velopharyngeal function, 

allowing visualization of the nasal, pharyngeal, and laryngeal 

cavities. Using dynamic images directly from the anatomical 

structures (15), this method has multiple applications, 

including diagnosis, prognosis, and postoperative follow 

up (11). This test can be used to observe the pattern of 

closure even during speech, which involves wide variations 

in velum and pharyngeal wall motion. Videonasoendoscopy 

can also be used to identify the presence of the gap 

corresponding to the residual orifice during maximum 

contraction of the VPS (16, 17). 

As a counterpart to the use of more sophisticated 

tools for velopharyngeal assessment, clinical judgment by 

means of hearing is still considered an extremely important 

diagnostic tool for inferring velopharyngeal function (12). 

Using this method, the investigator can assess a subject’s 

oral communication performance and determine the extent 

of speech impairments related to resonance (18, 12, 19, 

20, 21). 

Impaired velopharyngeal closure prevents separation 

of the oral and nasal cavities during the production of oral 

phonemes, exposing the nasal cavity to the entry of 

unexpected air flow. This impairment in velopharyngeal 

closure, known as velopharyngeal dysfunction (VPD), can 

be congenital, as with cleft lip. 

There is a widespread consensus among researchers 

and healthcare professionals that the surgical and clinical 

findings of subjects with cleft lip/palate should be based 

on an auditory-perceptual evaluation and at least one 

instrument-based evaluation of velopharyngeal function 

(13, 22, 23, 24). The use of both assessment modalities 

is highly valuable and widely used in clinical practice, as 

the findings of one method complement the other. 

Despite this common practice, there are few studies 

comparing patient evaluations using videonasoendoscopy 

(clinical estimation of gap size) and auditory-perceptual 

assessments (hypernasality). This study aimed to determine 

whether the findings of videonasoendoscopy in 

patients with cleft lip/palate are associated with 

demographic features, clinical factors, or the findings of 

auditory-perceptual assessments. 

METHODS 

This retrospective, cross-sectional study assessed 

49 individuals, of both genders, with cleft lip/palate who 

were followed up at the Otorhinolaryngology Service and 

at the Speech Therapy outpatient clinic of Hospital de 

Clínicas de Porto Alegre (HCPA). The study was approved 

by the HCPA Research Ethics Committee under protocol 

number 10-0490. 

The population consisted of individuals follow up at 

the HCPA in the Plastic Surgery Service, Craniofacial 

Surgery outpatient clinic; Otorhinolaryngology and at the 

“SpeechTherapy and Craniofacial Malformations” outpatient 

clinic. This group of patients was primarily treated at HCPA 

and at other institutions. 

The present study compared the results of 2 methods 

for evaluating velopharyngeal function. The auditoryperceptual 

evaluation by speech therapy screening is 

reported as speech findings. This assessment was carried 

out by a speech therapist with more than 10 years of 

experience in the area. The results of videonasoendoscopy 

were analyzed by 2 experienced evaluators. The speech 

therapy screening and videonasoendoscopy data were 

collected in October 2012. The inclusion criterion was 

assessment by speech therapy screening and 

videonasoendoscopy between September 2011 and August 

2012. We excluded from the study patients with blurred 

videonasoendoscopy images and those with excess 

secretion from the nasal cavity or missing data. 

The speech therapy screening assessed the following 

auditory-perceptual parameters: resonance, presence, and 

severity of hyponasality and hypernasality (mild, moderate, 

severe) (25); speech disorders, identified as compensatory 

(such as glottal stops) or obligatory (weak intraoral pressure, 

facial mimicry, audible nasal air emission, nasal snoring). 

For analysis purposes, hypernasality and its severity were 

included as obligatory disorders (26). During screening, the 

speech therapist used a speech sample comprising 2 

sentences with phonetic predominance of oral plosive 

phonemes/p/ (“papai pediu pipoca”) and fricative 

phonemes/s/ (“o saci sabe assobiar” The patients also 

performed a segment of continuous speech, counting from 

1 to 10. 


266



Using videonasoendoscopy, we analyzed the portion 

of the test related to the sustained emission of the /s/ 

phoneme, chosen because it leads to complete closure of 

the VPS, thereby minimizing misinterpretations due to 

interference by the production of another phoneme. The 

evaluators made a clinical estimation of the VPS gap size 

using an adapted version of a protocol described in previous 

studies (10, 27). The VPS gap size was classified according 

to the following scale: 1, no gap (complete velopharyngeal 

closure); 0.8–0.9, small gap (efficient closure); 0.4–0.7, 

moderate gap (intermediate closure); 0.1–0.3 large gap 

(inefficient closure); 0, very large gap (lack of closure). This 

protocol assessed the following: presence or absence of 

adenoids contributing to velopharyngeal closure; presence 

or absence of mobility of the palate and lateral and posterior 

pharyngeal walls; VFS closure type (coronal, sagittal, circular, 

or circular with Passavant ridge). 

Quantitative variables were described as mean and 

standard deviation or median and interquartile range. 

Categorical variables were described as absolute or relative 

frequencies. The Pearson’s chi-square test was used to 

evaluate the association between videonasoendoscopy 

and perceptual-hearing evaluation. The McNemar’s test 

was applied to assess the differences between evaluators, 

and the kappa coefficient was applied to assess interevaluator 

agreement. Student’s t-test (quantitative variables 

with symmetric distribution), Mann–Whitney test 

(quantitative variables with asymmetric distribution), and 

Pearson’s chi-square and Fisher’s exact tests (categorical 

variables) were applied to investigate the association 

between clinical factors and examination methods. Poisson’s 

regression model was used to control confounding factors. 

The criterion for including a variable in the model was a p 

value < 0.10 in the bivariate analysis. We considered 

significance to be 5% (p d” 0.05). Analyses were performed 

using SPSS (Statistical Package for the Social Sciences) 

version 17.0. 

RESULTS 

The median age at the time of evaluation was 11 

years, with the majority of the cohort between 9 and 16 

years. The cohort was predominantly male (61.2%). Speech 

therapy treatment was ongoing in 14.3% of the subjects. 

The most common cleft type was the left unilateral 

complete cleft (30.6%, n = 15), followed by bilateral 

complete cleft lip/palate (28.6%, n = 14), right unilateral 

(20.4%, n = 10), cleft palate (14.3%, n = 7), and submucosal 

cleft (6.1 %, n = 3). 

All patients had undergone primary palatoplasty at 

a mean age of 19.5 months. Secondary palatoplasty was 

performed in only 4.1% of the subjects, at a median age of 

18.5 years. 

Table 1 shows the results from the speech therapy 

screening, including the assessment of resonance as well as 

compensatory and obligatory articulation disorders. We 

found that 77.6% of the subjects presented with 

hypernasality, which was moderately severe in 36.7% and 

mildly severe in 28.6% of these subjects. As illustrated in 

Table 1, articulation disorders were found in 81.6% of 

subjects, 75.5% of whom had obligatory disorders and 

57.1% of whom had compensatory disorder (glottal stops). 

The most frequently observed obligatory disorder was 

weak intraoral pressure, which was present in 75.7% of the 

subjects. The second more frequent disorder was audible 

nasal air emission (62.2%). 

Inter-evaluator comparison of the findings of the 

videonasoendoscopy, as well as comparison of these test 

results with those of the auditory-perceptual evaluation 

was assessed using the emission of the /s/ phoneme. 

The inter-rater agreement was established using the 

Kappa agreement coefficient, matching the findings of 

one rater with those of the other. In this study, the Fleiss’ 

kappa agreement coefficients (28) were interpreted as 

previously reported (29):



velopharyngeal closure, mobility of pharyngeal walls, 

predominant type of movement, closure type, and VPS 

gap size during emission of the /s/ phoneme. The 

predominant closure type was coronal. One evaluator’s 

results indicated that 20.4% of the subjects had no VPS gap, 

40.8% had a small gap, 16.3% had a moderate gap, and 

22.4% had a large gap. 

Demographic data indicated that the subjects with 

more severe velopharyngeal closure impairment underwent 

later primary palatoplasty; the presence of a moderate to 

large gap was significantly associated with an age at 

primary palatoplasty of over 23 months. All individuals 

requiring secondary palatoplasty (n = 2) showed impairment 

in velopharyngeal closure, although this result was not 

statistically significant. There were no other statistically 

significant associations between variables. 

We compared the VPS gap size as estimated by 

clinical and auditory-perceptual assessments (Table 2). We 

also investigated the relationship between the gap size and 

both the severity of hypernasality and the presence of 

speech disorders (compensatory and obligatory disorders). 

Our results indicate that more severe impairment of 

velopharyngeal closure was observed more often in subjects 

with moderate/severe hypernasality, with statistical 

significance for severe hypernasality (p = 0.021). In addition, 

we found severe hypernasality was significantly associated 

with the presence of other speech disorders (p = 0.035), 

whether compensatory and/or obligatory, increasing the 

likelihood of having a moderate to large gap (intermediate 

to inefficient velopharyngeal closure). 

Ten subjects (20.4%) showed discrepant results 

with regard to velopharyngeal function, having moderate/ 

severe hypernasality + other speech disorders together 

with complete and efficient gap closure. Conversely, 6 

subjects (12.2%) had intermediate/inefficient closure with 

no moderate/severe hypernasality. 

These discrepant findings may be due to the 

differences in the analytical parameters (speech and 

continuous sound emission), although both parameters 

involve velopharyngeal function. The auditory-perceptual 

evaluation assessed a larger speech sample (counting of 

numbers and 2 sentences focusing on /s/ and /p/ 

phonemes). The instrumental evaluation observed the 

sustained emission of the /s/ phoneme, which provides 

maximum VPS contraction. In such cases that present 

physical evidence of closure but indicate abnormal 

resonance, it is very important for the interdisciplinary 

team to re-evaluate the findings to perform a differential 

diagnosis of velopharyngeal dysfunction. Therefore, it can 

be inferred that the maintenance of motor action in speech 

is not consistent. 

Table 2. Relationship between auditory-perceptual assessment and gap size. 

Variables Complete/efficient closure Intermediate/inefficient closure p 

Speech disorder, n (%) 0.636 

Present 26 (86.7) 18 (94.7) 

Absent 4 (13.3) 1 (5.3) 

Moderate/severe hypernasality + 

other speech disorders, n (%) 0.035 

Yes 10 (33.3) 13 (68.4) 

No 20 (66.7) 6 (31.6) 

Type of disorder, n (%) 0.157 

Obligatory 12 (46.2) 4 (22.2) 

Compensatory 1 (3.8) 0 (0.0) 

Obligatory + compensatory 13 (50.0) 14 (77.8) 

Types of obligatory disorders*, n (%) 

Audible nasal air emission 13 (43.3) 10 (52.6) 0.733 

Weak intraoral pressure 17 (56.7) 11 (57.9) 1.000 

Facial mimicry 4 (13.3) 7 (36.8) 0.081 

Nasal snoring 2 (6.7) 0 (0.0) 0.515 

Hypernasality 21 (70.0) 17 (89.5) 0.165 

Resonance, n (%) 0.021 

Balanced 9 (30) 2 (10.5) 

Mild hypernasality 11 (36.7) 3 (15.8) 

Moderate hypernasality 9 (30) 9 (47.4) 

Severe hypernasality 1 (3.3) 5 (26.3)** 

*multiple choice question; **statistically significant association by the test of residuals adjusted to a 5% of significance level. 


268



DISCUSSION 

The physiology of the velopharyngeal mechanism 

has been investigated in several disciplines (30, 31). 

Studies comparing different methods of assessing 

velopharyngeal function report conflicting results. Few of 

these investigations have considered the following factors 

in the same study: (1) protocols for clinical and instrumentbased 

assessments recommended in the literature, including 

a detailed description of the criteria used for analysis of the 

variables under study; (2) inter-evaluator agreement for 

assessments using videonasoendoscopy; (3) the possible 

variables interfering with velopharyngeal closure 

(participation of adenoids and speech therapy treatment 

for velopharyngeal occlusion). 

Our study assessed hypernasality, compensatory 

articulation disorders, and other obligatory disorders (26). 

These speech anomalies are of interest to researchers who 

investigate speech production in individuals with cleft lip/ 

palate (32, 33 34, 35, 25). 

A recently study (26) has emphasized that obligatory 

disorders should receive attention from a structural point of 

view and not only from the perspective of velopharyngeal 

function; the identification of velopharyngeal dysfunction 

can help to establish whether speech therapy intervention 

is indicated for individuals with cleft lip/palate. The auditoryperceptual 

evaluation used in the present study took these 

structural features of obligatory disorders into account. 

Hypernasality was reported in 77.6% of our subjects, the 

severity of which was moderate in 36.7% and mild in 

28.6%. Speech disorders were identified in 89.8% of the 

subjects, of whom 87.8% had obligatory disorders and 

57.1% compensatory disorder (glottis stop). One of the 

most frequent obligatory disorders was weak intraoral 

pressure, present in 75.7% of the subjects. Our findings 

corroborate those in the literature reporting a higher 

occurrence of weak intraoral pressure, hypernasality, and 

glottis stop (37, 4, 37). The results of this study thus suggest 

that the weak intra-oral pressure caused by VPD produces 

audible nasal air emission and hypernasality in speech. In 

turn, glottis stops may occur as a consequence of poor 

articulation habits learned in childhood that do not necessarily 

reflect physical or neuromuscular changes (38). 

We believe that the high occurrence of hypernasality 

and other articulation disorders in our cohort is related to their 

referrals from speech therapy, indicating that they had an 

issue involving oral communication. Although these patients 

were followed up for a longer time by the HCPA 

interdisciplinary team that provides a variety of services, a 

speech therapy outpatient clinic linked to Universidade 

Federal do Rio Grande do Sul was added in 2011 to treat 

patients with cleft lip/palate. Before the creation of this 

outpatient clinic, the patients were treated just by a speech 

therapist from HCPA, with a period of care limited to one 

shift for this population. As it constitutes a curricular internship, 

in which undergraduate and graduate students practice the 

activity, the response to this demand is still limited. 

Reports in the literature point out that experience 

is crucial in both the conduction and analysis of the 

videonasoendoscopy test. Accordingly, we assessed the 

inter-evaluator agreement with regard to gap size in the 

emission of the /s/ phoneme, observing that it was almost 

perfect (kappa, 0.83–0.95). We thus conclude that the 

evaluation team is highly qualified. This result also illustrates 

that the criteria adopted for interpreting the findings were 

very homogeneous between the raters. These findings 

corroborate those described in other scientific studies using 

this protocol (10), indicating that the data are in accordance 

with the proposed objective (39, 40, 41). 

We observed that 20.4% of the subjects did not have 

a VPS gap; 40.8% had a small gap, 16.3% had a moderate 

gap, and 22.4% had a large gap. Thus, 61.2% of the total 

cohort had complete or efficient velopharyngeal closure. 

The predominant velopharyngeal closure type was coronal 

(69.4%, n = 34) which has greater mobility of the anterior 

wall of the VPS corresponding to the soft palate. The 

prevalence of the sagittal type was 24.5% (12), and the 

circular type was 6.1% (3). Studies have demonstrated that 

the coronal pattern is also the most frequent among individuals 

without cleft lip/palate (42, 22, 30, 7), but individuals with 

cleft palate tend to have a broader distribution between the 

other patterns of closure (43, 7, 44). 

Among the associations related to demographic and 

clinical data, only age at the time of primary palatoplasty 

was associated with the clinical estimation of VPS gap size. 

Our findings indicate that the later primary palatoplasty is 

performed the greater the compromise in velopharyngeal 

closure (moderate to large gap size), with a significant 

associated with ages above 23 months (p = 0.016). 

However, when analyzing the variables independently 

associated with intermediate/inefficient velopharyngeal 

closure (by controlling confounding factors), age at primary 

palatoplasty was not significantly associated but was near 

the threshold (PR = 1.01; 95% CI, 1.00–1.02; p = 0.088). 

The trend in the data indicates that every additional month 

until the performance of the first palatoplasty leads to a 2% 

increase in the prevalence of inefficient closure. 

The author of a previous study (46) proposes that 

the appropriate time for surgical repair of the palate is 12– 

18 months of age, taking into account maxillary growth and 

velopharyngeal function. One report on the association 

between various clinical factors and velopharyngeal closure 


269



in cleft lip/palate found that velopharyngeal closure was 

higher among individuals with deciduous dentition than 

among those with mixed or permanent dentition (47). 

The present study aimed to compare the findings of 

auditory-perceptual evaluation and those of 

videonasoendoscopy. Our data indicate that subjects with 

more compromised velopharyngeal closure have a higher 

incidence of moderate and severe hypernasality, showing 

that both tests indicated the compromise in velopharyngeal 

function. A statistically significant association was found 

between severe hypernasality (p = 0.021) and intermediate/ 

inefficient closure with a gap size ranging from moderate 

to large. 

We found one study that aimed to evaluate auditoryperceptual 

assessment, but the authors adopted a different 

classification system for the findings of videonasoendoscopy 

and did not relate them to the efficiency of velopharyngeal 

closure. A retrospective study investigated the relationship 

between the auditory-perceptual characteristics of speech 

and velopharyngeal gap size (20), and the authors concluded 

that information regarding velopharyngeal gap size can be 

predicted from speech assessment alone. Confidence in 

the prediction was stronger when the patient had moderate 

to severe hypernasality, which was more commonly 

associated with a large gap. This last finding was similar to 

that reported in our study. 

We found a statistically significant interaction (p = 

0.035) of the severity of hypernasality and the presence of 

other articulation disorders with the clinical estimate of VPS 

gap size. The interaction of both changes identified in the 

auditory-perceptual evaluation increased the likelihood of 

the presence of a moderate to large gap. Multivariate 

analysis confirmed this association (PR = 1.26; 95% CI: 

1.03–1.54; p = 0.026). This result is observed in the clinical 

practice, as the presence of hypernasality is usually 

associated with at least one articulation change, whether 

obligatory or compensatory. The articulation changes 

associated with hypernasality reflect the difficulty in 

acquiring and maintaining velopharyngeal closure (47). 

To gain a better understanding of these cases, we 

investigated velopharyngeal physiology during the motor 

action related to speech. Although no statistically significant 

difference was found, 2 interesting situations were observed. 

First, 10 subjects (20.4%) had complete/efficient 

velopharyngeal closure but also had moderate/severe 

hypernasality. Second, 6 subjects (12.2%) had intermediate/ 

inefficient closure with no moderate/severe hypernasality. 

Although both videonasoendoscopy and auditoryperceptual 

evaluation assess velopharyngeal function, this 

study used different samples and speech extensions. The 

videonasoendoscopy analyzed only the sustained emission 

of the /s/ phoneme, using a comfortable intensity for the 

patient that was audible for the examiner. This phoneme 

was chosen because its emission requires the action of all 

velopharyngeal walls and their maximum contraction to 

achieve complete velopharyngeal closure. This information 

allows the examiner to identify the presence or absence of 

a VPS gap. 

Velopharyngeal closure differs during different motor 

actions and during speech (4). The observation that some 

patients have unsatisfactory findings in the auditoryperceptual 

evaluation and good findings in 

videonasoendoscopy suggests that resonance in continuous 

speech is unaffected. However, articulation disorders can 

hamper accurate assessment of hypernasality severity. 

Hypernasality is often associated with the length of time 

required for VPS opening and not directly with the degree 

of opening or even with the air flow that escapes from the 

nasal cavity (48). For example, patients with adequate 

velopharyngeal closure as assessed by instrument-based 

assessment may have hypernasality because of the 

abnormalities in the temporal spectrum of velopharyngeal 

closure. 

The great physiological variability of the VPS may 

be related to factors such as speed of speech, characteristics 

of isolate phoneme emission, and association of different 

phonemes (consonant-vowel) (1). This variability may 

account for the patients who have intermediate/inefficient 

closure but no moderate/severe hypernasality. Further 

factors may explain this versatility in velopharyngeal 

closure as follows: the action of several muscles associated 

with the levator veli palatini (palatoglossus, 

palatopharingeus, and superior pharyngeal constrictor); 

mechanical factors, especially the position of the tongue in 

the oral cavity; and the specific phonological rules of each 

linguistic system (49, 5). 

In summary, we recommend that patients with 

discrepant results between evaluations and those with 

unsatisfactory results should be referred to interdisciplinary 

clinical evaluations to determine the best course of action. 

(26). X et al. Emphasizes that obligatory and compensatory 

articulation disorders affect speech, and that obligatory 

disorders should receive attention from both the structural 

and functional points of view (26). Therefore, by identifying 

velopharyngeal dysfunction, appropriate therapeutic 

strategies can be devised. 

CONCLUSIONS 

It was found that our patient cohort had a high 

prevalence of hypernasality and compensatory and 


270



articulation disorders. In addition, we observed a high 

frequency of individuals with a small gap, and a 

predominance of the coronal type closure. The individuals 

with more severe velopharyngeal closure impairment 

underwent late palatoplasty, although this comparison did 

not remain significant after adjustment by the multivariate 

model. 

Comparison of the 2 evaluation methods showed 

that subjects with moderate/severe hypernasality had 

more severely impaired velopharyngeal closure. 

Hypernasality is more closely associated with clinical 

estimation of gap size than are other obligatory and 

compensatory disorders. The interaction between 

hypernasality severity and the presence of other disorders 

increases the likelihood of having a gap ranging from 

moderate to large. Although we found cases with 

discrepancies between the findings of the auditoryperceptual 

and instrument-based evaluations, we observed 

an association between the findings of these 2 evaluation 

methods. 

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DOI: 10.7162/S1809-97772013000300007 

Clinical and fiberoptic endoscopic assessment of swallowing in patients 

with chronic obstructive pulmonary disease 

Marina Rodrigues Bueno Macri 1 , Jair Mendes Marques 2 , Rosane Sampaio Santos 3 , Ana Maria Furkim 4 , Irinei Melek 5 , 

Daniel Rispoli 6 , Maria Cristina de Alencar Nunes 7 . 

1) Speech Therapist. Masters in Communication Disorders from the University of Paraná Tuiuti. 

2) Degree in Mathematics. Doctorate in Geodetic Sciences from the Federal University of Paraná (HC-UFPR). 

3) Speech Therapist. Student Doctorate in Internal Medicine from the HC-UFPR. 

4) Speech Therapist. Doctorate in Human Communication Disorders from the Federal University of Sao Paulo. 

5) Doctor. Pulmonologist. 

6) Doctor. Otolaryngologist. 

7) Speech Therapist. Student Doctorate in Internal Medicine from the HC-UFPR. 

Institution: University of Paraná Tuiuti. 

Curitiba / PR - Brazil. 

Mailing address: Marina Rodrigues Bueno Macri - Rua Saldanha da Gama 86, apt. 42b - Curitiba / PR - Brazil - Zip code: 80060-170 - E-mail: buenomarina405@hotmail.com 

Article received on January 17 th , 2013. Article accepted on April 7 th , 2013. 

SUMMARY 

Introduction: Chronic obstructive pulmonary disease is characterized by progressive and partially reversible obstruction of 

pulmonary airflow. 

Aim: To characterize swallowing in patients with chronic obstructive pulmonary disease and correlate the findings with the 

degree chronic obstructive pulmonary disease, heart and respiratory rate, oxygen saturation, and smoking. 

Method: We conducted a prospective cohort study of 19 patients (12 men and 7 women; age range, 50–85 years) with confirmed 

medical diagnosis of chronic obstructive pulmonary disease. This study was performed in 2 stages (clinical evaluation and functional 

assessment using nasolaryngofibroscopy) on the same day. During both stages, vital signs were checked by medical personnel. 

Results: Clinical evaluation of swallowing in all patients showed the clinical signs of cough. The findings of nasolaryngofibroscopy 

highlighted subsequent intraoral escape in 5 patients (26.5%). No patient had tracheal aspiration. There was no association of 

subsequent intraoral escape with degree of chronic obstructive pulmonary disease, heart and respiratory rate, oxygen saturation, 

or smoking. 

Conclusion: In patients with chronic obstructive pulmonary disease, there was a prevalence of oral dysphagia upon swallowing 

and nasolaryngofibroscopy highlighted the finding of subsequent intraoral escape. There was no correlation between intraoral 

escape and the degree of chronic obstructive pulmonary disease, heart and respiratory rate, oxygen saturation, or smoking. 

Keywords: Pulmonary Disease, Chronic Obstructive; Deglutition Disorders; Respiration; Smoking; Heart Rate; Respiratory Rate. 

INTRODUCTION 

Chronic obstructive pulmonary disease (COPD) is 

characterized by progressive and partially reversible airway 

obstruction. This airflow obstruction is associated with an 

abnormal inflammatory response of the lungs and occurs 

between 5% and 15% of the adult population (1-3) and is 

a leading cause of death worldwide. Smoking is responsible 

for more than 90% of the cases, with a prevalence of 

disease found in men (4). 

The diagnosis of COPD should be considered in the 

presence of cough, sputum production, dyspnea, and a 

history of exposure to risk factors such as smoking, 

environmental pollution, and occupational exposure to 

toxic gases or particles (1). 

Several factors can lead to inadequate food intake in 

patients with COPD, causing weight loss, oropharyngeal 

dysphagia (possibly due to difficulty in chewing), dyspnea, 

cough, fatigue, and secretion (5). 

Oropharyngeal dysphagia is a swallowing disorder 

with specific signs and symptoms that are characterized by 

alterations at any stage and/or between the steps of the 

dynamics of swallowing; this condition may be congenital 

or acquired (6,7). Stable dysphagic patients with COPD can 

present important clinical complications such as malnutrition, 

pulmonary complications, dehydration, and discomfort 

when eating (8,9). 

In patients with oropharyngeal dysphagia, clinical 

evaluation of swallowing associated with instrumental 

evaluation techniques such as nasolaryngofibroscopy (FEES) 

(10) is required, which assists in the application of therapeutic 

approaches. 

The present study aimed to characterize swallowing 


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Clinical and fiberoptic endoscopic assessment of swallowing in patients with chronic obstructive pulmonary disease. 

Macri et al. 

in patients with COPD and correlate the findings of 

swallowing with the degree of COPD, heart and respiratory 

rate, oxygen saturation, and smoking. 

METHOD 

A prospective cohort study was performed in 19 

patients with confirmed diagnosis of COPD. Seven patients 

(40.0%) were female and 12 patients (60.0%) were male. 

Patient age ranged between 50 and 85 years, with a mean 

of 66.7 years. This study was approved by the research 

ethics committee of our institution (No. OF. CEP Hospital 

Angelina Caron 42/09). Subjects signed a consent form 

after being informed of the objectives, procedures, and 

responsibilities of the study, as well as receiving answers to 

any questions regarding the study. 

Inclusion criteria included patients of both genders 

aged over 50 years with a diagnosis of COPD according to 

the GOLD scale (11), who had not used inhaled medication 

up to 4 h before evaluations, and were smokers and nonsmokers. 

Patients with a lowered level of consciousness 

and clinically unstable patients were excluded from the 

study. 

The time for COPD diagnosis was 5.7 years on 

average, with a minimum of 2 months, a maximum of 12 

years, and a standard deviation of 10.0 years. Of the 19 

patients, 14 (75.0%) were smokers with a mean duration 

of smoking of 41.1 years and a standard deviation of 

smoking of 5.0 years. The remaining 5 patients (25.0%) 

had never smoked. 

The study was conducted in 2 stages on the same 

day. Patients referred to the pulmonology clinic with a 

clinical diagnosis of COPD were transferred to the 

otolaryngology clinic of the same hospital, where the tests 

were conducted. The first stage consisted of clinical 

evaluation of swallowing and the second stage consisted of 

functional assessment of swallowing using FEES (10), with 

vital signs being checked by the medical team during both 

assessments. 

During the first stage, the protocol data for clinical 

evaluation of swallowing used in our hospital were followed. 

The clinical signs of aspiration (cough, dyspnea, and “wet” 

voice) were recorded (12). The food consistencies used 

(liquid, nectar, honey, pudding, and solid) followed the 

pattern of the American Dietetic Association (ADA) (13). 

For this evaluation, patients completed a sequence of 3 

swallows (free swallow, 5 mL, and 10 mL) for each food 

consistency. Swallowing function was evaluated by uptake 

of the bolus, closing of the lips, preparation of the bolus, 

subsequent extraoral exhaust, waste in the oral cavity, 

throat clearing, and coughing reflex. After evaluation, the 

Functional Oral Intake Scale (FOIS) (14) was applied to 

assess the level of food intake of each patient. 

During the second stage, FEES (10) was performed 

by otolaryngologists following the protocol data for FEES 

evaluation of swallowing used in our hospital. We used the 

same consistency of foods offered during the clinical 

evaluation of swallowing function, plus the inorganic dye 

aniline blue to contrast with the pink color of the mucosa. 

During examination, the presence of exhausted intraoral 

posterior pharyngeal residue in the posterior pharyngeal 

wall, epiglottic vallecula, and piriform sinus as well as 

pharyngeal clearance (number of swallows needed for 

clearance) and laryngeal penetration or tracheal aspiration 

(with or without reflex cough) were observed. The Severity 

Scale for Dysphagia: Penetration and Aspiration (15) was 

applied to the results. 

RESULTS 

Regarding respiratory impairment, 16 patients 

(85.0%) were in ambient air and 3 patients (15.0%) were 

oxygen dependent, one (5.0%) with 2 liters of oxygen, 

one (5.0%) with 3 liters of oxygen, and one (5.0%) with 5 

liters of oxygen. Regarding breathing pattern, 4 patients 

(20.0%) had wheezing, 1 (5.0%) showed mouth breathing, 

4 (20.0%) were mixed, 1 (5.0%) had tachypnea, and 9 

(50.0%) had dyspnea. 

Upon clinical evaluation of swallowing, all patients 

showed clinical signs of cough. Regarding food intake, all 

19 patients (100.0%) were at level 7 (oral full and 

unrestricted) of the FOIS. FEES findings indicated that 

exhausted intraoral posterior residue prevailed in 5 patients 

(26.5%) and no patient had tracheal aspiration. Residue in 

the epiglottic vallecula occurred in 1 patient (5.0%) with 

liquid and in 2 patients (10.5%) with solid food, both with 

bleaching. 

At the significance level of 0.05, there was no 

significant relationship between subsequent intraoral escape 

and the degree of COPD, heart and respiratory rate, 

oxygen saturation, or smoking, which can be observed in 

Tables 1, 2, 3, 4, and 5, respectively. The Severity Scale for 

Dysphagia: Penetration and Aspiration score was 1 (contrast 

does not enter the airway) in all 19 patients (100.0%). 

DISCUSSION 

Defining the incidence of oropharyngeal dysphagia 

in patients with COPD, as well as the identification of 

possible risk factors, may be useful in the management and 


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Macri et al. 

Table 1. Relationship between the degree of copd and intraoral escape. 

COPD GRADE 

INTRAORAL ESCAPE 

Pudding Liquid Solid 

A P A P A P 

II 2 (10.5%) - 1 (5.0%) 1 (5.0%) 2 (10.5%) - 

III 8 (42.5%) 1 (5.0%) 9 (47.5%) - 7 (37.0%) 2 (10.5%) 

IV 7 (37.0%) 1 (5.0%) 6 (31.5%) 2 (10.5%) 5 (26.0%) 3 (16.0%) 

p 0.6784 0.3756 0.3359 

COPD = chronic obstructive pulmonary disease, A = absent, P = present. 

Fisher’s test at a significance level of 0.05. 

Table 2. Relationship between heart rate and intraoral escape. 

HR 


(bpm) Pudding Liquid Solid 

A P A P A P 

Less than 80 2 (10.5%) 1 (5.0%) 3 (16.0%) - 2 (10.5%) 1 (5.0%) 

80–89 7 (37.0%) - 7 (37.0%) - 6 (31.5%) 1 (5.0%) 

90–99 6 (31.5%) - 3 (16.0%) 3 (16.0%) 5 (26.5%) 1 (5.0%) 

100 or more 2 (10.5%) 1 (5.0%) 3 (16.0%) - 1 (5.0%) 2 (10.5%) 

p 0.7368 0.0867 0.4443 

HR = heart rate, bpm = beats per minute, A = absent, P = present. 


Table 3. Relationship between respiratory rate and intraoral escape. 

RR 


(bpm) Pudding Liquid Solid 

A P A P A P 

Less than 17 7 (37.0%) - 7 (37.0%) - 7 (37.0%) - 

17–18 8 (42.5%) 1 (5.0%) 6 (31.5%) 3 (16.0%) 6 (31.5%) 3 (16.0%) 

19 or more 2 (10.5%) 1 (5.0%) 3 (16.0%) - 1 (5.0%) 2 (10.5%) 

p 0.3860 0.2270 0.0681 

RR = respiratory rate, bpm = breaths per minute, A = absent, P = present. 


Table 4. Relationship of oxygen saturation with intraoral escape. 

O 2 

SATURATION 


(mmHg) Pudding Liquid Solid 

A P A P A P 

Less than 80 1 (5.0%) 1 (5.0%) 2 (10.5%) - 1 (5.0%) 1 (5.0%) 

80–89 2 (10.5%) - 2 (10.5%) - 1 (5.0%) 1 (5.0%) 

90 or more 14 (73.5%) 1 (5.0%) 12 (64.0%) 3 (16.0%) 12 (64.0%) 3 (16.0%) 

p 0.3860 0.4696 0.2722 

O 2 

= oxygen, A = absent, P = present. 


Table 5. Relationship between smokers and non-smokers and intraoral escape. 

GROUP 


Pudding Liquid Solid 

A P A P A P 

TAB 12 (63.5%) 2 (10.5%) 12 (65.0%) 2 (10.0%) 10 (55.0%) 4 (20.0%) 

NTAB 5 (26.0%) - 4 (20.0%) 1 (5.0%) 4 (20.0%) 1 (5.0%) 

p 0.5322 0.6244 0.6026 

TAB = smoker, NTAB = non-smoker, A = absent, P = present. 



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Macri et al. 

prevention of complications resulting from this disease, 

assisting in the control of morbidity and mortality and cost 

reduction (16). 

When the results of a previous study were corrected 

for smoking, the risk for chronic bronchitis became equal 

for men and women (17). In the current study of 19 

patients, 60.0% were male and 73.5% had contact with 

smoke or were smokers, which is similar to results found in 

the literature. 

Dyspnea is the most common symptom of COPD, 

and is a term used to characterize the subjective experience 

of respiratory distress. There is a correlation between 

COPD and swallowing disorders, which shows that 

breathing during swallowing is halted and resumed 

predominantly in the inspiratory phase, increasing the 

risk of aspiration (18). Cough can be considered as a 

variable parameter in clinical evaluation, since it can be 

present in both COPD and dysphagia. The presence of 

this symptom in patients with oropharyngeal dysphagia, 

regardless of form or intensity, is a warning sign of the 

presence of potential tracheal aspiration, especially when 

it is associated with food. This kind of aspiration increases 

the risk of aspiration pneumonia, regardless of the 

mechanism of action. 

In the present study, posterior intraoral escape was 

the variable most commonly found in patients during FEES. 

This finding is related to motor impairment of swallowing, 

and the longer the delay in firing the swallowing reflex, the 

greater the chance of aspirating part of the bolus, since the 

airway remains open (19,20). 

The presence of food residues in the epiglottic 

vallecula and/or piriform sinus can occur because of changes 

in the preparatory phase and/or oral swallowing, inefficiency 

of the ejection bolus, delayed triggering of the swallowing 

reflex, a decrease in peristalsis, reduced laryngeal elevation, 

or anterior and/or incoordination of the cricopharyngeal 

muscle (21). 

Since the presence of the characteristic symptoms 

of COPD affects the quality of life of these patients, we 

chose to correlate symptoms including degree of COPD, 

heart and respiratory rate, oxygen saturation, and smoking 

with intraoral exhaust with a view to subsequent observation 

of the impact of swallowing on worsening of pulmonary 

symptoms. Patients with COPD have impaired swallowing 

and a greater risk of aspiration pneumonia when compared 

with healthy patients (22). 

Patients with COPD have abnormal autonomic control 

of cardiac function and this study corroborates the research 

in question (23). 

The lack of coordination between swallowing and 

breathing increases the risk of aspiration in tachypneic or 

dyspneic patients, since they may not be able to tolerate 

longer periods or even short periods of apnea during 

swallowing. The normal respiratory rate based on a normal 

adult ranges from 12 to 20 breaths per minute (24). 

In the current study, it was observed that for 

pudding and liquid food consistencies, 10.5% of patients 

had posterior intraoral escape, but for solid food consistency, 

21.0% of patients had subsequent intraoral escape. There 

have been no previous studies on this association published 

in the literature. When cough is a major symptom during 

clinical evaluation of patients with COPD, it is evident that 

instrumental assessment is important for a more accurate 

diagnosis. With the evolution of disease, patients with 

COPD develop a profile of dysphagia, and the cough reflex 

should be taken into consideration by the audiologist as a 

possible sign of swallowing disorders (12). 

The role of the speech therapist in multidisciplinary 

teams is effective in dysphagic patient outcomes, and their 

early intervention allows regress of the increased risk of 

dysphagia in patients with COPD. The late identification of 

swallowing disorders can lead to severe pulmonary 

complications associated with aspiration (25). 

With health care programs aimed at recognition by 

professionals involved in the care of patients with COPD, 

the signs and symptoms of swallowing disorders can be 

incorporated into multidisciplinary care. 

CONCLUSION 

In this study, it was concluded that patients with 

COPD showed no oropharyngeal dysphagia upon clinical 

evaluation of swallowing. FEES revealed that there was a 

prevalence of oral dysphagia with the finding of subsequent 

intraoral escape. There was no relationship between 

subsequent intraoral escape and the degree of COPD, 

heart and respiratory rate, oxygen saturation, or smoking. 

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DOI: 10.7162/S1809-97772013000300008 

Characteristics of polypoid lesions in patients undergoing microsurgery of 

the larynx 

Jorge Massaaki Ido Filho 1 , Bettina Carvalho 2 , Flavio Massao Mizoguchi 3 , Guilherme Simas do Amaral Catani 1 , 

Evaldo Dacheux de Macedo Filho 1 , Osvaldo Malafaia 4 , Henrique Jorge Stahlke Jr. 5 

1) ENT doctor recognized by ABORL (Physician at Hospital IPO and at the ENT Department of HC/UFPR.) 

2) ENT doctor recognized by ABORL (Fellow at Hospital IPO) 

3) ENT doctor recognized by ABORL (Physician at Hospital IPO) 

4) PhD in Medical Anatomy (1976). Professor associated with the postgraduate program in Surgical Principles at the Faculdade Evangelica do Parana. 

5) PhD in Clinical Surgery in the postgraduate program at UFPR (2002).Professor and Coordinator of Vascular Surgery at HC/UFPR. 

Institution: Hospital IPO. 

Curitiba / PR – Brazil. 

Mailin address: Hospital IPO - Dra Bettina Carvalho - Av. República Argentina, 2069 - Água Verde - Curitiba / PR – Brazil - Zip Code: 80620-010 - Telephone: 

(+55 41) 3314-1500 - http://ipo.com.br - E-mail: contato@ipo.com.br 

Article received on January 24 th , 2013. Article accepted on March 19 th , 2013. 

SUMMARY 

Introduction: Dysphonia is the main symptom of lesions that affect the vocal tract. Many of those lesions may require surgical 

treatment. Polyps are one of the most common forms of vocal cord lesions and the most prevalent indication for laryngeal 

microsurgery. There are different types of polyps, and their different characteristics can indicate different prognosis and treatments. 

Aim: To conduct a comparative study of polypoid lesions (angiomatous and gelatinous) in patients undergoing laryngeal 

microsurgery via an electronic protocol. 

Method: We prospectively evaluated 93 patients diagnosed with vocal fold polyps; the polyps were classified as angiomatous 

or gelatinous. 

Results: In total, 93 patients undergoing laryngeal microsurgery were diagnosed with vocal fold polyps. Of these, 63 (64.74%) 

had angiomatous and 30 (32.26%) gelatinous polyps. Most patients with angiomatous polyps were men; their polyps were 

frequently of medium size, positioned in the middle third of the vocal fold, and accompanied by minimal structural alterations 

(MSA). In contrast, the majority of patients with gelatinous polyps were women; their polyps were smaller, positioned in the 

middle and posterior third of the vocal fold, and were not accompanied by MSA. Both types of polyps were more frequently 

located on the right vocal fold. 

Conclusion: Angiomatous polyps were more frequently encountered than gelatinous polyps. In addition, correlations between 

polyp type and sex, polyp size, position, location, and the presence of MSA were observed. Different surgical techniques were 

used, but the postoperative results were similar and satisfactory after speech therapy. 

Keywords: Polyps; Vocal Cords; Microsurgery. 

INTRODUCTION 

Dysphonia is the main symptom of lesions that 

affect the vocal tract. More than 50% of individuals with 

voice disorders have benign alterations of the vocal fold 

mucosa. Polyps are one of the most frequent vocal cord 

lesions and are the most prevalent indication for laryngeal 

microsurgery. Like nodules, polyps are caused by overuse 

and abuse of the voice (1), although they may also occur 

as a result of a single traumatic incident (2,3). Trauma can 

affect the superficial vases of the lamina propria causing 

the liquids within to overflow, displacing the epithelial 

layer and inducing scarring due to the deposition of fibrin 

and vascular proliferation. Depending on the type of 

vascularization, polyps are classified as angiomatous or 

hemorrhagic if accompanied by vascularity or as hyaline or 

gelatinous in the absence of vascularization. 

The clinical picture is characterized by dysphonia 

related to intense vocal use, and is generally well-defined 

and recognized by the patient. The dysphonia is constant, 

and may progressively worsen. The voice presents as 

hoarse and breathy; sometimes it can be rough and, 

infrequently, diplophonic. A diagnosis is made by assessing 

the clinical history, and by perceptive analysis and 

observation of the phonatory system, which includes 

assessments of the phonatory posture adopted, articulation, 

and attitude. Laryngoscopy with or without stroboscopy 

can confirm the diagnosis. Treatment of vocal polyps is 

essentially surgical (4). 

Vocal polyps can have many presentations and 

characteristics, and the aim of our study was to identify the 

characteristics of the polyps found in our population. 

The objective of this study was to analyze and 


279

Characteristics of polypoid lesions in patients undergoing microsurgery of the larynx. 

Ido Filho et al. 

compare the features of polyps (intrinsic characteristics, 

associated lesions, and treatment outcomes) from patients 

undergoing laryngeal surgery at our hospital. 

METHODS 

This prospective study was conducted from February 

2010 to February 2011 using an electronic computerized 

protocol once the approval of the ethics committee had 

been obtained (CAEE :0286.0208.000-11). We used the 

SINPE © electronic protocol with the SINPE© Analyzer for 

data analysis (5,6,7). The protocol-based software program 

is capable of storing and manipulating data on a theoretical 

basis. The SINPE© Analyzer module is used to create reports, 

graphs, and statistics summarizing the main findings. A 

specific protocol for laryngeal disorders among the master 

ENT protocol available in SINPE was used for the analysis; 

only patients diagnosed with vocal fold polyps were analyzed. 

In total, 245 microsurgeries of the larynx were 

performed in our Hospital during the study period. The 

inclusion criteria were as follows: a diagnosis of polyps, 

clinical laryngoscopy, and intraoperative confirmation of 

the diagnosis by anatomopathology. Exclusion criteria 

were as follows: a diagnosis of infiltrative processes or 

storage disease (vocal polyps not identified upon 

anatomopathologic examination). 

Of the 245 patients who underwent surgery during 

the study period, 93 (36.61% of lesions) with vocal polyps 

and an indication for microsurgery were evaluated. These 

93 patients were classified into 2 groups according to the 

physical and histological characteristics of the lesions: (a) 

those with angiomatous polyps (n = 63, 67.75%) and (b) 

those with gelatinous polyps (n = 30, 32.25%). Comparisons 

between the 2 groups were made according to 12 anatomic 

and surgical parameters based on the polyp characteristics. 

Parameters 1–8 refer to the intrinsic characteristics of the 

polyps (Table 1), parameters 9 and 10 refer to polypassociated 

lesions (Table 2), and parameters 11 and 12 

refer to the treatment strategy (Table 3). 

Table 1. Polyp Intrinsic Characteristics. 

Parameter Description 

1. Sex male or female 

2. Age 

3. Size a) small: the polyp takes up one-third of the vocal fold 

b) medium: the polyp occupies two-thirds of the vocal fold 

c) large: the polyp fills more than two-thirds of the vocal fold 

4. Implantation a) sessile: the lesion is considered sessile if it has a wide base 

b) pedunculated: the polyp presenting small implantation with elevation of its base (with a stalk or peduncle) 

5. Lobulation a) unilobulated: only one lobulation 

b) bilobulated: two lobulations 

c) multilobulated: many lobulations 

6. Position a) anterior third: the polyp is within the anterior third of the vocal fold 

b) middle third: the polyp is within the middle third of the vocal fold 

c) posterior third: the polyp is within the posterior third of the vocal fold 

7. Location a) free edge: the polyp is located at the free edge of the vocal fold 

b) upper edge: the polyp is located at the top edge of the vocal fold 

c) lower edge: the polyp is located on the bottom edge of the vocal fold 

d) more than one location: the polyp covers various sites (e.g., transglottic polyp) 

8. Location of polyp a) right vocal fold 

on vocal fold b) left vocal cord 

c) bilateral: polyp on both the right and left folds 

Table 2. Associated lesions. 

Parameter 

Description 

9. Presence of associated lesions and their type a) nodular reaction d) groove bag g) mucous cyst 

b) varicosity e) stria minor h) mucosa bridge 

c) stria major f) intracordal cyst i) microdiaphragm 

10. Associated lesions in relation to the vocal fold a) ipsilateral - on the same vocal fold polyp 

b) contralateral - on opposite vocal fold polyp 


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Table 3. Treatment. 

Parameter Description 

11. Surgical technique a) polyp grip + microscissors (holding the polyp and performing resection with microscissors) 

b) medial microflap + microscissors (microbisturi incision, creation of a medial microflap, and resection with 

microscissors) 

12. Evolution of a)optimal: satisfactory treatment 

Speech therapy b) poor: unsatisfactory treatment 

Table 4. Comparative analysis of internal characteristics of angiomatous and gelatinous polyps. 

Parameter Angiomatous Gelatinous p < 0.05 

n = 63 (64.74%) n = 30 (32.26%) 

1. Sex 

Male 41 (65.08%) 10 (33.33%) 

Female 22 (34.92%) 20 (66.67%) p = 0.008 

2. Age 41–60 years (49.21%) 20–40 years (46.67%) 

3. Size Medium Small 

43 (68.25%) 17 (56.67%) p = 0.001 

4. Implantation Pedunculated Sessile 

35 (55.56%) 19 (63.33%) 

5. Lobulation Unilobulated Unilobulated 

53 (84.13%) 26 (86.67%) 

6. Position 

anterior third 25 (35.71%) 8 (26.67%) 

middle third 36 (51.43%) 11 (36.67%) p = 0.02 

posterior third 9 (12.86%) 11 (36.67%) 

*Number of positions: 34 (53.96%) 24 (80%) p = 0.03 

One 29 (46,04%) 6 (20%) 

More than one 

7. Location Free edge Free edge 

42 (66.67%) 20 (66.67%) 

8. Location of polyp on 

vocal fold: 

right 39 (61.9%) 14 (46.67%) 

left 22 (34.92%) 9 (30%) p = 0.009 

bilateral 2 (3.17%) 7 (23.33%) 

The protocols were performed on the day before 

surgery after the pre-anesthetic consultation, and 

supplemented during the postoperative follow-up. 

Endolaryngeal microsurgeries were performed in the 

operating room of the same institution using suspension 

laryngoscopy (SL) by 3 doctors from the Laryngology and 

Voice Service department. 

During SL, the vocal folds were subject to visual 

inspection and palpation with delicate microforceps. The 

microsurgical technique used depended on the preoperative 

evaluation and its confirmation during surgery. 

Statistical analyses were performed using the Chisquare 

test to compare the variables discussed above, and 

the significance level was set at p < 0.05. 

RESULTS 

All 93 patients underwent laryngeal surgery due to 

a diagnosis of polyps of the vocal folds during the period 

February 2010 to February 2011. Of these, 63 (64.74%) 

had angiomatous and 30 (32.26%) had gelatinous polyps. 

Regarding sex, 51 were male and 42 female. Their age 

ranged from 20 to 80 years. The distribution according to 

the 12 parameters for each type of polyp is shown in 

Tables 4, 5, and 6. 

DISCUSSION 

Benign lesions of the vocal folds represent a 


281



Table 5. Comparative analysis of parameters relating to lesions associated with angiomatous and 

gelatinous polyps. 


n = 63 (64.74%) n = 30 (32.26%) 

9. Associated lesions p = 0.02 

a) nodular reaction 26 (44.83%) 13 (65%) 

b) varicosity 8 (13.79%) 4 (20%) 

c) stria major 8 (13.79%) 1 (5%) 

d) groove bag 4 (6.9%) 0 

e) stria minor 3 (5.17%) 0 

f) intracordal cyst 4 (6.9%) 1 (5%) 

g) mucous cyst 2 (3.45%) 1 (5%) 

h) mucosa bridge 2 (3,45%) 0 

i) microdiaphragm 1 (1.72%) 0 

* Presence of MSA 

Present 30 (47,61%) 6 (20%) 

Absent 33 (52.39%) 24 (80%) 

10. Association of lesions 

with the vocal fold: 

Ipsilateral 44 (69.84%) 27 (76.67%) 

Contralateral 19 (30.16%) 7 (23.33%) 

Table 6. Comparative analysis of parameters for treatment of angiomatous and gelatinous polyps. 


n = 63 (64.74%) n = 30 (32.26%) 

11. Surgical technique 

Grip+ microscissors 36 (57.14%) 12 (40%) 

Medial microflap+ microscissors 27 (42.6%) 18 (60%) 

12. Evolution of speech therapy Optimal Optimal 

56 (88.89%) 28 (93.33%) 

significant problem for otolaryngologists because they are 

very common and require a multidisciplinary treatment 

approach. When such lesions do not respond to drug 

therapy and/or speech therapy, surgery is required with 

the aim of increasing phonatory function or establishing a 

histological diagnosis by biopsy (8, 9). 

In our study, we found 93 (36.61%) polyps among 

245 patients with vocal fold lesions who underwent laryngeal 

surgery during the period from February 2010 to February 

2011 in our Hospital. This was the most frequent diagnosis 

observed in this study, which supports the reports by Haas 

& Doderlein, Mossallam, and Lehmann and Kleinsasser, 

who noted that polyps were the main indication for 

laryngeal microsurgery (10-13). 

Angiomatous polyps were more common (63 

patients, 64.74%) than gelatinous polyps (30 patients, 

32.26%). In addition, we noticed a male predominance 

among patients with angiomatous polyps and a female 

predominance among those with gelatinous polyps. The 

Chi-square test (significance level, p = 0.008) showed that 

the type of polyp was dependent on sex. The male 

predominance of angiomatous polyps (65.08%) is 

consistent with the findings reported in the literature 

(3,14,15), but there was no male predominance of 

gelatinous polyps. Instead, these were more common in 

women (66.67%), which is a similar finding to that 

obtained by Dailey, who reported a female incidence of 

62% among patients with gelatinous polyps (16). This 

may be because women are more likely to seek medical 

advice than men. In addition, female patients with 

increased vocal fold mass have a lower pitch, which has 

a greater impact on the social life of these patients than 

is the case with male patients. 

Regarding size, the statistical analysis demonstrated 

that the polyp size was dependent on type. Most 

angiomatous polyps were of medium size (68.25%) whereas 

most gelatinous polyps were small (56.67%) (p = 0.001). 

Angiomatous polyps were also found most frequently in 

the middle third of the vocal fold (51.43%), whereas the 


282



gelatinous polyps tended to be found in the middle and 

posterior thirds of the fold (36.67% each) (p = 0.02). Thus, 

the position of the polyp in the vocal fold was also 

dependent on type. 

In our study, both angiomatous and gelatinous 

polyps were predominantly found on the right vocal fold 

(p = 0.009), and so there is also a relationship between 

polyp type and its location on the vocal fold. Eckley et al. 

reported similar findings (14), whereas Sakae et al. (17) 

reported that polyps were found in the left vocal fold in 

53% of cases. 

The presence of MSA occurred in 47.61% of patients 

with angiomatous polyps, in comparison with 20% of 

patients with gelatinous polyps (p = 0.02). There was thus 

also a correlation between polyp type and the presence of 

MSA (greater in angiomatous polyps). In Sakae et al.’s 

study (16), polyps were associated with MSA in 23.5% of 

patients. 

Reaction nodular lesions were found in 41.26% 

of the patients with angiomatous polyps and 43.33% of 

the patients with gelatinous polyps. There was no 

statistical difference between the two groups (p = 

0.97). In Eckley et al.’s study (14), 37% of patients had 

reaction lesions, confirming the suspicion that the 

impact of the polyp on the healthy vocal fold can cause 

long-term alterations in the epithelial layer of the 

contralateral vocal fold (14,18). 

Regarding the MSA, stria were the most frequently 

encountered lesions (49.9%) in angiomatous polyps, 

whereas varicosity was predominant in gelatinous polyps 

(66.66%). In Eckley et al.’s study (14), stria were the most 

frequently encountered MSA (70%). 

In our study, the patients underwent larynx surgery 

with SL, which led to considerable improvement in voice 

quality and the remission of other symptoms. The surgical 

technique most commonly used for angiomatous polyps is 

to grab the polyp and resect it with a microscissors 

(57.14%). For gelatinous polyps, the main surgical technique 

is to create a medial microflap and then resect it with a 

microscissors (60%). There was no difference in outcome 

when these techniques were compared. 

After surgery, all of the patients underwent speech 

therapy with optimal developments in most cases (88.89 

and 93.33% for those with angiomatous and gelatinous 

polyps, respectively). There is a consensus regarding the 

use of postoperative speech therapy and appropriate 

follow-up and successful outcome (9). We plan to undertake 

further analysis of the therapy outcomes in subsequent 

research projects. 

CONCLUSION 

In this study, angiomatous polyps were more 

frequently encountered than gelatinous polyps. There was 

a male predominance among patients with angiomatous 

polyps, and a female predominance among those with 

gelatinous polyps. Angiomatous polyps were more 

frequently associated with MSA. There was also a correlation 

between the size of the polyp, and its position and location 

in the vocal fold and the presence of MSA. Different 

surgical techniques were used, but the postoperative 

results were similar and satisfactory once the therapy was 

complete. 

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DOI: 10.7162/S1809-97772013000300009 

Audiological outcomes of cochlear implantation in Waardenburg Syndrome 

Ana Tereza de Matos Magalhães 1 , Paola Angélica Samuel 1 , Maria Valeria Schimdt Goffi-Gomez 2 , Robinson Koji Tsuji 3 , 

Rubens Brito 3 , Ricardo Ferreira Bento 3 . 

1) Audiologist. Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil. 

2) Audiologist, PhD. Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil. 

3) MD, PHD. Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil. 

Institution: Department of Otolaryngology, University of São Paulo School of Medicine. 

São Paulo / SP - Brazil. 

Mailing address: Ana Tereza de Matos Magalhães - Rua Capote Valente, 432 conjunto 14 - São Paulo / SP - Brazil - Zip code: 05409-001 - E-mail: anatereza@forl.org.br 

Article received on February 11 th , 2013. Article accepted on April 23 th , 2013. 

SUMMARY 

Introduction: The most relevant clinical symptom in Waardenburg syndrome is profound bilateral sensorioneural hearing loss. 

Aim: To characterize and describe hearing outcomes after cochlear implantation in patients with Waardenburg syndrome to 

improve preoperative expectations. 

Method: This was an observational and retrospective study of a series of cases. Children who were diagnosed with Waardenburg 

syndrome and who received a multichannel cochlear implant between March 1999 and July 2012 were included in the study. 

Intraoperative neural response telemetry, hearing evaluation, speech perception, and speech production data before and after 

surgery were assessed. 

Results: During this period, 806 patients received a cochlear implant and 10 of these (1.2%) were diagnosed with Waardenburg 

syndrome. Eight of the children received a Nucleus 24 ® implant and 1 child and 1 adult received a DigiSonic SP implant. The 

mean age at implantation was 44 months among the children. The average duration of use of a cochlear implant at the time 

of the study was 43 months. Intraoperative neural responses were present in all cases. Patients who could use the speech 

processor effectively had a pure tone average of 31 dB in free-field conditions. In addition, the MUSS and MAIS questionnaires 

revealed improvements in speech perception and production. Four patients did not have a good outcome, which might have 

been associated with ineffective use of the speech processor. 

Conclusion: Despite the heterogeneity of the group, patients with Waardenburg syndrome who received cochlear implants 

were found to have hearing thresholds that allowed access to speech sounds. However, patients who received early intervention 

and rehabilitation showed better evolution of auditory perception. 

Keywords: Hearing; Cochlear Implants; Hearing Loss; Waardenburg Syndrome; Speech Perception. 

INTRODUCTION 

Cochlear implantation outcomes are dependent on 

several factors that lead to a good prognosis, such as early 

diagnosis and intervention, systematic rehabilitation, family 

permeability, and type of communication, as well as other 

factors related to hearing loss including etiology, period of 

deafness, and the presence of other associated impairments 

(1-3). 

Genetic causes of deafness include Waardenburg 

syndrome (WS), which accounts for 2%–5% of patients 

with congenital hearing loss (4). WS is an autosomal 

dominant disease characterized by hyperplasia of the 

medial portion of the eyebrows, a broad nasal root, 

heterochromia iris, white forelock or early graying, and 

congenital sensorineural hearing loss (5). 

The most relevant clinical symptom in WS is the 

hearing loss, which can be unilateral or bilateral, and 

moderate to profound. Severe to profound deafness is 

more evident in patients with Type I and Type II WS, with 

an incidence of 35%–75% and 55%–91%, respectively 

(6). Cochlear implantation is indicated for patients with 

bilateral and severe to profound hearing loss who are 

unable to benefit from conventional hearing aids. 

Few studies have evaluated the audiological 

outcomes of cochlear implantation in users with syndromes. 

Some have noted limited success depending on the 

characteristics associated with the syndrome and the age at 

implantation. Studies of WS have reported good outcomes 

for those with no other impairments associated with the 

syndrome (7-10). 

The purpose of this study was to characterize and 

describe hearing outcomes after cochlear implantation 

in patients with WS to improve preoperative 

expectations. 


285

Audiological outcomes of cochlear implantation in Waardenburg Syndrome. 

Magalhães et al. 

METHOD 

This was a retrospective and observational study of 

a series of cases and was performed from March 1999 

through July 2012. Data wee collected from the cochlear 

implant team database. Patients who met the following 

criteria were included in the study: 

• Diagnosed with WS; 

• Multichannel cochlear implant user. 

The following data were collected: 

• Age at diagnosis of deafness; 

• Age at rehabilitation initiation; 

• Age at cochlear implant activation; 

• Duration of cochlear implant use (in months); 

• Number of active electrodes; 

• Intraoperative neural telemetry results; 

• Aided average pure tone threshold in sound field c 

before and after surgery; 

• Pre- and post-operative speech perception and 

production test results. 

Intraoperative neural telemetry data were recorded 

by Nucleus NRT 3.1 ® or Custom Sound EP 2.0 ® software 

from Cochlear Corporation ® . A response was considered 

present when at least 3 electrodes presented reproducible 

responses. Electrical Auditory Brainstem Response (EABR) 

data were recorded by Bio-logic v.7.0 ® and stimulated by 

Digistim ® from Neurelec ® . 

Free field audiometry data were collected using 

Madsen Midimate 622 ® and retrieved from patient records. 

Where no threshold was available (such as during preoperative 

assessment), a value of 130 dB was used to 

calculate the average (greater than the amplifier limit); the 

calculation was performed according to the BIAP 

recommendation (11). 

Speech perception and production were evaluated 

using our standard protocols and were assessed according 

to age (12). For children up to the age of 4 years 11 months, 

the Early Perception Test (ESP) was used (the Portuguese 

form by Orlandi and Bevilacqua (13)). For children aged 5 

years or older, the Portuguese form of the Glendonald 

Auditory Screening Procedure (GASP) was used (14). In 

both tests, the results were classified into the speech 

perception categories described by Geers (15). 

Two inventories were submitted to the parents, one 

addressing information on the frequency with which the 

child showed significant auditory behaviors in their everyday 

life (IT-MAIS - Infant-Toddler Meaningful Auditory 

Integration Scale) (16, 17), the other providing information 

on the frequency with which the child demonstrated 

Table 1. Degree of permeability of the family and the cognitive 

style of the children. 

Score 

Classification 

90–100% Excellent 

60–89% Satisfactory 



Table 2. Characteristics of cochlear implant patients. 

ID SEX* Implantation age Implanted ear Number of electrodes Intraoperative neural Brand of cochlear 

(months) activated telemetry implant ** 

1. MLFN F 53 Right 22/22 Present N24 

2. JLCS M 20 Right 22/22 Present N24 RE 

3. GAS M 36 Right 22/22 Present N24 

4. MSLG M 18 Right 22/22 Present N24 

5. ASLG F 106 Left 22/22 Present N24 

6. AMNCT F 71 Right 22/22 Present N24 RE 

7. ACAFD F 38 Right 22/22 Present N24 RE 

8. VMM M 32 Right 22/22 Present N24 RE 

9. ERM M 30 Left 18/20 Present Digisonic 

10. AAC F 22 years Right 19/20 Present Digisonic 

*M = male; F = female; **N24 = Nucleus 24; N24RE = Nucleus 24 Freedom. 

Table 3. Data on hearing loss, rehabilitation, degree of permeability of the family, and the cognitive style of the children. 

ID Diag. Hearing aid Rehab. Rehabilitation Number of sess. Freq. Permeabil Cognitive 

(months) (months) (months) (per week) Style 

1. MLFN 6 15 12 Total Communicat. Once Inconsistent Low Satisfactory 

2. JLCS 10 16 12 Audio-oral Twice Consistent Excellent Satisfactory 

3. GAS 14 16 16 Audio-oral Twice Consistent Excellent Satisfactory 

4. MSLG 9 12 15 Audio-oral Twice Inconsistent Low Low 

5. ASLG 12 36 36 Audio-oral Twice Inconsistent Low Satisfactory 

6. AMNCT 20 24 24 Audio-oral Twice Consistent Low Satisfactory 

7. ACAFD 20 26 26 Audio-oral Twice Consistent Excellent Low 

8. VMM 5 18 12 Audio-oral Twice Consistent Satisfactory Satisfactory 

9. ERM 6 14 14 Audio-oral Twice Consistent Satisfactory Low 

10. AAC 7 24 24 Audio-oral Twice Consistent — — 

ID: identification; Diag: Age at diagnosis; Hearing aid: Age when began using hearing aids; Rehab.: Beginning of rehabilitation; 

sess.: sessions; Freq.: Frequency of rehabilitation; Permeabil: Degree of permeability of the family. 

Table 4. Audiological outcomes and speech perception among children with a cochlear implant. 

ID Effective use of CI Time of CI use PTA (em dBNA) Category IT-MAIS/MAIS MUSS 

Pre CI Pos CI Pre CI Pos CI Pre CI Pos CI Pre CI Pos CI 

1. MLFN Yes 174 110 25 0 5 25% 100% 20% 100% 

2. JLCS Yes 60 105 20 0 6 0% 100% 40% 97.5% 

3. GAS Yes 54 105 25 0 6 7.5% 100% 45% 100% 

4. MSLG No 48 100 60 0 1 30% 17.5% 25% 2.5% 

5. ASLG No 36 70 50 0 2 55% 70% 80% 85% 

6. AMNCT No 24 75 50 0 1 0% 60% 0% 75% 

7. ACAFD No 6 ABS 110 0 0 10% 30% 40% 37% 

8. VMM YES 24 75 30 0 4 5% 75% 20% 80% 

9. ERM YES 6 ABS NR 0 1 0% 20% 0% 15% 

CI: cochlear implant; PTA (Pure tone average) Average threshold at 500 Hz and 4000 Hz (11); ABS = Absent; NR=unrealized; 

Category: Category of speech perception (15). 

MUSS and MAIS questionnaire responses did not show any 

improvement in speech perception or production. 

Case 10 was able to discriminate all of the vowels 

and 80% of a closed-set sentence after 9 months of using 

the speech processor. 

DISCUSSION 

All patients were diagnosed with severe to profound 

congenital hearing loss, which is in accordance with Barzotto 

and Folador (21), who showed that the most common form 


287



of hearing loss in WS is profound sensorineural. The 

prevalence of patients with WS who received a cochlear 

implant in this study was 1.2%, which is close to the value 

generally reported in the literature (8-10, 22). 

During the pre-implant evaluation, no patient was 

found to have benefited from conventional hearing aids, 

which corresponds to category 0 of speech perception and 

an inability to detect speech sounds. Thus, cochlear 

implantation was indicated. 

All patients had complete insertion of electrodes 

and showed an intraoperative neural response, which 

means that the auditory nerve responded to the first 

electrical stimulation of the cochlear implant. Guedes et 

al.(1) showed that adult patients who showed intraoperative 

telemetry responses had better results in speech perception 

tests, but this relationship was not statistically significant 

among children. 

Assessment of the hearing outcomes of all patients 

who were able to use the cochlear implant effectively 

showed that all had audiometric thresholds that enabled 

perception of speech sounds (according to the audiogram 

of Portuguese speech sounds) (23). 

The IT-MAIS questionnaire results also showed 

significant clinical improvements in most cases, reflecting 

improvements in listening skills, not only for detection, but 

also for the recognition of some sounds, since most of the 

patients had a good hearing threshold. Kubo et al. (3) 

showed that after 6 to 12 months of use of a cochlear 

implant, children were able to distinguish and recognize 

sounds. In cases 4, 5, and 7 in the present study no clinical 

improvement was detected by IT-MAIS because the child 

didn´t use the cochlear implant effectively, that is, there 

were care and maintenance problems as well as infrequent 

use of the implant during the rehabilitation process. 

The MUSS results, which reflect oral language skills, 

showed slow improvements. These skills are dependent 

on daily experience, systematic rehabilitation, and 

stimulation by the family according to Kobo et al. (3). In our 

study, we found that children with low family permeability 

did not show any difference in their MUSS responses after 

cochlear implantation. Cases 4 and 5 are brothers and the 

family was not involved with their therapy or the fitting of 

their speech processors. In case 7, the family stopped 

using the speech processor because the child did not seem 

to improve. 

These findings indicate that cochlear implants provide 

access to speech sounds, but that the development of 

auditory and language skills is dependent on systematic 

rehabilitation and family involvement (2). 

There are a few studies of cochlear implantation in 

patients with syndromes in the literature, and these show 

that patients who have no other associated intellectual 

impairments, who receive their implant early, and who are 

subject to sufficient stimulation have good outcomes (7- 

10, 24). 

In cases 2 and 3 in the present study, significant 

improvements in speech perception were observed and 

the family was also a meaningful participant in the 

therapeutic process. In case 1, however, although an 

improvement in hearing behavior was observed, the 

patient’s oral language was below average after 

implantation. The family showed a low level of participation 

in the patient’s rehabilitation process and there was 

inconsistent use of the implant owing to poor care of the 

equipment, which led to numerous maintenance and 

technical assistance events, and thus undermined the 

patient’s performance. 

Out of the 10 cases described here, 3 (cases 5, 6, and 

7) presented with late fitting of hearing aids, late auditory 

rehabilitation, and late implantation, which was reflected in 

their speech perception tests. Several studies have shown 

that children experience greater benefits from cochlear 

implantation when the implant is fitted when they are 

younger than age 2, which is the ideal period for better 

leveraging the outcomes of the cochlear implant (25, 26). 

These children may show development patterns similar to 

those of children with normal hearing (27). 

Andrade et al. (10) also confirmed that prelingually 

deafened WS children who have prior nonsignificant 

or marginal benefit from acoustic amplification 

but normal inner ear anatomy are potentially good 

candidates for audio-oral rehabilitation with a cochlear 

implant. Postoperative performance outcomes of 7 cases 

with WS were also assessed and compared to results 

obtained by children with non-syndromic congenital 

deafness. No statistical differences were found between 

the groups. 

Therefore, early intervention and rehabilitation is 

essential for children with WS as well the profoundly 

hearing impaired. This will ensure that they are offered 

better conditions to achieve good outcomes with a cochlear 

implant. Parental involvement throughout the rehabilitation 

process is also important for improving the quality of 

communication. 

Results from case 10 were not satisfactory despite 

having early intervention and childhood rehabilitation. 

On the other hand, the patient has not used the cochlear 

implant for very long, and these results may improve 

over time. 


288



Genetic counseling is important for predicting the 

risk of transmission as well as for studying the family of the 

affected individual (21, 22), and genetic findings may 

influence the prognosis and treatment opportunities. 

CONCLUSION 

In our group of patients with WS who received a 

cochlear implant, hearing thresholds that allow access to 

speech sounds were achieved. However, those who showed 

good evolution of the perception of auditory and oral 

language skills were those who received early stimulation, 

systematic rehabilitation, and who had a family that was 

actively involved in the process. 

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DOI: 10.7162/S1809-977720130003000010 

Performance analysis of ten brands of batteries for hearing aids 

Silvio Pires Penteado 1 , Ricardo Ferreira Bento 2 . 

1) Electronic Engineer, PhD in Medical Science. Department of Otorhinolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil. 

2) PhD, Professor, Chairman. Department of Otorhinolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil. 

Institution: Department of Otorhinolaryngology, University of São Paulo School of Medicine. 

São Paulo / SP – Brazil. 

Mailing address: Silvio Pires Penteado - Av. Dr. Enéas Carvalho de Aguiar 255, 6 th floor - São Paulo / SP – Brazil – ZIP code: 05403-000 - Telephone: (+55 11) 

2661-6539 - E-mail : penteadosp@gmail.com 

Financial Support: Fundação Otorrinolaringologia 

Article received on February 22 th , 2013. Article accepted on April 30 th , 2013. 

SUMMARY 

Introduction: Comparison of the performance of hearing instrument batteries from various manufacturers can enable otologists, 

audiologists, or final consumers to select the best products, maximizing the use of these materials. 

Aim: To analyze the performance of ten brands of batteries for hearing aids available in the Brazilian marketplace. 

Methods: Hearing aid batteries in four sizes were acquired from ten manufacturers and subjected to the same test conditions 

in an acoustic laboratory. 

Results: The results obtained in the laboratory contrasted with the values reported by manufacturers highlighted significant 

discrepancies, besides the fact that certain brands in certain sizes perform better on some tests, but does not indicate which 

brand is the best in all sizes. 

Conclusions: It was possible to investigate the performance of ten brands of hearing aid batteries and describe the procedures 

to be followed for leakage, accidental intake, and disposal. 

Keywords: Hearing Aids; Performance Tests; Benchmarking; Batteries; Reference Standards; Laboratory Equipment. 

INTRODUCTION 

Dillon (2000) posits that the history of the 

development of hearing aids can be divided into four eras: 

the acoustic, carbon valve, transistor, and digital ages. It was 

only during the first two of these eras that batteries were 

not needed to power electrical or electronic circuits. 

Lybarger (1988) states that the first powered hearing aid in 

the U.S. was produced by Miller Reese Hutchinson in 1902; 

later, some hearing aids with portable tubes and a drain 

current of 60 mA were manufactured. Lybarger describes 

that the evolution of tubes into transistors brought no 

significant change in the noise performance of hearing aids; 

it did, however, drastically reduce battery drain and the size 

of the batteries required (the drain current was decreased 

by about 100 times). Modern hearing aids use the topology 

of transistor analog hearing aids with other electronic 

circuits that result in devices with better performance and 

electroacoustic features, but higher power consumption 

(Cudahy and Levitt, 1994). Kates (2008) states that the 

digital processor, memory, and analog/digital converter 

(the internal circuits of the digital signal processor) are 

responsible for about 70% of the entire energy consumption 

of a digital hearing aid. 

|Hearing aid batteries based on mercury were 

gradually replaced by zinc-air batteries, providing positive 

effects on the environment and advantages for patients 

(Sparkes and Lacey, 1997). As described by Bloom (2003), 

“the tiny button cells used in contemporary hearing 

instruments typically have double the life of the old 

mercury cells and three times that of silver oxide” and they 

are “small, lightweight, and leak resistant, offering large 

capacity, stable voltage, and start-up on demand.” 

Knutsen (1982) describes a cell as a device for 

converting chemical energy into electrical energy, with a 

set amount of voltage and current necessary to power an 

electrical or electronic circuit. Bocchi, Ferracin, and Biaggio 

(2000) review the confusion arising from the terms pills 

and batteries, and state that while the former should be 

understood as a device consisting of two electrodes and an 

electrolyte, the second is an association of two or more 

pills. 

Pinkwart and Tuebke (2011) present the following 

definitions: 

1.) Electrode: electrical conductor submerged in electrolyte; 

2.) Electrolyte: liquid or gel that contains free ions, which 

can be decomposed by electrolysis; 

3.) Electrolysis: non-spontaneous process in which a direct 

current is used with the goal of obtaining a chemical 

reaction; 

4.) Anode: the electrode where reduction occurs (to which 

electrons move towards), known as the positive pole; 


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Performance analysis of ten brands of batteries for hearing aids. 

Penteado et al. 

5.) Cathode: the electrode where oxidation occurs (from 

which electrons move away), also known as the negative 

pole. 

One of the manufacturers of zinc-air batteries 

(Energizer, 2004) states that electricity is obtained from the 

following electrolytic reactions: 

A.) Anode: Zn + 2OH ZnO + H2O + 2e 

B.) Cathode: O2 + 2H2O + 4e 4OH 

C.) Final: 2Zn + O2 2ZnO 

Reducing the terms gives the following reaction: 

Zn + O2 ZnO (1) 

Zinc (Zn) particles are mixed with an electrolyte, 

while water and oxygen in the air react to form hydroxides 

at the cathode, which migrate to form zincate (Zn(OH) 4 

2- 

). Electrons are released and flow to the cathode where 

reduction produces zincate oxide (ZnO), while water is 

returned to the system. Water and zinc hydroxide are 

recycled at the anode for the cathode, so that water 

serves as a catalyst for the reaction. A typical voltage 

resulting from this reaction is 1.4 V (Energizer, 2004). If 

stored at room temperature without removal of the seal 

to the air inlet, a zinc-air cell can store 95% of its capacity 

for one year, or 90% of its capacity for up to two years. 

Valente et al. (2007) state that the positive holes in 

batteries serve to reset the O 2 

battery, resulting in 

electric battery terminals (Formula 1). Zinc-air batteries 

are practical with good energy density, are stable and 

safe with a low voltage and current, and must be 

discarded after use (Wei et al., 2000). Zinc does not 

harm the environment, is easier to store than other 

materials (e.g., O 2 

), and can be processed in water-based 

electrochemical systems (Zhang, Bruce, and Zhang, 

2011). 

IEC60086-1:2006 and IEC60086-2:2006 are 

applicable to primary batteries and specify their physical 

dimensions as well as their test conditions and discharge 

performance requirements. The following terms are taken 

from the later standard: 

I.) Nominal voltage of primary battery: suitable 

approximate value of voltage used to identify the 

voltage of a primary battery; 

II.) End-point voltage: specified voltage of a battery at 

which the battery discharge is terminated; 

III.) Closed circuit voltage: voltage across the terminals of 

a battery when it is on discharge; 

IV.) Primary cell: one or more primary cells, including case, 

terminals, and marking; 

V.) 

Storage life: duration under specified conditions at the 

end of which a battery retains its ability to perform a 

specified service output; 

VI.) Terminals: conductive parts provided for the 

connection of a battery to external conductors; 

VII.) Application test: simulation of the actual use of a 

battery in a specific application; 

VIII.) Off-load voltage: voltage across the terminals of a 

battery when no current is flowing; 

IX.) Service output: service life, or capacity, or energy 

output of a battery under specified conditions of 

discharge; 

X.) 

Discharge: operation during which a battery delivers 

current to an external circuit; 

XI.) Leakage: unplanned escape of electrolyte, gas, or 

other material from a battery. 

Halliday and Resnick (1988) report the following 

definitions: 

a.) Voltage-electrical potential: difference between two 

poles, may be continuous voltage (one pole is always 

positive and the other always negative) or alternating 

current (the poles vary in their polarity); 

b.) Electrical current: orderly movement of electrons, which 

can be direct or alternating; 

c.) Electrical resistance: electrical component that hinders 

the passage of electric current, dissipating heat energy 

to the mean; 

d.) Load-end component: circuit that receives electrical 

current at its terminals; 

e.) Recharging the battery: the inverse process to the 

normal operation of a battery in which tension is 

applied at its terminals, to recombine the electrolyte to 

the battery so that it can continue to feed a load. 

Digital signal processors force the involuntary shut 

down of hearing aids when the supply voltage reaches 1.0 

V (SDT, 2007) by ensuring that the voltage is not sufficient 

to power the electronic circuit, preventing unpredictable 

behavior and avoiding insufficient amplification or 

occurrence of spurious signals with high levels of distortion. 

Kates (2008) states that a battery for a hearing aid should 

last for at least 50 hours. 

As we describe later, even battery manufacturers do 

not always make the technical data for their batteries 

available. Only one distributor of hearing aid batteries 

(Microbattery, 2013) provides an online table comparing 

the specifications of 10 brands, by presenting the data 

sheets from various manufacturers. However, this focuses 

on presenting information for marketing purposes in order 

to promote sales through their website. 

With this information in mind, it can be seen that 

it is difficult for otologists and audiologists to recommend 

the brand of hearing aid battery with the best performance 

to patients. Factors such as patient comparisons of battery 

brand durability, the risk of battery leaks and how to deal 

with them, procedures to use in the case of ingestion, how 

to dispose of hearing aid batteries, whether zinc-air 


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batteries can be recharged, and if rechargeable batteries 

fully replace zinc-air batteries have not been fully 

investigated. There are no publications in the literature 

addressing these basic concerns, although some 

information can be found in scientific publications and lay 

media. 

Thus, we attempted to address the above concerns 

and develop laboratory tests for the practical purpose of 

comparing the performance of 4 different sizes of 10 

brands of batteries for hearing aids that can be found in the 

Brazilian marketplace. We did not conduct a financial 

analysis between zinc-air batteries and rechargeable 

batteries. The primary objective of this research was to 

investigate the performance of 10 brands of hearing aid 

batteries under the same test conditions. The secondary 

objectives were to describe courses of action to be taken 

for battery leaks, accidental intake, and disposal. 

Battery identification 

Hearing aid pills are commonly marketed as batteries; 

therefore, we refer to pills, cells, and batteries as batteries 

in this work. Once the batteries were checked they were 

identified as ExtraPower (A), ClearCell (B), PowerOne (C), 

Renata (D), Energizer (E), Duracell (F), Rayovac (G), 

icellTech (H), Sony (I), or Panasonic (J). These identifications 

made it possible to avoid any confusion concerning the 

manufacturer and model, and were marked on the batteries 

with a knife. This marking system did not cause the 

exchange of heat with the batteries and thus did not 

change the electrolytes inside the batteries. Figure 1 shows 

a #675 battery by ExtraPower. Figure 2 shows a #675 

battery by ClearCell viewed under a microscope. Two 

packs were acquired from each of the manufacturers listed 

in Chart 1 so that we could retest any of the batteries as 

required (Figure 1 and 2). 

METHOD 

This study was performed in the Laboratory of 

Acoustics at the Department of Otorhinolaryngology 

between June 17, 2011 and February 5, 2012. 

Battery acquisition 

Hearing aid batteries can be found in sizes #675, 

#13, #312, #10, and #5 (in descending size). In the 

Brazilian marketplace, it is hard to find hearing aids with 

batteries of size #5, so this size was not tested in the 

current study. Before battery acquisition, we performed 

a quick survey of experienced audiologists to determine 

which brands of hearing aid batteries were most used by 

them, and which brands patients recommended. With this 

information, manufacturers, dealers, and distributors were 

contacted by mail with a standard message, and, 

depending on the manufacturer, they sent us samples, 

data sheets, material safety data sheets, and marketing 

material. For example, Mazalab (ExtraPower) sent a free 

pack of batteries but no technical documents, while 

Ammon & Rizos (Renata) sent a battery pack and the 

respective data sheets. Although a survey of all the 

manufacturers was conducted, some did not provide data 

sheets for their products, namely ExtraPower, ClearCell, 

PowerOne (specifications only), and Sony. Possession of 

data sheets allowed observation of common technical 

standards and a direct comparison of the performance of 

batteries from several manufacturers. All the battery 

suppliers were located in the city of São Paulo. The six 

suppliers contacted are listed in Chart 1. The last three 

vendors listed in the chart donated their batteries, while 

the others sold them at retail value. 

Figure 1. ExtraPower #675 identification. 

Figure 2. ClearCell #675 identification. 


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Chart 1. General battery information. 

Supplier Manufacturer/ Model Size Identification/ Nominal Service Quantity/ Best 

brand designation voltage output pack before 

(V) (mAh) 

Digitall Panasonic PR675H 675 PR-675HEP/6C 1.4 605 6 10/2013 

PR13H 13 PH13HEP/6C 1.4 300 6 09/2013 

PR312 312 PR-312HEP/6C 1.4 170 6 10/2013 

PR230H 10 PR-230HEP/6C 1.4 65 6 05/2013 

icellTech Platinum 675 PR44 1.4 630 6 10/2013 

Platinum 13 PR48 1.4 310 6 12/2013 

Platinum 312 PR41 1.4 180 6 05/2013 

Digital Sound 10 PR70 1.4 105 6 05/2012 

Joave Sony 675 675 675(PR44) 1.4 NI 6 02/2014 

13 13 13(PR48) 1.4 NI 6 10/2014 

312 312 312(PR41) 1.4 NI 6 10/2013 

10 10 10(PR70) 1.4 NI 6 10/2014 

Duracell Activair 675 PR44 1.4 600 4 08/2014 

Activair 13 PR48 1.4 290 4 11/2014 

Activair 312 PR41 1.4 150 4 12/2014 

Activair 10 PR70 1.4 90 4 02/2015 

Energizer AudioPRO 675 AC675-4AP 1.4 635 4 10/2012 

AudioPRO 13 AC13-4AP 1.4 280 4 10/2013 

AudioPRO 312 AC312-4AP 1.4 160 4 07/2012 

AudioPRO 10 AC10-4AP 1.4 91 4 01/2012 

PowerOne PowerOne 675 p675 1.4 650 6 07/2013 

PowerOne 13 p13 1.4 310 6 01/2014 

PowerOne 312 p312 1.4 180 6 01/2014 

PowerOne 10 p10 1.4 100 6 01/2014 

CTEA Rayovac Extra Advanced 675 675AE-6LD 1.45 NI 6 06/2014 

Extra Advanced 13 13AE 1.45 NI 6 08/2014 

Extra Advanced 312 312AE-6LD 1.45 NI 6 01/2014 

Extra Advanced 10 10AE-6LD 1.45 NI 6 10/2014 

SANCIEX ClearCell Premium 675 675 1.4 630 4 10/2013 

Premium 13 13 1.4 300 4 10/2013 

Premium 312 312 1.4 180 4 10/2013 

Premium 10 10 1.4 100 4 10/2013 

MazaLab ExtraPower ExtraPower 675 A675 1.4 630 6 12/2013 

ExtraPower 13 A13 1.4 300 6 07/2013 

ExtraPower 312 A312 1.4 180 6 07/2013 

ExtraPower 10 A10 1.4 100 6 07/2013 

Ammon & Rizos Renata Maratone+ 675 ZA675 1.4 650 6 05/2013 

Maratone+ 13 ZA13 1.4 310 6 11/2013 

Maratone+ 312 ZA312 1.4 180 6 03/2014 

Maratone+ 10 ZA10 1.4 100 6 05/2014 

NI - not informed. 

Tests details 

Tests were initialized 10 days after the receipt of 

all the batteries so that the effects of storage in the 

laboratory did not alter the performance of the batteries. 

With the possession of data sheets, it was observed that 

there is no standardization for performance evaluation. 

For example, Renata #675 follows standard IEC60086-2, 

which prescribes a discharge cycle of 12 hours in a load 

resistor of 619 Ω followed by a subsequent 12 hours of 

rest (for chemical recombination with subsequent partial 

recovery), with a temperature and humidity of 21 o C and 

50%, respectively. icellTech #675 prescribes a discharge 

cycle of 16 hours in a load resistor of 620 Ω followed by 

8 hours of rest, with an ambient temperature of 25 o C and 

a relative humidity of 50%, without mentioning any 

standard. Therefore, we chose to use fixed and high 

precision resistors (Chart 2) to simulate a fixed load in a 


294



closed circuit voltage along with a prescribed discharge 

cycle of 12 hours followed by a subsequent 12 hour rest 

period. Both the values of the resistors, the charge and 

the discharge cycle, meet the requirements of IEC60086- 

2 (Table 7.4.2. in this standard) pertaining to each of the 

battery sizes. 

Chart 2. Resistor values for closed circuit voltage simulation. 

Battery size Load resistor (Ω) Precision (%) 

#675 620 1 

#13 1500 2 

#312 1500 2 

#10 3000 1 

Neither the temperature nor the humidity was 

controlled by an air conditioning system, on account of the 

fact that the laboratory where the tests were conducted 

does not have a precision system, only a split air conditioning 

system. However, both the temperature and the relative 

humidity were monitored by a Minipa hygrometer (MT241), 

and measurements were recorded randomly during testing 

(lowest 45%, highest 74%). We used a calibrated Minipa 

multimeter (ET-2042C) to measure voltages. 

All battery seals were removed from zinc-air batteries 

and the batteries were then left for 10 minutes for activation 

(Renata ref. ZA675 Maratone+ Rev. 3/January 2009), 

although Energizer (2004) recommends 30 seconds for the 

same procedure. 

It was necessary to assemble a test jig (Figure 3), 

i.e., a dedicated device for assisting in the evaluation of 

battery performance. For the construction of the test jig, 

only discrete components such as resistors, relays, switches, 

fuses, and connectors were used, and the logical drive was 

handled by an EcoGold programmable timer (EG-TMR009; 

Figure 4). 

Figure 3. Test jig, top view. 

The general scheme of operation of the jig can be 

seen in Figure 5. 

A closed circuit composed of a resistor and a relay 

(in which electrical contacts opened or closed its 

corresponding circuit) was used to test each battery 

individually. This design met the specifications of 

IEC60086-2 fixed-charge. Thus, the battery (P1) fed the 

load resistor (R1; as shown in Chart 1) by contact S1 (K1 

relay). This configuration was repeated 24 times. A 

general key (S) enabled or did not enable the circuit, 

while a fuse (F) protected against test jig overcurrent. A 

direct current supplier (P; AC to DC converter) fed the 

relay coils, according to the schedule set in the 

programmable timer (T). The timer was powered by 

mains 110 V conventional R. 

Through the test jig, it was possible to test two 

batteries of each brand simultaneously. Two batteries of 

each brand were used in simultaneous testing so that the 

worst of the two values could be excluded; thus, only the 

best performance for each of the sizes and brands of each 

battery was considered. In this way, up to 44 batteries were 

tested simultaneously in the test jig. 

Figure 4. Programmable timer, top view. 


295



Measurements were conducted immediately, following 

the sequence A, B, C, (...) until the last battery. The next 

day, measurements started with the last battery and followed 

the sequence backwards to battery A. On holidays, Saturdays, 

and Sundays the building facilities were closed, thus a 

different procedure was required. The night before a 

holiday, Saturday, or Sunday, 15 minutes was added to the 

programmable timer, so as to allow any additional battery 

discharge before measurements. Therefore, we sought to 

offset the effects of partial recombination charge, which 

could have masked the last readings of voltage, especially 

at the beginning of testing, when the batteries had a higher 

capacity for recombination of partial charge. 

All batteries were tested under this scheme. A 

flowchart detailing the logic employed in the test is shown 

in the Annex. 

To record images, we used a Leica binocular 

microscope (EZ4) and a Samsung digital camera (SL30). 

RESULTS 

The results are graphs 1 to 4 and Table 1. 

Figure 5. Simplified schematics implemented in the test jig. 

To ensure that each circuit was functioning individually, 

the multimeter was used to verify if there was voltage across 

each of the resistors, which indicated that the circuit was 

functioning correctly. Twice daily voltage measurements 

were performed in a random order at each of the resistors. 

After measuring the initial voltages of the batteries 

without load (open circuit voltage), they were then 

subjected to load (closed circuit). These cycles were 

alternated in accordance with a prescribed logic, to assess 

how many hours a battery would last until its final voltage 

of 1.1 V. This was followed by four more measurements, in 

order to ensure that once a battery had reached this value, 

it was unable to supply voltage (end-point voltage). The 

value of 1.1 V was used as the cutoff voltage because it was 

higher than the amount proposed by SDT (2007) with 

some safety margin and, in general, it is observed that 

values below 1.1 V can cause unpredictable behavior of 

hearing aids. In addition, the manufacturers’ data sheets 

showed that at around this value, zinc-air batteries have 

virtually no more capacity for power supply. 

Accordingly, the programmable timer was set to 

energize the test jig at 10:05 am following a discharge cycle 

of 12 hours, which peaked at 8:05 am on the next morning. 

Graphic 1. Discharge curve of zinc-air size #675. 



296



Annex. Logic implemented on tests 



Table 1. Zinc-air battery values (average and standard 

deviation). 

Size Average service (hours) Nominal voltage (volts) 

#675 (270 ± 45) (1.357 ± 0.039) 

#13 (266 ± 26) (1.376 ± 0.057) 

#312 (199 ± 32) (1.370 ± 0.068) 

#10 (245 ± 15) (1.339 ± 0.067) 

DISCUSSION 

The necessity to use a standard for evaluating the 

performance of hearing aid batteries may be questioned, 

since such evaluation can be performed by experienced 

patients or driven by engineers. For example, each patient 

has a need for selective amplification, and amplification is 


297



related to battery consumption in the following ratio: the 

higher the amplification, the greater the battery drain. In 

general, the batteries tested in the current study had the 

capacity to supply power for up to 270 hours (Table 1). 

This means that patients would need to continue to test 

batteries under the same conditions for about 22 days (270 

hours divided by 12 hours/day). It would be a hindrance to 

the patient to maintain rigorous battery use at the same 

volume for 22 consecutive days. Furthermore, this procedure 

would have to be repeated for all brands in the four sizes 

of batteries available. Battery drain varies greatly with 

acoustic feedback. When a hearing aid mold is not well 

coupled to the ear (BTE design hearing aid cases), this is 

enough to produce feedback. Tests conducted in our 

laboratory indicate that when feedback occurs, hearing aids 

have a current drain (4.34 mA, Figure 7) several times 

higher than a hearing aid without feedback (0.94 mA, 

Figure 6). Thus, while tests with patients may directly 

transcribe their views, assessment of hearing aid batteries 

demands specialized and sequentially standardized testing, 

which is only possible using application tests in a laboratory. 

The objectives of the present study included testing 

batteries within the conditions prescribed by IEC60086-1, 

IEC60086-2, and IEC60086-3; however, this was not always 

possible since the laboratory where this study was performed 

is not one of a certifying body, but one of a battery 

consumer. For example, the above referenced IEC standards 

require testing of nine batteries of the same brand and 

model (this study tested two batteries of each brand and 

model), and combine the measurement of physical battery 

size with electrical testing with fixed load (performed in 

this study) and load with standard and high pulse drain (not 

performed in this study). Additionally, both the temperature 

and the relative humidity should vary only under restricted 

margins, which can be seen in Tables 4 and 7 of IEC60086- 

1. In this regard, the storage temperature of batteries must 

be between +10 o C and +25 o C (50 o F and 77 o F, respectively), 

and should never exceed +30 o C (86 o F), which makes 

storage at low temperatures (-10 o C up to +10 o C or 14 o F up 

to 50 o F) ideal, either for testing purposes or for marketing 

purposes. 

However, Annex G of IEC60086-1 defines that any 

battery consumer can establish a standard methodology for 

measuring the performance of batteries (SMMP) that meets 

the following criteria: 

a) The test methods should be defined in such a way that 

the test results correspond as closely as possible to the 

performance results as experienced by consumers 

when using the product in practice; 

b) It is essential that the test methods are objective and 

give meaningful and reproducible results; 

c) Details of the test methods should be defined with a 

view to optimum usefulness to the consumer, taking 

Figure 6. Hearing aid curves without feedback. 

Figure 7. Hearing aid curves with feedback. 

into account the ratio between the value of the product 

and the expenses involved in performing the tests; 

d) Where use has to be made of accelerated test procedures, 

or of methods that have only an indirect relationship to 

the practical use of the product, the technical committee 

should provide the necessary guidance for correct 

interpretation of test results in relation to normal use of 

the product. 

The present study meets the above criteria, so its 

results allow a performance analysis comparison between 

batteries of various brands. 

It was observed that battery manufacturers do not 

always provide data sheets for their products, making it 

difficult to compare the performance of various battery 

brands. The data sheets that were provided did not follow 

a specific standard, which again made it difficult to compa- 


298



re the results obtained in this experiment with the 

manufacturers’ data. Among the restrictions for comparison 

of performance, it was found that the documentation 

provided by PowerOne transcribed only a few numerical 

specifications (voltage, typical energy, and capacity), and 

thus abstained from describing the dynamic behavior of the 

battery. This can be described by graphs, in a similar way 

to the data sheets provided by Renata, Energizer, Duracell, 

Rayovac, and icellTech. The Panasonic data sheet only 

showed dynamic curves of high drain, resulting in a 

disturbing and misguided image of low battery performance 

for this manufacturer. 

Comparing the manufacturers’ data sheets with the 

curves obtained in the current study highlighted many 

discrepancies. To this end, we inserted a line parallel to the 

abscissa axis until it crossed the voltage of 1.1 V both in the 

graphs provided in data sheets and the graphs obtained 

using the procedure described in this study. Thus, the 

discharge time was defined as the time (in hours) that the 

batteries provided voltage above 1.1 V. The following 

table shows the data for each battery from each of the 

manufacturers. 

From Table 2 it can be seen that for batteries of size 

#675, there was large variation between the values listed 

in the data sheets (lowest value = 110 hours, highest value 

= 560 hours) compared to the values measured in this 

study (lowest value = 240 hours, highest value = 372 

hours). While the average service measured in this study 

(Table 1) was (270 ± 45) hours, the average service from 

the data sheets (Table 2) was (290 ± 161) hours. 

Table 2 also shows that batteries of size #13 showed 

wide variation in their data sheets (lowest value = 140 

hours, highest value = 440 hours) when compared with the 

values obtained in this study (lowest value = 240 hours, 

highest value = 300 hours). Table 1 indicates that the 

average service measured was (266 ± 26) hours, while the 

data sheets (Table 2) showed a final measurement of (306 

± 107) hours. 

Regarding batteries of size #312, there was great 

variability among the values of the data sheets (lowest 

value = 140 hours, highest value = 360 hours) compared to 

the values obtained in this study (lowest value = 156 

hours, highest value = 276 hours). The average service 

measured was (199 ± 32) hours, whereas the same 

parameter from the data sheets (Table 2) was (204 ± 88) 

hours. 

Finally, the data sheets for batteries of size #10 

showed considerable variation (lowest value = 130 hours, 

highest value = 360 hours) compared to the values 

obtained by measurements made in this study (lowest 

Table 2. Average service time taken from the manufacturers’ 

data versus the results of the current study. 

Manufacturer Size Average Average Difference 

service 1 service 2 (%) 

(hours) (hours) 

Renata #675 560 240 57 

#13 440 300 32 

#312 360 204 43 

#10 360 240 33 

Energizer #675 290 264 9 

#13 310 240 23 

#312 180 156 13 

#10 190 252 -33 

Duracell #675 280 372 -33 

#13 310 286 8 

#312 170 276 -62 

#10 180 252 -40 

Rayovac #675 110 252 -129 

#13 140 276 -97 

#312 140 204 -46 

#10 130 276 -112 

icellTech #675 290 240 17 

#13 330 240 27 

#312 170 204 -20 

#10 208 252 -21 

Notes: 

1.) Data from manufacturers’ data sheets; 

2.) Data from the current study. 

value = 240 hours, highest value = 276 hours). The data in 

Table 1 show that the average service obtained in this 

study was (245 ± 15) hours, whereas the data sheets (Table 

2) indicated a value of (214 ± 87) hours for the same 

parameter. 

Taken together, the information provided above 

highlights the fact that there was a large variability in the 

values presented in the manufacturers’ data sheets, while 

laboratory test results reflected a lower variability, which 

confirms the reliability of tests performed in the laboratory. 

Asymmetric information was provided in data sheets, e.g., 

the data sheet of one manufacturer (icellTech #675) had 

an average service of 290 hours and that for a battery of the 

same size but from another manufacturer (Renata) had an 

average service of 560 hours (93% variation). It is not clear 

what the technological aspects were that enabled this 

intriguing variation in performance from one manufacturer 

to the other, since it is assumed that existing technology 

was not manipulated in a significantly different way. For 

example, when these batteries were subjected to the same 

dynamic tests, both had a discharge time of 240 hours. In 

addition, with regards to batteries of size #675, it is difficult 

to explain how Rayovac battery data sheets showed an 

average service of only 110 hours, as compared to 290 


299



hours and 560 hours in the data sheets of Renata and 

icellTech, respectively. In dynamic testing, Rayovac 

batteries had an average service of 252 hours, which was 

close to the values registered for Renata and icellTech 

batteries (240 hours). Similar results were obtained with 

other batteries. 

In a similar way, the data sheet for size #13 Rayovac 

batteries reported an average service of 140 hours, while 

Renata’s data sheet stated a service of 440 hours, which is a 

variation of more than 200%. When this was measured 

dynamically, the values changed by 25% (240 hours and 

300 hours, respectively). Similar results were observed with 

respect to batteries of size #312, since the Renata data 

sheets reported an average service of 380 hours, Rayovac’s 

stated a service of 140 hours, and icellTech’s stated a service 

of about 170 hours, whereas the dynamic values obtained 

in this study indicated a service time of 204 hours. A similar 

result was also found with respect to size #10 batteries: the 

data sheet from Renata stated an average service of 370 

hours, whereas those from Energizer and Duracell stated 190 

hours and 200 hours, respectively. Laboratory tests indicated 

the values of 240, 252, and 252 hours, respectively. 

The American brands Energizer, Duracell, and 

Rayovac have data sheets referencing both IEC60086-2 

and American standards (ANSI-7003ZD battery #675, ANSI- 

7000ZD battery #13, ANSI-7002ZD battery #312, and 

ANSI-7005ZD battery #0). The American and European 

standards are not identical, so there are variations in the 

presentation of results, making it difficult to compare the 

performance of American manufacturers with that of 

European manufacturers. Ideally, the adoption of one 

pattern should be applied in Brazil. Manufacturers should 

also provide data sheets in Portuguese, which would lead 

to a better understanding of the product by the reader. This 

would also make the reader feel valued as a result of their 

native language being included in the product information. 

The results for the size #675 batteries can be divided 

into three distinct groups: a group composed of six brands 

with similar behavior, an intermediate group consisting of 

three brands with a slight descent in performance, and a 

final group of one brand with the best performance. Thus, 

the worst batteries in terms of performance were ClearCell, 

ExtraPower, icellTech, Sony, Rayovac and Renata (average 

of 250 hours), the intermediate group comprised Energizer 

(264 hours), PowerOne (300 hours), and Panasonic (312 

hours), and best performance Duracell (372 hours). 

Battery performance for size #13 batteries can also 

be divided into three groups: a group composed of four 

brands with similar performance, a second group comprising 

also four brands with a slight descent in performance, and 

a third group containing the top two brands. ClearCell, 

ExtraPower, icellTech, and Energizer showed the worst 

performance (240 hours), followed by Panasonic, Duracell, 

, PowerOne, and Rayovac (264, 276, 276, and 276 hours, 

respectively), with Renata (300 hours) and Sony (312 

hours) showing the best performance. 

The results for batteries of size #312 can be divided 

into four groups: a first group containing the worst 

performers, a second group with two brands whose results 

were slightly higher in relation to the previous group, a 

third group consisting of five brands with similar results, and 

a fourth consisting of one brand . Energizer (156 hours) and 

ExtraPower (168 hours) make up the first group, ClearCell 

(180 hours) and PowerOne (192 hours) follow in the 

second group; icellTech, Renata, Sony, Panasonic, and 

Roayovac (204 hours) comprise the third group, and 

Duracell (276 hours) in the fourth group. 

Three groups can also be used to categorize the 

behavior of #10 batteries. The first group is constituted by 

the four worst performers, followed by a second group with 

slight higher performance, and finally, the brands with the 

best performance. ExtraPower and ClearCell (228 hours), 

PowerOne and Renata (240 hours) constitutes the first 

group; the second group consists of Duracell, Sony, icellTech, 

and Energizer ( 252 hours); Panasonic (264 hours) and 

Rayovac (276 hours) are the brands in the last group. 

Zinc-air batteries are usually referred as mercury 

free, when, in fact, some have mercury in their constitution. 

For example, icellTech states that they use less than 25 mg 

of mercury per battery (icellTech, 2004) while Duracell 

(2008) reports that their batteries satisfy the limit of 0.1 

mg/m 3 . Zhang, Bruce, and Zhang (2011) state that despite 

the benefits of reduced mercury in zinc-air batteries, there 

are still some disadvantages such as limitation of power 

(low voltage and current), evaporation of the electrolyte 

(failure due to the entry of air into the battery), adverse 

reactions arising from the presence of other gases in the 

environment (e.g., the entry of carbon dioxide can produce 

solid carbide), and production of solid elements (difficult 

and costly to dispose of). These authors suggest that 

lithium-air technology may replace zinc-air batteries in the 

near future. 

Cochlear implants also require batteries, for two 

functions: operation of the transmission electronic circuit 

and voltage as well as operation of the modulated radio 

frequency signal from the antenna external to the implanted 

module (Clark, 2008; Sit and Sarpeshkar, 2008; Bhoir and 

Panse, 2009); this leads to high current consumption 

(Wilson, 2004; Zeng, Rebscher, and Harrison, 2008). It is 

therefore recommended to test a larger number of 

manufacturers and models of batteries within the hearing 

aid conditions of any specific technical standard. Further 


300



studies could incorporate testing batteries for cochlear 

implants. In this case, it would be feasible to perform a 

financial analysis of zinc-air batteries and rechargeable 

ones, given that the latter are very expensive compared to 

the former, but may be used several times. 

Rechargeable batteries 

Solar Ear distributes rechargeable batteries for hearing 

aids in Brazil. They sent us eight batteries in sizes #675 and 

#13 to test, plus two solar chargers (Figure 8). These solar 

charger hearing aid batteries are not charged directly by 

solar energy, since solar energy is only used to charge the 

two #AA batteries inside the charger; instead, the #AA 

batteries function as accumulators of electricity for charging 

the hearing aid batteries. This process is possible because 

#AA batteries have a higher load capacity than hearing aid 

batteries, allowing a controlled discharge of current from 

#AA batteries to hearing aid batteries. This also occurs 

when there is electricity in the internal #AA batteries 

controlled by an electronic circuit located in the charger. 

As stated in the solar charger user’s manual (in 

English, without references) it is necessary to charge the 

internal batteries before charging hearing aid batteries. 

According to this manual, the charging process can be 

performed in two ways: solar charging (by leaving the 

charger exposed to sunlight or artificial light) or through an 

external battery charger. We decided to remove the #AA 

batteries from the solar charger and left it for six hours to 

charge via an external charger (Duracell, CEF14N model - 

not supplied), as shown in Figure 9. We did this because 

if the batteries were recharged by the #AA solar charger, 

this would require 20 hours of exposure to the sun or a light 

source. Additionally, our laboratory does not have a window 

that receives direct sunlight, rainfall may have disrupted 

charging, or the solar charger may even have fallen and 

been damaged if it was not positioned in a safe place. In 

urban locations, it is more practical to utilize the convenience 

of residential electricity, a USB connector (universal serial 

bus: standard connection to a computer and its peripherals 

that can rely on a DC power supply), or even power from 

a car than actual solar energy. This is a result of the difficulty 

in obtaining direct sunlight for the solar charger, caused by 

buildings that obscure the availability of natural light in the 

environment, not to mention loading restrictions on cloudy 

or rainy days. Therefore, removal of the #AA batteries and 

external charging was the best option. 

Thus, the #AA batteries were charged and put back 

in the solar charger. Then the process of charging the #675 

and #13 batteries was started, by inserting them into the 

connectors on the solar charger and waiting until the green 

LED solar charger light went out. The charging time lasted 

Figure 8. Solar chargers. 

Figure 9. Rechargeable #AA batteries. 

8 hours for #675 batteries and six hours for #13 batteries, 

as stated in the user’s manual. During the tests, Solar Ear 

provided us with a new version of the solar charger which 

had an input for an external power supply (Figure 8, right), 

but we preferred to continue to use the first solar charger 

supplied (Figure 8, left). 

According to IEC60086, zinc-air batteries cannot be 

compared directly with rechargeable batteries, because 

the former are said to be primary cells while the later are 

said to secondary batteries. However, such comparison is 

inevitable in terms of the average service given, which is 

one of the parameters considered when making the 

decision regarding use of one battery or the other. Thus, 

the rechargeable batteries were tested with the same 

procedures described for zinc-air batteries. In total, eight 

batteries of both sizes were subjected to tests, the results 

of which are represented in two formats: as absolute values 

(Table 3) and as a graphic version (Graphic 5). Solar Ear 

batteries have proper identification on the anode (Ni-MH 

cell HL40H and Ni-MH for #675 and #13, respectively), so 

there was no need for battery identification. 


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above 1.1 V as “the battery may be underutilized resulting 

in insufficient use of the available capacity.” 

The charge capacity of the rechargeable batteries 

was 50 and 18 mAh for the #13 and #675 sizes, respectively. 

By way of comparison, the #675 Duracell battery had a 

load capacity of 600 mAh, which is 12 times that of the 

same size Solar Ear battery, whereas the #13 Duracell 

battery had a load capacity of 290 mAh, which is 16 times 

the capacity of the same size Solar Ear battery. 

Graphic 5. Discharge curves of Solar Ear rechargeable 

batteries in sizes #675 and #13 

Table 3. Rechargeable battery values (average and standard 

deviation). 

Size Average service (hours) Nominal voltage (volts) 

#675 (58 ± 5) (1.229 ± 0.133) 

#13 (36 ± 10) (1.240 ± 0.115) 

Since the data sheets of the rechargeable batteries 

did not mention test conditions or related regulations, we 

cannot comment with regards to agreement or 

disagreement with their respective standards. However, 

judging by their capacity (50 mAh and 18 mAh for #675 

and #13 batteries, respectively), a higher average service 

was noted for zinc-air batteries than for rechargeable 

batteries. This observation is reaffirmed when the results 

of Tables 1 and 3 are compared. From these tables, it can 

be seen that #675 zinc-air batteries had an average 

service greater than five times that of the same size 

rechargeable batteries. A similar result was found for #13 

zinc-air and rechargeable batteries (average service seven 

times greater). The average values of all voltage 

measurements of zinc-air batteries were superior to those 

of the rechargeable batteries due to the higher load 

capacity of zinc-air batteries. 

The Solar Ear battery data sheet (Ni-MH cell button 

technical data) recommends that the cutoff of its products 

is 1.0 V, which results in a small variation (17%) of tension 

relative to their nominal voltage (1.2 V) as compared with 

the same parameter of zinc-air batteries for the same 

value of shear stress (29%). The same Solar Ear battery 

data sheet emphasizes that the cutoff for hearing aids is 

Varta (Varta Microbattery GmbH, Ellwangen, 

Germany) produces zinc-air batteries under the brand 

PowerOne (tested in the present study) as well as the 

rechargeable ACCU plus series in sizes #675, #13, #312, 

and #10 (Varta Material Safety Data Sheet MSDS 2,001,002, 

9/28/2009 Edition). These have a charger in the format of 

a pen (pencharger) that works similarly to the Solar Ear 

model, i.e., it has two #AAA batteries inside that carry load 

to hearing aid batteries housed in the charger. Varta also 

produces a pocket charger (pocketcharger) for #13, 

#312, and #10 batteries, the energy of which is stored in 

a rechargeable internal lithium charger. Exclusively for 

#675 batteries, Varta has a unique charger model 

(PowerOne 675 charger). All rechargeable batteries from 

Varta have a nominal voltage of 1.2 V that, according to 

IEC61951-2, provides the following average service values: 

74, 23, 31, and 12 mAh for #675, #13, #312, and #10 

batteries, respectively. We could not find a distributor of 

Varta rechargeable batteries in Brazil, so these batteries 

were not tested in the present study. 

In total, 180 zinc-air batteries were acquired (Chart 

1) and 96 were tested according to the methodology 

described. In addition, 16 rechargeable batteries were 

tested. All the batteries were segregated and will be 

returned to the manufacturers for disposal. 

Leakage 

Energizer (2011) states that zinc-air batteries should 

neither be recharged or wired in an inverted way nor 

placed in a short circuit because such events can cause 

leakage or explosion, and in extreme cases there may be 

injury to the operator. To prevent leakage, Panasonic 

(2010) stresses that their zinc-air batteries should not be 

deformed or mixed or soldered with other batteries. 

icellTech (2004) adds that its zinc-air batteries cannot be 

dismantled or placed in a fire as there is a risk of leakage 

or even explosion. The latter manufacturer stresses that 

the content of zinc-air batteries can cause irritation or 

burns to the skin; if this occurs, contamination must be 

removed with a cloth moistened with soap and water. In 

the case of contamination of the eyes, they must be 


302



washed with water for a minimum of 10 minutes and then 

specialist help should be sought immediately. Duracell 

(2008) states that in the event of leakage, their zinc-air 

batteries would release caustic potassium hydroxide, 

reaching a total volume of 2.5 mL. If there is leakage of 

the hearing aid battery, the patient should seek assistance 

directly from the manufacturer of the device, as the use 

of cleaner can cause stains or irreversible damage to 

hearing aids. Leaks inside hearing aids invariably and 

permanently damage electronic components (digital signal 

processor, microphone, and receiver) and electrics (battery 

contacts, switches, and wiring). This can be avoided if 

only batteries from a good supplier within their validity 

are used and preventive maintenance of hearing aids is 

performed within the time recommended by the 

manufacturer. 

Accidental intake 

icellTech (2004) explains that continuous exposure 

to its zinc-air batteries does not cause any harmful effects 

on health, but in case of ingestion, the advice of a doctor 

should be sought immediately. However, Duracell (2008) 

warns that if accidental intake occurs, batteries must be 

recovered immediately as they can cause burning or 

perforation of the esophagus; it is not recommended to 

induce vomiting. 

Litovitz et al. (2010) describe a longitudinal study of 

8,648 cases of battery ingestion. When lodged in the 

esophagus, it was possible for batteries to cause severe 

damage simply within two hours of ingestion. Damage 

could progress to esophageal perforation, 

tracheoesophageal fistula appearance, vocal cord paralysis, 

and even death (13 deaths were recorded). Of all the cases 

of ingestion, 36% were reported to involve hearing aid 

batteries. In a previous study with 2,382 cases, Litovitz and 

Schmitz (1992) reported 952 cases (32%) of the accidental 

intake of hearing aid batteries. 

Proper disposal 

Brazilian law covers some aspects of battery disposal. 

From an institutional perspective, the Brazilian Association 

of the Electrical and Electronics Industry (Associação Brasileira 

da Indústria Eletro e Eletrônica - ABINEE) maintains 

a policy of disposal of solid waste based on the National 

Environmental Council (Conselho Nacional do Meio Ambiente 

- CONAMA) Resolution 401/2008 called the Reverse 

Logistics Program for Household Batteries, which has 

deployed systems and logistics for disposal after the end of 

life for ordinary batteries, zinc-manganese alkaline batteries, 

rechargeable batteries, and portable batteries. Zinc-air 

batteries are a subclass of zinc-manganese batteries. This 

policy also states the ABINEE goal in Resolution 257/99 of 

CONAMA, which reads: 

“Article 1 o : Batteries in their compositions containing 

lead, cadmium, and mercury and its compounds, necessary 

for the operation of any type of equipment, vehicles, or 

systems, mobile or fixed, as well as electric and electronic 

products that contain batteries integrated into their structure 

so that they are not replaceable after energy depletion, will 

be delivered to users by establishments that sell or network 

authorized services by the respective industries, to be 

transferred to manufacturers or importers, so that they 

adopt, directly or through third parties, the procedures for 

environmentally sound reuse, recycling, treatment, or 

disposal.” 

From the state perspective, the Department of the 

Environment of São Paulo defined SMA Resolution 38/ 

2011, among other guiding “principles of vision and 

systemic post-consumer responsibility,” which implies the 

direct responsibility of manufacturers, importers, and 

distributors for their waste, even after the consumption of 

products, without defining the processes for allocation. A 

previous law (Law No. 12.300/2006 State, Article 53) has 

already highlighted the fact that: 

“Manufacturers, importers, or distributors of products 

require or may require special systems for packaging, 

storage, collection, transportation, treatment, or disposal, in 

order to avoid damage to the environment and public 

health, even after consuming their waste from these items, 

and are responsible for servicing requirements set by the 

environmental agency.” 

From the federal perspective, the CONAMA has a 

National Policy on Solid Waste instituted by Law No. 

12.305/10, which provides for the creation of systems of 

reverse logistics for collection and disposal of electronic 

products, lubricating oils, fluorescent lamps, packaging in 

general, and drugs. However, the Ministry itself (Brazil, 

2013) warns that “other products, however, as there are 

already regulations in place in this regard, such as those 

relating to pesticides and batteries, and tires and oil, 

working groups were not created to discuss reverse logistics 

in these chains.” However, this legislation appears to lack 

a comprehensive system that can handle marketing, 

disposal, collection, allocation, monitoring, evaluation, and 

feedback. 

Within this setting, Panasonic (2010) states that if its 

zinc-air batteries are thrown to the ground, they will leak 

electrolyte; they have not, however, assessed the possible 

resulting environmental damage. Energizer (2011) merely 

report that “disposal must comply with federal, state, or 


303



local law” and “technologies such as incineration or landfill 

should be considered.” 

CONCLUSION 

It was possible to investigate the performance of 

ten brands of hearing aid batteries, in addition to describing 

the procedures recommended for leakage, accidental 

intake, and disposal. 

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DOI: 10.7162/S1809-977720130003000011 

Contribution of audiovestibular tests to the topographic diagnosis of 

sudden deafness 

Jeanne Oiticica 1 , Roseli Saraiva Moreira Bittar 2 , Claudio Campi de Castro 3 , Signe Grasel 4 , Larissa Vilela Pereira 5 , 

Sandra Lira Bastos 5 , Alice Carolina Mataruco Ramos 5 , Roberto Beck 5 . 

1) MD PhD. Department of Otolaryngology, University of São Paulo School of Medicine. 


3) MD PhD. Heart Institute [InCor], University of São Paulo School of Medicine. 


5) MD. Department of Otolaryngology, University of São Paulo School of Medicine. 

Institutions: (A) Department of Otolaryngology, University of São Paulo School of Medicine. 

(B) Heart Institute (InCor), University of São Paulo School of Medicine. 


Mailing address: Jeanne Oiticica, M.D., Ph.D. ENT Assistant Doctor Department of Otolaryngology University of São Paulo School of Medicine - R. Marjorie Prado 

160 - São Paulo / SP - Brazil - Zip Code: 04663-080 - E-mail: jeanneoiticica@bioear.com.br 

Article received on February 27 th , 2013. Article accepted on March 17 th , 2013. 

SUMMARY 

Introduction: Sudden hearing loss (SHL) is an ENT emergency defined as sensorineural hearing loss (SNHL) > 30 dB HL 

affecting at least 3 consecutive tonal frequencies, showing a sudden onset, and occurring within 3 days. In cases of SHL, a 

detailed investigation should be performed in order to determine the etiology and provide the best treatment. Otoacoustic 

emission (OAE) analysis, electronystagmography (ENG), bithermal caloric test (BCT), and vestibular evoked myogenic potential 

(VEMP) assessments may be used in addition to a number of auxiliary methods to determine the topographic diagnosis. 

Objective: To evaluate the contribution of OAE analysis, BCT, VEMP assessment, and magnetic resonance imaging (MRI) to 

the topographic diagnosis of SHL. 

Method: Cross-sectional and retrospective studies of 21 patients with SHL, as defined above, were performed. The patients 

underwent the following exams: audiometry, tympanometry, OAE analysis, BCT, VEMP assessment, and MRI. Sex, affected side, 

degree of hearing loss, and cochleovestibular test results were described and correlated with MRI findings. Student’s t-test was 

used for analysis of qualitative variables (p < 0.05). 

Results: The mean age of the 21 patients assessed was 52.5 ± 15.3 years; 13 (61.9%) were women and 8 (38.1%) were men. 

Most (55%) had severe hearing loss. MRI changes were found in 20% of the cases. When the audiovestibular test results were 

added to the MRI findings, the topographic SHL diagnosis rate increased from 20% to 45%. 

Conclusion: Only combined analysis via several examinations provides a precise topographic diagnosis. Isolated data do not 

provide sufficient evidence to establish the extent of involvement and, hence, a possible etiology. 

Keywords: Deafness; Hearing Loss, Sudden; Diagnosis; Vestibular Function Tests; Hearing Tests. 

INTRODUCTION 

Sudden hearing loss (SHL) is an ENT emergency 

that was first described in 1944 (1), but remains poorly 

understood. According to the National Institute for Deafness 

and Communication Disorders (NIDCD), it can be defined 

as any sensorineural hearing loss (SNHL) > 30 dB affecting 

at least 3 consecutive frequencies, showing a sudden 

onset, and occurring within 3 days (2). 

The incidence of SHL is 5–20 per 100,000 population 

per year in the United States (3), 8 per 100,000 population 

per year in Thailand (4), and 27.5 per 100,000 population 

per year in Japan (5), where a increase has been observed 

over the past 30 years. The natural course leads to 

spontaneous recovery in 45–65% of the cases (6-8). 

Among patients undergoing drug therapy, recovery rates 

vary between 50% and 78% (5, 9). About half of the 

patients undergoing treatment recover hearing within the 

first few days and the other half within 3 months, but a small 

percentage show delayed recovery (9). 

Despite its sudden onset, which is often associated 

with symptoms such as dizziness and tinnitus, the 

pathophysiology of this condition remains undefined. 

Routine tests for diagnostic evaluation fail to detect the 

etiology in up to 88% of the cases (10). The list of 

potentially causative or associated agents is long; many of 

these are etiologic factors such as vestibular nerve 

schwannoma, infections, stroke, and neoplastic lesions, 

whereas others are only associated factors for which a 

causal relationship remains to be established (viral, 

autoimmune, vascular mechanisms) (11-13). Early diagnosis 


305

Contribution of audiovestibular tests to the topographic diagnosis of sudden deafness. 

Oiticica et al. 

and therapeutic management improve the patients’ quality 

of life. 

Tinnitus and aural fullness are reported in 95% of the 

patients with SHL, whereas dizziness is present in 55% of 

the cases showing the involvement of the posterior labyrinth 

and suggesting a worse prognosis (14). A detailed 

investigation of patients with SHL should be performed in 

all cases, the main objective of which should be to 

determine the etiology of the event in an effort to provide 

the best treatment for that patient. Furthermore, clinical 

evaluation may provide additional new data and a more 

detailed overview of the prognosis of patients with 

idiopathic SHL. 

Recent studies have demonstrated the role of tests 

such as otoacoustic emission (OAE) analysis, 

electronystagmography (ENG), bithermal caloric test (BCT), 

and vestibular evoked myogenic potential (VEMP) 

assessment in indicating disease prognosis, and also 

elucidated various auxiliary methods for determining the 

topographic diagnosis (15-17). 

OAE analysis is an important test for objective 

assessment of the functioning of the inner ear, specifically 

the outer hair cells (OHCs) of the cochlea. OAEs are lowintensity 

acoustic signals generated by nonlinear mechanical 

activity of the OHCs of the organ of Corti (18). OAEs can 

occur spontaneously (spontaneous OAEs) or in response 

to acoustic stimuli (evoked OAEs), which, once amplified, 

can be detected in the external auditory canal (EAC) (19). 

The sound stimulus reaches the cochlea and induces 

vibration of the basilar membrane, which in turn causes 

deflection of OHC stereocilia, ion flow, a voltage difference, 

and subsequent contraction of these cells to generate 

electromotility, which is thought to be responsible for the 

phenomenon of OAEs. The presence of OAEs indicates 

that the conductive mechanisms of the ear (external ear 

canal, tympanic membrane, and ossicular chain) and the 

OHCs are functioning properly, and therefore, in any kind 

of hearing loss (HL), OAE assessment is a valuable step. 

However, we must remember that OAEs do not provide 

information about the inner hair cells (IHC), the eighth 

cranial nerve, or the ascending auditory pathways. 

Spontaneous OAEs reveal narrow band acoustic energy 

from the cochlea regardless of the presence of a sound 

stimulus. They are of little clinical importance because they 

are present in only 40–60% of subjects with normal hearing 

(20). Evoked OAEs can be classified as transient-evoked 

otoacoustic emissions (TEOAEs) and distortion-product 

otoacoustic emissions (DPOAEs). TEOAE responses are 

caused by acoustic stimuli, usually clicks, but frequencyspecific 

stimuli such as tone bursts and tone pips can also 

induce these responses. Although a click is a broadband 

stimulus that activates the whole cochlea, TEOAEs can 

provide the “frequency-specific” pattern of the cochlea. 

They can be divided into frequency bands representing 

responses from different segments of the cochlea (21). 

DPOAEs are generated in the cochlea in response to the 

simultaneous presentation of 2 pure tones (f1 and f2 

stimuli). The cochlea has nonlinear properties that produce 

changes in the output signal that are not directly related to 

the input signal, creating responses at frequencies other 

than those provided by the 2 input signals. These responses 

are called distortion products and indicate normal activity 

of the inner ear. The 2f1-f2 ratio is the most commonly 

used as it results in the most robust and reliable responses. 

DPOAEs are present in almost all subjects with normal 

hearing thresholds. OAEs have been widely used as an 

objective and non-invasive screening method for HL. OAEs 

can still be useful in the differential diagnosis of cochlear 

and retrocochlear HL. As they arise from OHCs (peripheral 

auditory system), responses are supposed to be compatible 

with auditory thresholds in the case of sensory HL. In the 

case of retrocochlear pathology, DPOAE responses may be 

present even with thresholds worse than 45 dB HL and 

abnormal ABR since DPOAEs reflect pre-neural sensory 

activity from the cochlea. However, this is an uncommon 

finding. Studies indicate that about 20% of patients with a 

retrocochlear pathology have normal DPOAEs. Expanding 

lesions in the internal auditory canal (IAC) or posterior fossa 

may decrease the cochlea blood flow and affect the 

presence of OAEs. In SHL, the OAE test is a fast and elegant 

method for confirming HL, excluding any psychogenic 

deafness, and monitoring treatment outcome (17). 

The ENG permits electrical recording of eye 

movements and is the most common method used for the 

diagnosis of peripheral vestibular disorders. The caloric test 

allows for independent assessment of the right and left 

labyrinths (horizontal semicircular canals) in response to 

bithermal irrigation of the external auditory canal. Each ear 

is irrigated twice to elicit both excitatory and inhibitory 

responses. Thus, the caloric test provides a functional 

assessment of the horizontal semicircular canal and superior 

vestibular nerve, contributing to the topographic study 

of the peripheral organ and ascending vestibular pathways. 

The VEMP assessment is a newly developed vestibular 

test that is used clinically to analyze otolith function 

and is the only specific test for the inferior vestibular nerve. 

In primitive vertebrates, the saccule is not part of the 

vestibular system but is a structure of the auditory system. 

In most vertebrates and humans, the saccule is sensitive to 

acoustic stimuli but is involved with vestibular function. 

Furthermore, as a noninvasive and low-risk test, the VEMP 

assessment does not depend on cochlear integrity and may 

be present in patients with profound deafness. This potential 

can be evoked by a sound stimulus and recorded in the 

cervical region. In this way, VEMP analysis assesses the 


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integrity of the sacculocollic reflex, which depends on the 

functional integrity of the macula of the saccule, inferior 

vestibular nerve, lateral vestibular nucleus, descending 

vestibulospinal tract, and the accessory nerve to the 

sternocleidomastoid muscle (SCM) and its neuromuscular 

junction. Therefore, unlike other exams, VEMP assessment 

enables the study of structures not commonly assessed by 

traditional vestibular tests (the saccule and inferior vestibular 

nerve) as well as the descending and ascending vestibular 

pathways. Lesions anywhere in this pathway can 

result in abnormal test results. The literature on VEMP in 

patients with SHL remains very controversial. Some authors 

describe a positive correlation between the presence of 

normal VEMP and a good prognosis for hearing recovery in 

patients with SHL (22, 23). Other authors have noted 

normal VEMP results in all patients with SHL (24), or did not 

relate these to hearing outcome. However, VEMP 

assessment can contribute to the diagnosis of different 

neurotologic diseases, including Meniere’s disease, superior 

semicircular canal dehiscence, benign paroxysmal 

positional vertigo (BPPV), vestibular neuritis, and vestibular 

schwannoma, and it is a great method for topographic 

diagnosis. It evaluates not only the neural structures, but 

also the sensory structures of the saccule, which are 

sensitive and responsive to acoustic stimuli, although they 

do not contribute to hearing. For example, in a case of SHL 

of vascular origin, the lesion is expected to be large and 

involve not only the cochlea, but also the vestibule, 

damaging a greater number of sensory-neural structures. In 

such cases, combined analysis of audiological and 

electrophysiological test results and imaging studies may 

contribute directly to the topographic diagnosis of the 

lesion and to the subsequent prognosis of the patient’s 

SHL. Currently, the role of these diagnostic methods in the 

field of SHL remains uncertain, and more studies are 

needed to better determine the practical implications of 

these tests. 

OBJECTIVE 

To evaluate the contribution of OAE analyses, the 

bithermal caloric test, VEMP assessments, and magnetic 

resonance imaging (MRI) to the topographic diagnosis of 

SHL. 

METHOD 

This cross-sectional study included patients with a 

history of SHL, as defined above, who consulted the 

Department of Neurotology, Hospital das Clínicas, University 

of São Paulo School of Medicine (HC-FMUSP) from January 

2011 to January 2012. This study was previously approved 

by the Hospital’s Ethics Committee on Research (1179/ 

07). All patients followed the outpatient care protocol for 

SHL, including providing a detailed history, and undergoing 

an ENT physical examination as well as the following 

exams: pure tone and speech audiometry, tympanometry, 

DPOAE analysis, ENG, VEMP assessment, laboratory tests, 

and MRI. All tests were performed at the University of São 

Paulo School of Medicine. 

Inclusion criteria 

We included all patients who satisfied the following 

criteria: 

• Were diagnosed with SHL (sensorineural hearing loss > 

30 dB over at least 3 contiguous frequencies developed 

within 72 hours) and confirmed by pure tone audiometry; 

for patients who had no prior audiometry results, the 

audiometry findings of the contralateral side were 

considered representative of the original auditory 

threshold. 

• Performed the DPOAE test. 

Exclusion criteria 

We excluded patients who met any of the following 

criteria: 

• Did not agree to participate in the study 

• Failed to comply with the follow-up procedure or who 

had contraindications for any test (metallic objects 

implanted in the body preventing the realization of 

MRI, tympanic membrane perforation preventing the 

completion of ENG with water, middle ear effusion, 

otosclerosis or ossicular chain disjunction preventing 

DPOAE or VEMP assessments, as these conditions 

would interfere with the outcome). 

Pure tone and speech audiometry, 

tympanometry 

Air- and bone-conducted pure tone thresholds were 

obtained in the frequency range of 250 to 8000 Hz and 500 

to 4000 Hz, respectively, in addition to speech recognition 

threshold (SRT) and word recognition scores (WRS). When 

the patient showed no speech discrimination at the highest 

intensity permitted by the equipment, we tested the 

speech detection threshold (SDT). Immitance 

measurements included tympanometry and contralateral 

acoustic reflex thresholds at 500 to 4000Hz. The reflex was 

considered present when detected for at least 1 of 4 

frequencies and absent when no response was detected 

for any frequency. The PTA (Pure Tone Average) was 

obtained by averaging the pure tone thresholds of 0.5, 1, 

2, 4, 6, and 8 kHz. 


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Otoacoustic emissions - OAE 

Before the OAE test, an otoscopy was performed to 

prevent cerumen or debris from blocking the probe (21). 

To ensure proper acquisition of OAEs, the test was 

performed in a quiet environment with a noise level < 40dB 

HL. The patient was instructed to relax and avoid jaw 

movements, swallowing, or voice emissions that could 

generate noise in the external auditory canal (21). DPOAEs 

were tested at the intensities of 65 dB HL (f1) and 55 dB 

HL (f2) in the frequency range 750 to 8000 Hz. A response 

was considered to be significant when the signal-to-noise 

ratio was > 6dB. When significant responses were obtained 

for 5 or more frequencies, DPOAEs were considered to be 

present. In this case, further analysis was undertaken to 

determine whether DPOAEs were consistent with auditory 

thresholds. Present responses showed proper cochlear 

function of OHCs at these frequencies. We used SCOUT 

software (Natus Medical Incorporated, Mundelein, Il, USA) 

for these analyses. 

Bithermal Caloric Test - BCT 

Before the BCT analysis, the patient underwent a 

standard ENG test battery with the aim of excluding other 

functional findings that could influence the post-caloric 

response. The test sequence consisted of recordings of eye 

movements in response to stimuli: (1) saccade test, (2) 

spontaneous nystagmus with open eyes (SNEO), (3) 

smooth pursuit (SP), (4) optokinetic test (OPK), (5) static 

position tests – supine, right ear down, left ear down, Rose, 

sitting, body right and body left, (6) BCT. For the BCT, the 

patient was in a supine position with the head bent forward 

30 o and eye movements were recorded after irrigation with 

water for 40 seconds in the following sequence: (a) warm 

irrigation at 44 o C, left ear, (b) warm irrigation at 44 o C, right 

ear, (c) cool irrigation at 30 o C, left ear, (d) cool irrigation at 

30 o C, right ear. In the BCT analysis, we considered nystagmus 

of both labyrinths, measured through the angular velocity 

of the slow-phase velocities (SPV). We observed the 

nystagmus direction, rhythm, amplitude, and frequency, 

and compared the functioning of the labyrinths. The SPV 

measure was provided by the computer system and was 

considered normal between 7 and 50 o /second. The results 

were classified according to the post-caloric values: (1) 

normal: post-caloric responses within these limits, (2) 

hyperactivity: post-caloric responses exceeding 50 o /second, 

(3) hypoactivity: post-caloric responses below 7 o /second, 

and (4) no response: complete absence of caloric responses 

after stimulation. To evaluate the response symmetry 

between the vestibules, 2 values were calculated: (a) 

Unilateral Weakness (UW) and (b) Directional 

Preponderance (DP). UW shows the relative difference 

between the right and left ear responses, and DP shows the 

relative difference of right beating vs. left beating nystagmus 

directions. We considered UW up to 18% and DP up to 20% 

as reference values (25). UW has a high clinical value and 

indicates a vestibular asymmetry of peripheral or central 

origin; it always points to the weaker ear. DP indicates the 

stronger nystagmus direction. We considered signs of 

central origin to include the absence of the inhibitory effect 

of ocular fixation suppression (FS) and reversal of the 

direction of post-caloric nystagmus. 

Vestibular evoked myogenic potentials - 

VEMP 

A cervical VEMP assessment was performed using 

AEP software, version 7.0.0, Bio-logic Navigator Pro system 

(Natus Medical Incorporated, Mundelein, Il, USA). During 

the test, the patient remained comfortably seated with neck 

rotation contralateral to the sound stimulation. The sound 

stimuli were presented through insert earphones (ER-3) 

calibrated according to ANSI S1.40-1984 (American National 

Standard Institute, 2001). The surface electrodes were 

placed on the forehead (ground), the upper part of the 

sternum (negative), and the upper third of the contracted 

SCM muscle (positive electrode). The impedance was 40% (with the 

lowest amplitude from the SHL side) or the absence of a 

response on the affected side, suggesting saccule and 

inferior vestibular nerve involvement. 

Magnetic resonance imaging (MRI) of 

the inner ear and brain stem 

MRI of the inner ear was carried out by spin-echo 

and fast spin-echo sequences in T1 and T2, with multiplanar 


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acquisition before and after intravenous administration of 

the paramagnetic contrast agent (gadolinium). FIESTA 

series were also included in volume acquisition with cuts of 

0.8 mm. MRI was considered abnormal only when findings 

were obviously related to SHL, such as schwannoma of the 

eighth cranial nerve (intracanalicular or cerebellopontine 

angle), internal carotid artery obstruction, stroke, and 

cochleovestibular lesions (inflammation or vascular), as 

previously described (26). All other MRI findings were 

described as normal, including those whose etiological 

association with SHL were possible but not previously 

proven (vascular anomalies, demyelinating diseases) or 

unknown (white matter changes, vascular loops, 

contralateral cochlear abnormalities, enhancement of 

mastoid cells or the endolymphatic duct, ventricular 

dilatation, asymmetry of the cerebellum). 

Study variables 

Study variables included the following: (a) categorical 

variables (CVs), and (b) quantitative variables (QVs). The 

CVs were described by their frequency distribution, and 

included the following variables: (1) sex; (2) the affected 

side; (3) classification of the degree of HL according to pure 

tone thresholds (up to 40 dB HL mild, 40–70 dB HL 

moderate, 70–90 dB HL severe, and >90 dB HL profound) 

(27). We considered anacusis as the complete absence of 

responses at all frequencies; (4) The presence or absence 

of the acoustic reflex during immitance measurements; (5) 

the presence or absence of DPOAE responses; (6) the 

presence of normal reflexes, hyperfunction, hypofunction, 

or no responses in the BCT; (7) normal or abnormal VEMP 

responses; and (8) normal and abnormal MRI findings. The 

QV were described by mean and standard deviation, and 

included (1) age; (2) PTA; (3) WRS. 

Statistical analysis 

CV results were described based on their frequency. 

QV results were expressed as the mean and standard 

deviation. Comparisons of QV were calculated using an 

unpaired t-test. The level of statistical significance was set 

at 5% (p < 0.05). We also calculated the 95% confidence 

interval of the mean and verified whether the 2 QV had 

equal standard deviations. Statistical analyses were 

performed using the GraphPadInstat program. 

RESULTS 

Between January 2011 and January 2012, 40 patients 

diagnosed with SHL were treated at the Department of 

Neurotology, Hospital das Clínicas, University of São Paulo 

15% 

Figure 1. Classification of NSHL in patients with SHL. 

School of Medicine. Twenty-one of these had DPOAEs and 

constituted our final sample. No patient refused to participate 

in the study, had contraindications to any of the exams, or 

missed their follow-up visits. The analysis of the 21 patients 

who met the selection criteria showed that the mean age 

and standard deviation was 52.5 ± 15.3 years, and that 13 

(61.9%) were females and 8 (38.1%) males. The right side 

was affected in 14 (66.6%) patients and the left side in 7 

(33.4%). 

Pure tone and speech audiometry, 

tympanometry 

Of the 21 enrolled patients, 20 underwent audiometry 

at the beginning and end of the study, only 1 patient only 

underwent the initial audiometry tests. Figure 1 shows the 

distribution of the degree of NSHL observed in 20 patients 

at the beginning of the analysis. The initial mean PTA and 

standard deviation was 80.5 ± 25.7 dB HL (n = 20), with a 

95% confidence interval of the mean between 68.5 and 

92.6 dB. The mean PTA at the end of the study and the 

standard deviation was 57.6 ± 34.3 dB HL (n = 20), with a 

95% confidence interval of the mean between 41.5 and 

73.7dB. The difference between the initial and final PTA 

was statistically significant (p = 0.0221, unpaired t-test), 

indicating that, in general, there was an improvement in 

the thresholds during follow-up due to treatment of SHL. 

ENG and PC 

15% 15% 

55% 

Moderate 

Severe 

Profound 

Anacusis 

Nineteen of the 21 patients (90.5%) had ENG with 

caloric tests. Two (9.5%) failed to show up for the test. Of 

the 19 patients on whom the tests were performed, 8 

(42.1%) had normal and 11 (57.9%) abnormal findings. 

One subject had DP on the same side as the SHL. The 

distribution of the remaining 18 test results of the affected 

ears can be seen in Figure 2. 


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22% 

36% 

45% 

Normal 

11% 

Hypoactivity 

Normal 

64% 

22% 

Hyperactivity 

Abnormal 

No response 

Figure 2. Distribution of bithermal caloric test responses in 

patients with SHL. 

Figure 3. Distribution of VEMP responses in patients with 

SHL. 

14% 

86% 

Present DPOAE 

Absent DPOAE 

Figure 5. Expansive lesion inside the right IAC. 

Figure 4. Distribution of DPOAE results in patients with SHL. 

VEMP 

Fourteen of 21 patients (66.6%) completed the 

VEMP test. Nine of these (64.3%) had normal tests. Of the 

5 (35.7%) with abnormal test results, 3 had an IADR > 40%, 

with the lowest amplitude response on the SHL side in all 

cases; 2 had no responses on the affected side (Figure 3). 

DPOAE 

All 21 patients included in the study completed 

DPOAE assessments. Only 3 (14.3%) showed present 

DPOAEs at most frequencies. Although DPOAE were 

requested at the time of initial evaluation, in view of the 

test schedules and the demand of the institution, some of 

these tests were eventually completed during follow-up of 

SHL after partial or complete recovery of NSHL, and the 

results were consistent with the audiometric thresholds 

obtained at the same time as the DPOAE tests. In the 

remaining 18 (85.7%) patients, DPOAEs were considered 

absent according to our criteria (Figure 4). 

MRI 

MRI was performed in 20 (95.2%) of 21 patients as 

1 patient failed to complete the test. The MRI findings 

were normal in 16 (80%) patients and abnormal in 4 (20%). 

Analyzing the 4 abnormal tests, we found that in 2 cases the 

lesion arose from the eighth cranial nerve (schwannoma) 

ipsilateral to the SHL. In case 9, MRI revealed an expansive 

lesion inside the right IAC, protruding into the ipsilateral 

cerebellopontine angle (CPA) (Figure 5). In case 11, MRI 

showed an expansive lesion located in the right CPA and 

IAC, with enlargement and partial obliteration of the 

ipsilateral cistern (Figure 6). Among the 2 patients with 

eighth cranial nerve schwannomas, DPOAEs were absent 

in 1 (case 9) but present in the other (case 11). In this case, 

the test was performed later, during follow-up of SHL, and 

after complete recovery of audiometric hearing thresholds. 

Similarly, VEMP was absent in case 9 and present in case 11. 

ENG showed hypofunction in case 9 and no caloric 

function at all in case 11. In the other 2 cases with abnormal 

MRIs, the lesion was located in the cochlea on the same 

side as the SHL. The lesion was described by the radiologist 


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as a focus of post-contrast enhancement in the cochlea, 

vestibule, and ipsilateral semicircular canals suggestive of 

inflammation (viral labyrinthitis, fibrotic tissue) in 1 (case 

6), and as enhancement of the ipsilateral cochlea (possible 

inflammation) in the other (case 18). In the 2 latter cases, 

DPOAEs were absent, which was in agreement with the 

MRI findings showing cochlear enhancement, and helped 

to prove that the auditory lesion was peripheral, involving 

the OHCs, and not neural. VEMP was abnormal in case 6 

and was not assessed in case 18. Thus, ENG showed no 

vestibular function ipsilateral to the lesion in both cases, 

even without any sign on MRI of a lesion extending into the 

posterior labyrinth in case 18. 

We also evaluated the mean difference between 

the initial and final PTA to compare the average hearing 

recovery among patients whose topographic diagnosis 

showed smaller, more restricted lesions (absent or Cn or 

SVn lesions) or more extensive lesions (Cn + VSn or Cn + 

VSn + IVn). The mean PTA recovery and standard deviation 

Figure 6. Expansive lesion in the right IAC and CPA with 

widening and partial obliteration of the ipsilateral CPA cistern. 

Table 1. Test results for all 21 subjects. 

Case Side Audiometry I DPOAE BCT VEMP MRI Topographic Diagnosis 

Initial PTA Final PTA 

(affected nerve) 

(dB HL) (dB HL) 

1 R 75.8 73.3 NP - h NP nl Cn 

2 L 80.8 25 + - nl nl nl Cn 

3 R 50.8 24 - + ¯ nl nl SVn 

4 L 59 NP + - NP NP nl Cn 

5 R 86.7 79 NP - ¯ Abn nl Cn + SVn + IVn 

6 R 47.5 29 NP - 0 Abn Abn* Cn + SVn + IVn 

7 R 81.6 25 NP + nl nl nl - 

8 L 120 95,8 NP - 0 Abn nl Cn + SVn + IVn 

9 R 120 120 NP - ¯ Abn Abn** Cn + SVn + IVn 

10 R 64 35 NP - ¯ nl NP Cn + SVn 

11 R 37.5 10 + 0 nl Abn*** SVn 

+ 

12 R 70,8 64,1 NP - nl nl nl Cn 

13 R 69 25,8 + - nl NP nl Cn 

14 R 65 46 NP - h nl nl Cn + SVn 

15 L 67.5 81 - - nl NP nl Cn 

16 R 81.6 22,5 - - nl NP nl Cn 

17 L 117.5 120 NP - DP Abn nl Cn + SVn + IVn 

18 L 120 120 NP - 0 NR Abn**** Cn + SVn 

19 L 83.3 47.5 NP - nl nl nl Cn 

20 R 120 76.6 NP - NR NR nl Cn 

21 R 112.5 104 NP - nl nl nl Cn 

I: immitance measurements; DPOAE: distortion-product otoacoustic emissions; BCT: bithermal caloric test; VEMP: vestibular evoked 

myogenic potential; MRI: magnetic resonance imaging; R: Right, L: left; dB: decibels; -: absent, +: present; : hyperactivity; : hypoactivity; 

nl: normal; 0: no response, DP: directional preponderance; NP: not performed; Cn: cochlear nerve; SVn: superior vestibular nerve; IVn: 

inferior vestibular nerve; Abn: Abnormal, -: none; *: Spotlights of post-contrast enhancement in the cochlea, vestibule, and right HSC that 

could represent inflammation (viral labyrinthitis, fibrotic tissue); **: expansive lesion within the right internal auditory canal protruding into 

the ipsilateral cerebellopontine angle; ***: expansive lesion in the right internal auditory canal and cerebellopontine angle with widening and 

partial obliteration of the ipsilateral cistern; ****: area of enhancement in the left cochlea (inflammation?). 


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was 29.3 ± 23.8 dB (n = 12), with a 95% confidence interval 

of the mean between 14.1 and 44.5 dB in patients with 

topographically more restricted lesions. In patients with 

topographically more extensive lesions the mean PTA 

recovery and standard deviation was 13.2 ± 10.9 dB (n = 

8) with a 95% confidence interval of the mean between 4 

and 22.4 dB. Case 4 was excluded from the analysis 

because only the initial audiometry results were available 

and no differences between the initial and final PTA could 

be calculated. The difference in the mean PTA recovery 

among patients with topographically more restricted lesions 

was statistically significantly different (p = 0.05, unpaired 

t-test) from those with more extensive lesions, indicating 

that patients with more extensive lesions show poorer 

hearing recovery. 

DISCUSSION 

In this cross-sectional study of 21 patients with SHL, 

abnormal MRI findings were seen in 20% of cases, which is 

similar to the results of a previous report on SHL at our 

institution that showed abnormal MRI findings in 25% of 

those studied (28). The small difference in abnormal MRI 

findings may be due to the smaller sample size used in this 

study. We chose to use DPOAE as an inclusion criterion 

because the test permits the evaluation of each frequency 

separately and responses may be present with hearing 

thresholds up to 45 dB HL, whereas TEOAEs are usually 

absent when the thresholds exceed 20–30 dB HL (29). 

Therefore, this test is not only important for the differential 

diagnosis of peripheral and central lesions, but also because 

absent responses in the initial SHL evaluation exclude the 

possibility of psychogenic deafness (PD) or simulation. 

Psychogenic deafness (PD) is a type of conversion 

disorder and can be defined as HL that cannot be explained 

by organic lesions or anatomical or physiological changes. 

In such cases, the patient’s clinical history reveals 

psychological factors that could act as a trigger at the 

beginning of the event. It is possible to establish the 

diagnosis by comparing behavioral (pure tone audiometry) 

and objective tests (ABR and DPOAE), as these usually 

show divergent results: patients typically exhibit elevated 

pure tone thresholds but normal ABR and DPOAE responses. 

Attention is drawn to case 7 in Table 1. This patient 

presented with initial severe HL although tests failed to 

show any evidence of a structural lesion and follow-up 

showed a full recovery. One hypothesis for this case is PD. 

Malingering may also lead to divergent results between 

behavioral and objective tests, but in contrast to PD, it is 

usually is associated with an inconsistent history, personal 

advantages associated with deafness, and differences 

between pure tone audiometry and SRT >15 dB, which can 

be detected by an experienced audiologist. Therefore, in 

routine clinical evaluation of patients with SHL, DPOAE is 

a valid tool and contributes to diagnostic accuracy. If an 

unexpected response is present during the initial evaluation, 

the possibility of a retrocochlear lesion should be considered 

and investigated. 

In our study, DPOAEs were eventually performed 

late during follow-up of SHL and not as part of the initial test 

as planned. When performed during follow-up, it may be 

useful for showing possible cochlear recovery. This can 

happen even if the cause of SHL is an expansive lesion of 

the IAC or PCA, provided cochlear blood flow is preserved 

and cochlear integrity is ensured. In case 11, normal VEMP 

and DPOAE test results suggested normal saccular, inferior 

vestibular nerve, and cochlear (OHC) function. Pure tone 

and speech audiometry results were normal at the time the 

DPOAE was performed, indicating complete hearing 

recovery after initial moderate HL. We speculate that the 

initial hearing impairment caused by the expansive lesion 

extending from the IAC to CPA may have improved as a 

result of decreased edema resulting in a favorable treatment 

outcome. In the same case, the absence of a right vestibular 

response, as shown by BCT, suggests that only the superior 

vestibular nerve was affected. 

In case 9, the lesion was primarily located in the 

right IAC (although protruding into the CPA), and the test 

results (complete deafness on PTA, absent DPOAEs, 

abnormal VEMP, hypoactivity in BCT) confirmed that the 

whole cochleo-vestibular system was affected on this side. 

Therefore, in our view, DPOAE analysis is an important test 

for SHL evaluation since it is the only one that assesses 

cochlear function. 

Patients underwent a complete ENG evaluation in 

order to rule out other changes to vestibular-ocular function 

suggestive of central involvement. No abnormalities 

suggesting central dysfunction were found in our series. 

Therefore, we considered only the BCT results in our 

analysis. The importance of vestibular evaluation in SHL 

becomes clear when we look at the cases with abnormal 

MRIs. Cases 6, 9, 11, and 18 were found to have structural 

lesions by MRI and all had impaired superior vestibular 

nerve function, with absent vestibular responses in 3 (75%) 

of the 4 cases. Only 1 case had residual function, but 

hypoactivity (SPV below 7 º/sec), highlighting the 

importance of BCT for SHL prognosis. Overall, 4 cases in 

our sample showed no response, 3 (75%) had abnormal 

MRIs and 2 of them (50%) tumors, and so absent caloric test 

responses require an imaging study. However, abnormal 

imaging findings do not predict permanent deafness, since 

cases 6 and 11 both experienced hearing recovery. 

Audiovestibular function tests and MRI are important tools 

that together provide us with a complete overview of the 

functional impairment and the sites involved in SHL, and 


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they may also be helpful for establishing the hearing 

prognosis for these patients. 

MRI demonstrated structural changes in 20% of the 

patients (4 cases: 3 with an extensive lesion and 1 with a 

restricted lesion). When the audiovestibular test results 

were combined with the MRI findings, the proportion with 

a topographic SHL diagnosis increased from 20% to 45%. 

CONCLUSION 

Only combined analysis of several test results allows 

for a precise topographic diagnosis. Isolated test results do 

not provide sufficient data to establish the extent of SHL 

involvement and hence a possible etiology. The 

combination of all tests was more efficient for topographic 

diagnosis than just audiometry and MRI. Combined 

assessment permits a functional evaluation that cannot be 

obtained with MRI alone. Each test evaluates a different 

segment of the cochleo-vestibular system and permits an 

overview of the degree of functional or structural 

impairment. The auditory evoked potentials (ABRs) could 

be included in the audiovestibular test battery. ABR may be 

useful to rule out malingering and patients with psychogenic 

hearing loss, and may also be helpful in follow-up of SHL, 

especially in patients with schwannomas. 

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2. National_Institute_of_Health. Sudden deafness. National 

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3. Byl FM, Jr. Sudden hearing loss: eight years’ experience 

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4. Wu CS, Lin HC, Chao PZ. Sudden sensorineural hearing 

loss: evidence from Taiwan. Audiol Neurootol. 

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5. Teranishi M, Katayama N, Uchida Y, Tominaga M, 

Nakashima T. Thirty-year trends in sudden deafness from 

four nationwide epidemiological surveys in Japan. Acta 

Otolaryngol. 2007 Dec;127(12):1259-65. 

6. Mattox DE, Simmons FB. Natural history of sudden 

sensorineural hearing loss. Ann Otol Rhinol Laryngol. 1977 

Jul-Aug;86(4 Pt 1):463-80. 

7. Wilson WR, Byl FM, Laird N. The efficacy of steroids in 

the treatment of idiopathic sudden hearing loss. A doubleblind 

clinical study. Arch Otolaryngol. 1980 

Dec;106(12):772-6. 

8. Cole RR, Jahrsdoerfer RA. Sudden hearing loss: an update. 

Am J Otol. 1988 May;9(3):211-5. 

9. Yeo SW, Lee DH, Jun BC, Park SY, Park YS. Hearing 

outcome of sudden sensorineural hearing loss: long-term 

follow-up. Otolaryngol Head Neck Surg. 2007 

Feb;136(2):221-4. 

10. Fetterman BL, Luxford WM, Saunders JE. Sudden bilateral 

sensorineural hearing loss. Laryngoscope. 1996 

Nov;106(11):1347-50. 

11. Bittar RS, Oiticica J, Zerati FE, Bento RF. Sudden hearing 

loss: a ten-year outpatient experience. Int Tinnitus J. 

2009;15(2):196-202. 

12. Oiticica J, Bittar RS. Metabolic disorders prevalence in 

sudden deafness. Clinics (Sao Paulo). 2010;65(11):1149- 

553. 

13. Mendes-Correa MC, Bittar RS, Salmito N, Oiticica J. 

Pegylated interferon/ribavirin-associated sudden hearing loss 

in a patient with chronic hepatitis C in Brazil. Braz J Infect 

Dis. 2011 Jan-Feb;15(1):87-9. 

14. Park HM, Jung SW, Rhee CK. Vestibular diagnosis as 

prognostic indicator in sudden hearing loss with vertigo. 

Acta Otolaryngol Suppl. 2001;545:80-3. 

15. Iwasaki S, Takai Y, Ozeki H, Ito K, Karino S, Murofushi 

T. Extent of lesions in idiopathic sudden hearing loss with 

vertigo: study using click and galvanic vestibular evoked 

myogenic potentials. Arch Otolaryngol Head Neck Surg. 

2005 Oct;131(10):857-62. 

16. Junicho M, Fushiki H, Aso S, Watanabe Y. Prognostic 

value of initial electronystagmography findings in idiopathic 

sudden sensorineural hearing loss without vertigo. Otol 

Neurotol. 2008 Oct;29(7):905-9. 

17. Mori T, Suzuki H, Hiraki N, Hashida K, Ohbuchi T, Katoh 

A, et al. Prediction of hearing outcomes by distortion product 

otoacoustic emissions in patients with idiopathic sudden 

sensorineural hearing loss. Auris Nasus Larynx. 2011 

Oct;38(5):564-9. 

18. Brownell WE. Outer hair cell electromotility and 

otoacoustic emissions. Ear Hear. 1990 Apr;11(2):82-92. 

19. Kemp DT. Stimulated acoustic emissions from within 


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20. Bonfils P. Spontaneous otoacoustic emissions: clinical 

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21. Kemp DT. Otoacoustic emissions, their origin in cochlear 

function, and use. Br Med Bull. 2002;63:223-41. 

22. Wang CT, Huang TW, Kuo SW, Cheng PW. Correlation 

between audiovestibular function tests and hearing 

outcomes in severe to profound sudden sensorineural 

hearing loss. Ear Hear. 2009 Feb;30(1):110-4. 

23. Korres S, Stamatiou GA, Gkoritsa E, Riga M, Xenelis J. 

Prognosis of patients with idiopathic sudden hearing loss: 

role of vestibular assessment. J Laryngol Otol. 2011 

Mar;125(3):251-7. 

24. Wu CC, Young YH. Vestibular evoked myogenic 

potentials are intact after sudden deafness. Ear Hear. 2002 

Jun;23(3):235-8. 

25. Halmagyi GM, Curthoys IS. A clinical sign of canal paresis. 

Arch Neurol. 1988 Jul;45(7):737-9. 

26. Aarnisalo AA, Suoranta H, Ylikoski J. Magnetic resonance 

imaging findings in the auditory pathway of patients with 

sudden deafness. Otol Neurotol. 2004 May;25(3):245-9. 

27. Hornsby BW, Johnson EE, Picou E. Effects of degree and 

configuration of hearing loss on the contribution of highand 

low-frequency speech information to bilateral speech 

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LG, Bento RF. Utilidade da Ressonancia Magnética no 

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29. Lonsbury-Martin BL, Martin GK. The clinical utility of 

distortion-product otoacoustic emissions. Ear Hear. 1990 

Apr;11(2):144-54. 

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pure-tone audiogram. Ear Hear. 1991 Dec;12(6):399-405. 

31. Velenovsky DS, Glattke TJ. The effect of noise bandwidth 

on the contralateral suppression of transient evoked 

otoacoustic emissions. Hear Res. 2002 Feb;164(1-2):39-48. 


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DOI: 10.7162/S1809-977720130003000012 

Diffusion of aniline blue injected into the thyroarytenoid muscle as a proxy 

for botulinum toxin injection: an experimental study in cadaver larynges 

Valéria Maria de Oliveira Alonso 1 , Azis Arruda Chagury 2 , Adriana Hachiya 3 , Rui Imamura 3 , Domingos Hiroshi Tsuji 4 , 

Luiz Ubirajara Sennes 4 . 

1) Otolaryngologist, PhD. Specialist in Otolaryngology, School of Medicine, University of São Paulo. 

2) Otolaryngologist. Specialist in Otolaryngology, School of Medicine, University of São Paulo. 

3) Otolaryngologist, PhD. Associate Doctor, Department of Otolaryngology, School of Medicine, University of São Paulo. 

4) Otolaryngologist, PhD. Professor in the Department of Otolaryngology, School of Medicine, University of São Paulo. 

Institution: Department of Otolaryngology, University of São Paulo School of Medicine. 

Av. Dr. Enéas de Carvalho Aguiar, 255, São Paulo / SP - Brazil - Zip Code: 05403-900 

Mailing address: Azis Arruda Chagury - Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - São Paulo / SP - Brazil - Zip Code: 05403-900 - Telephone: (+55 11) 

2661-6286 - E-mail: azischagury@gmail.com 

Article received on March 4 th , 2013. Article accepted on April 8 th , 2013. 

SUMMARY 

Introduction: Endolaryngeal injection of botulinum toxin into the thyroarytenoid (TA) muscle is one of the methods for 

treatment of focal laryngeal dystonia. However, after treatment, there is variation in laryngeal configuration as well as the side 

effects reported by patients. As a consequence of the functional variability of results, it was hypothesized that botulinum toxin 

diffuses beyond the limits of the muscle into which it is injected. 

Objectives: After injection of botulinum toxin into the TA muscle for the treatment of focal laryngeal dystonia, patients differ 

in terms of laryngeal configuration and side effects. We hypothesized that this toxin diffuses from the target muscle to adjacent 

muscles. 

Method: The TA muscles of 18 cadaver larynges were injected with aniline blue (0.2 mL). After fixation in formaldehyde and 

nitric acid decalcification, the larynges were sectioned in the coronal plane and the intrinsic muscles were analyzed. 

Results: We found diffusion of aniline blue to the lateral cricoarytenoid muscle, cricothyroid muscle, and posterior cricoarytenoid 

muscle in 94.3%, 42.9%, and 8.6% of the cases, respectively. In terms of the degree of diffusion to adjacent muscles, we found 

no differences related to the size (height and width) of the TA muscle or to gender. 

Conclusions: Our findings suggest that diffusion of botulinum toxin from its injection site in the TA muscle to the lateral 

cricoarytenoid muscle is likely in most cases. On the other hand, diffusion to the cricothyroid muscle occurs in approximately 

half of cases and diffusion to the posterior cricoarytenoid muscle occurs in very few cases. 

Keywords: Larynx; Dysphonia; Botulinum Toxins; Diffusion; Biological Transport. 

INTRODUCTION 

Adductor spasmodic dysphonia is a disorder 

characterized by involuntary contractions of the adductor 

muscles of the larynx during phonation, resulting in strained, 

strangled, or forced voice quality, as well as intermittent 

voice breaks (1,2). The use of botulinum toxin for the 

treatment of spasmodic dysphonia was described by Blitzer 

in 1986 (3). Since this report, botulinum toxin injection has 

been the treatment of choice for spasmodic dysphonia in 

various centers worldwide. Botulinum toxin injection is a 

minimally invasive method that provides excellent functional 

results. The toxin blocks presynaptic acetylcholine release 

at the neuromuscular junction, causing a partial and reversible 

chemodenervation leading to muscle weakness, which 

reduces spasms in patients with dystonia (4). 

The most widely used method for injecting botulinum 

toxin into the thyroarytenoid (TA) muscle is 

electromyography-guided injection (4). At our facility, 

botulinum toxin is typically injected with a flexible needle, 

which is passed through the biopsy channel of a fiberoptic 

laryngoscope and guided by video-assisted endoscopy 

(2,5). 

The reported side effects of botulinum toxin injection 

into the TA muscle include dysphagia, aspiration, and 

transient dyspnea, effects that vary in terms of incidence 

and severity (6,10). Another factor observed in clinical 

practice is a change in glottal configuration, including vocal 

fold bowing and incomplete glottal closure (with or without 

ventricular fold paralysis). 

Studies in ophthalmology and gastroenterology have 

shown that paralysis of adjacent muscles is the most serious 

complication of the use of botulinum toxin and is probably 

caused by excessive diffusion of the toxin (11-13). This 

probably accounts for the wide variability in laryngeal 

function and configuration after injection of botulinum 


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Diffusion of aniline blue injected into the thyroarytenoid muscle as a proxy for botulinum toxin injection: an experimental study in cadaver larynges. 

Alonso et al. 

toxin into the TA muscle, given that the adjacent (nontargeted) 

muscles include the lateral cricoarytenoid (LCA) 

muscle and the ventricular portion of the TA muscle itself. 

Therefore, the objective of the present study was to 

evaluate the diffusion of aniline blue, a stain specific to 

muscle fibers, after its injection into the TA muscles of 

larynges excised from human cadavers. 

METHOD 

This was an experimental study of 18 larynges that 

were excised from human cadavers. The larynges were 

obtained from the University of São Paulo School of 

Medicine, São Paulo Municipal Department of Death 

Certification, located in the city of São Paulo, Brazil. All 

larynges were removed within the first 24 h after death. 

We used 14 male larynges and 4 female larynges. All 

larynges were obtained from adult individuals of 30–87 

years of age (mean age, 55.5 years). The cause of death 

was not taken into consideration, given that all larynges 

were macroscopically intact. 

In the present study, we used aniline blue, a watersoluble 

stain that targets muscle fibers, at a concentration 

of 2%. The methodology employed was similar to that 

used for the injection of botulinum toxin in the Clinical 

Otolaryngology Department of the University of São 

Paulo School of Medicine Hospital das Clínicas (5). We 

used a flexible needle (model no. IN-2010; Machida 

Endoscope Co., Ltd., Tokyo, Japan) with a 0.5 mm tip. 

The needle was introduced into the TA muscle and 

middle third of the vibratory portion of the vocal fold, 

approximately 1 mm lateral to junction of the vibratory 

portion and the floor of the laryngeal vestibule (Figure 1). 

We injected 0.2 mL of aniline blue into the right and left 

vocal folds of each larynx. This volume (0.2 mL) is the 

volume that is used for botulinum toxin injections at our 

facility. The larynges remained in an anatomical position 

for 30 min, after which they were immersed in 10% 

buffered formalin and left for 7 days. The larynges were 

then placed in 7% nitric acid for 24 h for decalcification, 

being subsequently immersed in the same buffered 

formalin solution. The larynges were removed from the 

buffered formalin solution and stored at -10 o C. In order to 

standardize the laryngeal sections, we drew a line 

(corresponding to the projection of the right vocal fold) 

on the ipsilateral thyroid cartilage lamina, parallel to the 

lower border of the cartilage. After measuring the width 

of the lamina along this line, we divided the line into 4 

equal parts. The larynges were coronally sectioned with 

a microtome blade at 3 points (at the demarcated levels), 

resulting in 4 sections (designated sections I, II, III, and IV, 

from posterior to anterior). All sections were examined 

under a surgical microscope in order to identify the 

regions and muscles that showed aniline blue staining. For 

subsequent analyses, the sections were photographed 

with a digital camera (DSC-S30; Sony Corporation, Tokyo, 

Japan) at a resolution of 640 X 480 pixels. 

We examined the TA, LCA, cricothyroid (CT), and 

posterior cricoarytenoid (PCA) muscles for aniline blue 

staining. We examined both sides of the sections because 

of the possibility of finding different degrees of aniline 

blue staining at different depths. Stained muscles were 

defined as those in which the entire length of the muscle 

(in at least one of the sections) showed aniline blue 

staining. Partially stained muscles were defined as those 

in which part of the muscle, however small, did not show 

staining. In order to analyze the PCA muscle, we dissected 

the posterior lamina of the cricoid cartilage. 

We compared the genders in terms of dye diffusion 

to the muscles studied, each cadaver being considered as 

one case. Dye diffusion was defined as the presence of 

aniline blue staining on at least one side (right or left). We 

then measured the TA muscle in the section in which it 

was at its largest, using a ruler divided into millimeters. 

The TA muscle was measured in the lateromedial direction 

(width) and in the craniocaudal direction (height), as 

shown in Figure 2. 

In order to compare the muscles in terms of dye 

diffusion, we used the McNemar’s test for paired 

proportions. In order to compare the genders in terms of 

dye diffusion, we used Fisher’s exact test. In order to 

determine whether TA muscle width and height had any 

influence on dye diffusion to non-injected muscles, we 

adjusted the logistic regression model, testing the 

parameters with the Wald test. In order to compare the 

genders in terms of laryngeal size, we used the 

nonparametric Mann-Whitney test. For all tests, the level 

of significance was set at 5%. 

RESULTS 

We evaluated 18 larynges (with 36 vocal folds). The 

left vocal fold of one of the larynges was damaged during 

the sectioning process, and the larynx was therefore 

excluded from the study sample. Thus, our final sample 

consisted of 35 hemi-larynges. Table 1 shows the analysis 

of aniline blue staining of the TA, LCA, CT, and PCA 

muscles. 

Aniline blue staining was observed most often in the 

LCA muscle, followed by the CT and PCA muscles. We 

found statistically significant differences between the LCA 

and CT muscles and between the LCA and PCA muscles in 

terms of the frequency of dye diffusion (p < 0.00001). We 


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Alonso et al. 

Figure 2. Points at which the width and height of the 

thyroarytenoid muscle were measured. 

Figure 1. Introduction of the needle into the injection site. 

Table 1. Analysis of aniline blue staining of the thyroarytenoid, lateral cricoarytenoid, 

cricothyroid, and posterior cricoarytenoid muscles. 

Aniline Blue Staining 

Muscle No staining Partial staining Complete staining Any staining (total) 

n (%) n (%) n (%) n (%) 

TA - 2 (5.7%) 33 (94.3%) 35 (100%) 

LCA 2 (5.7%) 16 (45.7%) 17 (48.6%) 33 (94.29%) 

CT 20 (57.1%) 14 (40.0%) 1 (2.9%) 15 (42.86%) 

PCA 32 (91.4%) 3 (8.6%) - 3 (8.57%) 

Note: TA, thyroarytenoid; LCA, lateral cricoarytenoid; CT, cricothyroid; PCA, 

posterior cricoarytenoid. 

also found a statistically significant (albeit weaker) difference 

between the CT and PCA muscles in terms of the frequency 

of dye diffusion (p < 0.0013). 

Table 2 shows the results of the comparison between 

the genders in terms of the frequency of dye diffusion. 

Since there was dye diffusion to the LCA muscle in all 

larynges, it was impossible to perform a statistical analysis 

of this variable for the LCA muscle. We found that neither 

the width nor the height of the TA muscle had a significant 

influence on aniline blue diffusion to the LCA, CT, and PCA 

muscles (Table 3). 

DISCUSSION 

Botulinum toxin injections into the TA muscle have 

been widely used in the treatment of spasmodic dysphonia. 

Botulinum toxin is produced by the anaerobic bacterium 

Clostridium botulinum, and botulinum toxin type A is the 

Table 2. Comparison between the genders in terms of aniline 

blue diffusion to the lateral cricoarytenoid, cricothyroid, and 

posterior cricoarytenoid muscles. 

Gender 

Dye Diffusion Male Female 

n (%) n (%) 

Diffusion to the LCA muscle † 

Yes 14 (100%) 4 (100%) 

No 0 (0%) 0 (0%) 

Diffusion to the CT muscle* 

Yes 8 (57.14%) 3 (75%) 

No 6 (42.86%) 1 (25%) 

Diffusion to the PCA muscle* 

Yes 2 (14.29%) 0 (0%) 

No 12 (85.71%) 4 (100%) 

Note: LCA, lateral cricoarytenoid; CT, cricothyroid; PCA, 

posterior cricoarytenoid 

*p = 0.622 for the CT muscle; p = 1.000 for the PCA muscle. 

† 

Since there was dye diffusion to the LCA muscle in all larynges, it 

was impossible to perform a statistical analysis for this muscle. 


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Alonso et al. 

Table 3. Influence of the width and height of the thyroarytenoid 

muscle on aniline blue diffusion to the lateral cricoarytenoid, 

cricothyroid, and posterior cricoarytenoid muscles. 

Dye Diffusion TA Width (cm) TA Height (cm) 

Mean p Mean p 

Diffusion to the LCA muscle 

Yes 0.55 0.4535 0.51 0.8327 

No 0.51 0.52 

Diffusion to the CT muscle 

Yes 0.51 0.6272 0.53 0.7402 

No 0.50 0.52 

Diffusion to the PCA muscle 

Yes 0.51 0.8136 0.53 0.3110 

No 0.53 0.47 

Note: TA, thyroarytenoid; LCA, lateral cricoarytenoid; CT, 

cricothyroid; PCA, posterior cricoarytenoid. 

the LCA muscles studied showed aniline blue staining. The 

LCA muscle is an important adductor muscle that positions 

the vocal processes along the midline through the rotation 

of the arytenoids. Therefore, LCA muscle involvement can 

lead to inadequate closure of the posterior third of the 

glottis, with incorrect positioning of the vocal process, 

leading to breathiness and aspiration. 

Aniline blue diffusion to the CT muscle was observed 

in 42.86% of the cases (Figure 4). It is known that CT 

muscle involvement can lead to decreased fundamental 

frequency of phonation and, when accompanied by LCA 

and TA muscle paralysis, can decrease vocal intensity. The 

PCA muscle is the only abductor muscle of the larynx. In 

the present study, aniline blue diffusion to the PCA muscle 

was observed in 8.57% of the cases studied (Figure 5). 

form that is used therapeutically. Botulinum toxin blocks 

presynaptic acetylcholine release at the neuromuscular 

junction, causing partial and reversible chemodenervation 

leading to muscle weakness, thereby reducing spasticity in 

patients with dystonia (4). 

The most serious complication of botulinum toxin 

injection in the treatment of dystonia has been reported to 

be paralysis of muscles other than the target muscle, which 

is most likely attributable to toxin diffusion from the injected 

muscle to adjacent muscles. Various authors (14-16) have 

reported botulinum toxin diffusion to pharyngeal and laryngeal 

muscles after injection of the toxin into the 

sternocleidomastoid muscle for the treatment of spasmodic 

torticollis. According to these authors, the complications 

were dysphagia, hoarseness, and vocal fold paralysis. Ludlow 

et al (9) noted that, after injection of botulinum toxin into the 

TA muscle, there was transient dysphagia for liquids, 

breathiness, transient dyspnea, and aspiration, all of which 

were attributed to diffusion of the toxin to adjacent muscles. 

Figure 3. Lateral cricoarytenoid muscles showing aniline blue 

staining. 

The use of excised larynges allows the larynx to be 

cut into several sections after dye injection. However, an 

excised larynx has the disadvantage of being a devitalized 

tissue, which is immobilized (not subject to the motion that 

accompanies breathing, swallowing, and phonation) and 

without blood circulation or lymph flow. Therefore, it does 

not accurately reflect normal laryngeal function. In the 

excised larynges used in the current study, dye diffusion 

occurred passively, i.e., without the aid of circulation or 

active motion, and was probably due to hydrostatic pressure 

on the fluid-filled compartment of the muscle. 

In the present study, the LCA muscle, which is the 

muscle that is closest to the TA muscle, was the most 

affected by diffusion (Figure 3). We found that 94.29% of 

Figure 4. Cricothyroid muscle stained on the left. 


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Alonso et al. 

CONCLUSION 

Based on the results of the present study, we can 

conclude that the probability of botulinum toxin diffusion 

to muscles that are adjacent to the TA muscle is nearly 

100% for the LCA muscle and nearly 50% for the CT 

muscle. Albeit less common, diffusion of toxin to the PCA 

muscle can also occur. In addition, it seems that neither 

gender nor laryngeal size has any significant influence on 

the pattern of diffusion. 

REFERENCES 

1. Behlau MS, Pontes PAL, Dedo HH. Spastic Dysphonia of 

the focal laryngeal dystonia: the evolution of the concept 

of the same disease. Acta AWHO. 1991;10(2):89-95. 

Figure 5. Posterior cricoarytenoid muscle partially stained on 

both sides. 

Although the risk of bilateral diffusion is small, it 

should be taken into consideration when botulinum toxin 

is used in the treatment of patients with spasmodic 

dysphonia, particularly when the toxin is injected bilaterally, 

because bilateral toxin diffusion can lead to a clinical 

situation that is similar to bilateral adductor vocal fold 

paralysis. Although it is a rare complication, bilateral paralysis 

following botulinum toxin injection has been reported in 

patients with adductor spasmodic dysphonia (17). 

Therefore, different degrees of muscle paralysis and paresis 

(in isolation or in combination) can explain the different 

laryngeal configurations observed in such patients. 

Another parameter analyzed in our study was the 

influence of gender on aniline blue diffusion to noninjected 

muscles. This was tested for each muscle 

individually. For the LCA muscle, it was impossible to 

analyze this parameter because all of the larynges studied 

showed dye diffusion to the LCA muscle, with the exception 

of 2 hemi-larynges. With regards to the CT and PCA 

muscles, we found that gender had no statistically significant 

influence on dye diffusion to these muscles. Other authors 

have also found that there are no significant gender-related 

differences in diffusion (18). 

In addition, we tested whether the height and width 

of the TA muscle influenced dye diffusion to non-injected 

muscles. We found that neither the height nor the width of 

the TA muscle had any influence on dye diffusion to any 

of the adjacent muscles studied. 

2. Tsuji DH, Sennes LU, Pinho, SMR, Barbosa E. Technical 

application of botulinum toxin through the flexible 

endoscopel. In: Third Brazilian Congress from Laryngology 

and Voice, Annals. 1995; P 1. 

3. Blitzer A, Brin MF, Fahn S, et al. Botulinum toxin (BOTOX) 

for the treatment of “Spastic Dysphonia”as part of a trial of 

toxin injections for the treatment of other cranial dystonias. 

Laryngoscope. 1986; 96:1300-1. 

4. Evans CM, Williams RS, Shone, CC. Botulinum type B. Its 

purification, radioiodination and interaction with rat-brain 

synaptosomal membranes. Eur. J. Biochem.1986;154:409- 

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7. Shaari CM, George E, Wu BL, Biller HF, Sanders I. 

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8. Ludlow CL, Naunton RF, Sedory SE. Effects of Botulinum 

Toxin Injections on Speech in Adductor Spasmodic 

Dysphonia. Neurology. 1988;38:1220-5. 

9. Ludlow CL, Bagley JA, Yin SG. A comparison of 

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10. Brin MF, Blitzer A, Fahn S et al. Adductor Laryngeal 

Dystonia (Spastic Dysphonia): Treatment with Local 

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1989;4:287-96. 

11. Scott AB. Botulinum toxin injection of eye muscles to 

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12. Elston JS, Russel RW. Effects of Treatment with Botulinum 

Toxin on Neurogenic Blepharospasm. Br. Med. J. 

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13. Hallan RI, Melling, J, Womack NR. Treatment of Anismus 

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in Spasmodic Torticollis. J. Neurol. Neurosurg. Psychiatry. 

1988;51:920-3. 

15. Koay CE, Alun-Jones T. Pharyngeal Paralysis Due to 

Botulinum Toxin Injection. J Laryngol Otol. 1989;103:698-9. 

16. Liu TC, Irish, JC, Adams SG, Durkin LC, Hunt EJ. 

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Botulinum Toxin Injection for Spasmodic Dysphonia. J 

Otolaryngol. 1996;25(2):66-74. 

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DOI: 10.7162/S1809-977720130003000013 

Correlation of cephalometric and anthropometric measures with obstructive 

sleep apnea severity 

Paulo de Tarso M Borges 1 , Edson Santos Ferreira Filho 2 ,Telma Maria Evangelista de Araujo 3 , Jose Machado Moita Neto 4 , 

Nubia Evangelista de Sa Borges 5 , Baltasar Melo Neto 6 , Viriato Campelo 7 , Jorge Rizzato Paschoal 8 , Li M Li 9 . 

1) Master’s degree completed. Doctorate in progress. Adjunct Professor of Otolaryngology (Federal University of Piaui). 

2) Physician (Federal University of Piaui). 

3) Doctoral degree completed. Adjunct Professor of Nursing (Federal University of Piaui). 

4) Doctoral degree completed. Associate Professor of Chemistry (Federal University of Piaui). 

5) Phonoaudiologist (Paulo Borges Clinic). 

6) Physician (Federal University of Piaui). 

7) Doctoral degree completed. Associate Professor (Department of Parasitology and Microbiology, Federal University of Piaui). 

8) Doctoral degree completed. Associate Professor (Campinas State University (UNICAMP) School of Medicine). 

9) Doctoral degree completed. Full Professor (Campinas State University (UNICAMP) School of Medicine). 

Institution: Federal University of Piaui. 

Teresina / PI – Brazil. 

Mailing address: Paulo de Tarso Moura Borges - Av. Elias João Tajra, 1260 - Apto. 300 - Bairro: Jóquei Clube - Teresina / PI - Brazil - Zip Code: 64049-300 - Telephone: 

(+55 86) 3230-9797 / 3232-4306; E-mail: ptborges@gmail.com 


SUMMARY 

Introduction: Patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) often have associated changes in craniofacial 

morphology and distribution of body fat, either alone or in combination. 

Aim: To correlate cephalometric and anthropometric measures with OSAHS severity by using the apnea-hypopnea index (AHI). 

Method: A retrospective cephalometry study of 93 patients with OSAHS was conducted from July 2010 to July 2012. The 

following measurements were evaluated: body mass index (BMI), neck circumference (NC), waist circumference (WC), hip 

circumference (HC), the angles formed by the cranial base and the maxilla (SNA) and the mandible (SNB), the difference between 

SNA and SNB (ANB), the distance from the mandibular plane to the hyoid bone (MP-H), the space between the base of the 

tongue and the posterior pharyngeal wall (PAS), and the distance between the posterior nasal spine and the tip of the uvula 

(PNS-P). Means, standard deviations, and Pearson’s correlation coefficients were calculated and analyzed. 

Results: AHI correlated significantly with BMI (r = 0.207, p = 0.047), NC (r = 0.365, p = 0.000), WC (r = 0.337, p = 0.001), 

PNS-P (r = 0.282, p = 0.006), and MP-H (r = 0.235, p = 0.023). 

Conclusion: Anthropometric measurements (BMI, NC, and WC) and cephalometric measurements (MP-H and PNS-P) can be 

used as predictors of OSAHS severity. 

Keywords: Cephalometry; Sleep Apnea, Obstructive; Anthropometry; Body Mass Index; Abdominal Circumference; Waist 

Circumference. 

INTRODUCTION 

Obstructive sleep apnea-hypopnea syndrome 

(OSAHS) is a disorder characterized by recurrent episodes 

of partial or total upper airway obstruction during sleep. 

The apnea-hypopnea index (AHI) refers to the number of 

episodes of apnea and hypopnea that occur per hour of 

sleep (1). 

OSAHS affects 4–7% of the general adult population 

(2). Owing to its current prevalence, it is considered a 

major public health concern, which can manifest serious 

physical and social consequences if not managed properly 

(2,3). This disorder mainly affects middle-aged economically 

active patients, resulting in high costs and lost workdays 

(4). Medical costs can be significantly reduced when 

effective diagnosis and treatment are performed early (5). 

The diagnosis of OSAHS is based on a combination of the 

laboratory findings of apnea and hypopnea with clinical 

symptoms (6). 

Radiographic imaging of the upper airways allows 

for the study of bone and soft tissue anatomy, in addition 

to the determination of the site of obstruction and the 

choice of appropriate treatment for OSAHS patients (7). 

Cephalometry has been used since 1983 and was initially 

applied in patients with sleep-related breathing disorders. 

It consists of cephalometric tracings obtained by 

teleradiography of the facial profile. The aim of the test is 

to study the facial, maxillary, and mandibular skeleton and 

any relationships with the soft tissues that may cause 

pharyngeal obstruction (8). Cephalometry is an easy, lowcost, 

non-invasive, and widely available modality in the 


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Correlation of cephalometric and anthropometric measures with obstructive sleep apnea severity. 

Borges et al. 

majority of hospitals. Radiation use is minimal, readily 

accessible to clinicians, and not uncomfortable for the 

patient. It has proved to be useful for the evaluation of the 

upper airways and bone structure in normal subjects and 

OSAHS patients (9-11). 

A complete cephalometric analysis should be 

performed in patients with OSAHS to identify associated 

maxillofacial abnormalities (12). From this perspective, it 

has been used in several sleep disorder centers, with the 

purpose of diagnosing the site of obstruction in patients 

with obstructive sleep apnea. In some centers, this test is 

part of a service protocol that is important for the decision 

as to which type of surgery should be performed. Therefore, 

it is recommended in all patients with OSAHS undergoing 

surgery (8,9,12-15). It is also used with mandibular 

advancement devices to assess therapeutic efficacy in 

patients with mild to moderate OSAHS (15,16). 

Obesity, in particular the presence of visceral fat, is 

considered a predictive factor for OSAHS (17). Several 

studies have been performed using anthropometric 

measurements of obesity in patients with OSAHS, e.g., 

body mass index (BMI), neck circumference (NC), waist 

circumference (WC), and hip circumference (HC) (18-21). 

These measurements may be used both to assess the need 

for patient referral to polysomnographic evaluation and to 

anticipate treatment in high-risk patients, since this disorder 

may cause severe consequences in untreated patients 

(2,21). Polysomnography is not an accessible test for most 

individuals. It is expensive and easier, more affordable tests 

with less technological density, such as cephalometry (9- 

11), are required (17,19,22,23) to screen for OSAHS. 

Anthropometric measurements are easily obtained and 

fundamental for the preparatory study of a patient with 

suspected OSAHS. Therefore, the number of patients 

referred for polysomnography could be greatly reduced, 

lowering healthcare expenses, with simple measurement 

of cervical, waist, and hip circumferences. The use of these 

measurements in patients with snoring and those clinically 

suspected of having OSAHS would thus prioritize 

complementary polysomnography testing in patients with 

higher suspicion of disease (24). 

The aim of this study was to correlate cephalometric 

and anthropometric measurements with the AHI, in order 

to assess if these measurements can be used as predictors 

of OSAHS severity. 

METHOD 

Data obtained from the medical charts of 93 male 

and female patients with OSAHS, ranging in age from 19 to 

80 years, were studied. These patients had been examined 

from July 2010 to July 2012 in a specialist private clinic in 

Teresina. The medical charts of patients who had undergone 

previous surgical treatment for OSAHS, including use of 

continuous positive airway pressure devices or intraoral 

devices, in addition to patients with craniofacial deformities 

and upper airway tumors, were excluded from the study. 

Overnight polysomnography was analyzed by a 

single professional, who specialized in sleep disorders. 

Patients were considered to have OSAHS if, in addition to 

clinical complaints, they had an AHI > 5 upon overnight 

polysomnography testing (1). Severity was measured by 

the AHI. Cephalometry was also performed by a single 

radiologist, who specialized in orthodontic radiographs. 

Each examiner was blinded to the test results obtained by 

the other examiner. 

The following cephalometric traces were considered, 

since they are the most commonly used cephalometric 

measures: retroglossal posterior airway space (PAS), defined 

as the space between the base of the tongue and the 

posterior pharyngeal wall; the distance between the mandibular 

plane and the hyoid bone (MP-H); the SNA angle, 

formed by the junction between the sellar point (S, 

midpoint of the sella turcica), nasion (N, junction between 

the frontal and nasal bones), and point A (deepest concavity 

on the anterior profile of the maxilla); the SNB angle, 

formed by the junction between the sellar point (S), nasion 

(N), and point B (deepest concavity on the anterior profile 

of the mandibular symphysis); the distance between the 

posterior nasal spine and the tip of the soft palate (PNS-P); 

and the difference between SNA and SNB (ANB) (Figure 1) 

(8,9,12,15). 

Concerning anthropometric measurements, BMI, 

NC, WC, and HC were evaluated. BMI was calculated as the 

weight of the subject (in kilograms) divided by their height 

(in meters) squared. Obesity is defined as a BMI > 30 kg/ 

m 2 (25). NC was measured at the level of the crycothyroid 

cartilage. WC was measured between the last rib and the 

iliac crest and HC was measured as the maximum 

circumference at the level of the border of the trochanter. 

Anthropometric measurements were based on the World 

Health Organization manual (26). 

Data was entered into the Statistical Package for the 

Social Sciences (SPSS) version 16.0 program for calculation 

of simple descriptive statistics, e.g., percentage distribution, 

mean, and standard deviation. A normality test (Kolmogorov- 

Smirnov) was applied and the adequate statistical test was 

chosen for each type of variable (parametric or 

nonparametric). Pearson’s correlation coefficients were 

examined between AHI and the following variables: age, 

BMI, NC, WC, HC, and cephalometric measurements (SNA, 

SNB, ANB, MP-H, PAS, and PNS-P). Sex differences were 


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Table 1. Sample distribution according to gender and obesity. 

n % BMI, kg/m 2 

(mean ± SD) 

Gender Male 54 58.06 27.88 ± 3.30 

Female 39 41.94 27.41 ± 4.50 

Total 93 100.00 27.68 ± 3.83 

Obesity Nonobese 69 74.19 25.90 ± 2.29 

Obese 24 25.81 32.81 ± 2.50 

Total 93 100.00 27.68 ± 3.83 

Note: BMI = body mass index. 

Figure 1. Description of cephalometric parameters (Source: 

the author). 

compared by the Student’s t test. Statistical significance 

was set at p < 0.05. 

The project was approved by the Research Ethics 

Committee of the Universidade Federal do Piauí, under 

CAAE number 0047.0.045.000-10. 

RESULTS 

Of the 93 patients studied, 54 (58.1%) were male. 

The mean BMI was 27.68 ± 3.83 kg/m 2 (women, 27.41 ± 

4.50 kg/m 2 ; men, 27.88 ± 3.30 kg/m 2 ). There were 69 

(74.19%) nonobese (BMI, 25.90 ± 2.29 kg/m 2 ) and 24 

(25.81%) obese (BMI, 32.81 ± 2.50 kg/m 2 ) patients 

(Table 1). 

The mean age of the patients was 46.70 ± 15.46 

years (range, 19 to 80 years). Table 2 describes the sample 

characteristics and variables studied, including their variations 

and means. 

Table 3 shows an analysis of the Pearson correlation 

coefficients used to evaluate the relationship between 

AHI, age, and anthropometric/cephalometric 

measurements. Analyzing the relationship between age 

and OSAHS severity by AHI showed a positive correlation 

between these 2 data series, indicating that OSAHS was 

more severe in older patients. Similarly, there was also a 

Table 2. Characteristics of the sample including age, 

anthropometric parameters, cephalometric parameters, and 

AHI (n = 93). 

Variable Minimum Maximum Mean Standard 

deviation 

Age, years 19.0 80.0 46.70 15.46 

BMI, kg/m 2 19.72 40.18 27.68 3.83 

NC, cm 30.0 47.0 38.56 3.92 

WC, cm 73.0 125.0 97.59 10.10 

HC, cm 87.0 131.0 104.09 7.39 

SNAº 72.0 92.0 82.77 4.08 

SNBº 69.0 92.0 80.96 4.41 

ANBº -13.0 10.0 1.82 3.90 

MP-H, mm 4.0 45.0 19.21 8.22 

PAS, mm 3.0 20.0 10.04 3.80 

PNS-P, mm 20.0 52.0 39.84 5.37 

AHI, events/h 5.00 83.40 34.67 17.41 

Note: AHI = apnea-hypopnea index; BMI = body mass index; 

NC = neck circumference; WC = waist circumference; 

HC = hip circumference; SNA = angle formed by the junction 

of the sella (S), nasion (N), and point A; SNB = angle formed 

by the junction of the sella (S), nasion (N), and point B; 

ANB = difference between SNA and SNB; MP-H = distance 

between the mandibular plane and the hyoid bone; 

PAS = space between the base of the tongue and the posterior 

pharyngeal wall; PNS-P = distance between the posterior 

nasal spine and the tip of the soft palate. 

positive correlation between BMI and AHI, which allowed 

us to infer that the higher the BMI, the greater the AHI. 

Regarding body circumference measurements, both NC 

and WC showed a statistically significant positive correlation 

with OSAHS severity. Concerning the relationship between 

cephalometric data and AHI, a statistically significant positive 

correlation for MP-H and PNS-P was observed (Table 3). 

Comparing anthropometric parameters between 

men and women indicated a statistically significant difference 

for NC and WC, but not for HC. Regarding cephalometry, 

MP-H and PNS-P were significantly different between men 

and women (Table 4). 


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Table 3. Correlation of age and anthropometric/cephalometric data with AHI (n = 93). 

Age BMI NC WC HC SNA SNB ANB MP-H PAS PNS-P 

Pearson correlation 0.241 0.207 0.365 0.337 0.201 -0.044 0.031 -0.081 0.235 -0.102 0.282 

p-value (two-tailed) 0.020 0.047 0.000 0.001 0.053 0.676 0.769 0.441 0.023 0.329 0.006 

Note: AHI = apnea-hypopnea index; BMI = body mass index; NC = neck circumference; WC = waist circumference; HC = hip 

circumference; SNA = angle formed by the junction of the sella (S), nasion (N), and point A; SNB = angle formed by the junction 

of the sella (S), nasion (N), and point B; ANB = difference between SNA and SNB; MP-H = distance between the mandibular 

plane and the hyoid bone; PAS = space between the base of the tongue and the posterior pharyngeal wall; PNS-P = distance 

between the posterior nasal spine and the tip of the soft palate 

Tables 5 and 6 show an analysis of the Pearson 

correlation coefficients used to assess the relationship 

between AHI and age as well as anthropometric/ 

cephalometric measurements for males and females. 

For anthropometric measurements, AHI showed a 

statistically significant correlation with age, BMI, NC, and 

WC in males. Only NC showed a significant correlation in 

females. In both genders, the most significant correlation 

was with NC (Table 5). Regarding cephalometric 

measurements, the only correlation found was that of AHI 

with PNS-P measurement in males (Table 6). 

DISCUSSION 

Obesity may increase susceptibility to OSAHS by 

causing fat deposition in the upper airway tissues, narrowing 

the nasopharyngeal caliber and/or leading to hypoventilation 

in association with reduced wall complacency (27). 

Assessment of craniofacial morphology in OSAHS patients 

not only aids specialists concerned with recognizing 

morphologic changes induced by altered sleep patterns, 

but also provides the patient with adequate treatment 

(11). 

There is a vast amount of scientific literature on 

cephalometric and anthropometric measures, which compares 

control groups and snorers to OSAHS patients and 

aims at using these measurements as predictors of this 

condition (7,9-11,13,15,18,20,22,28-32). Some studies have 

been performed to assess appropriate treatments, surgical 

treatment plans, and the indications of intraoral devices 

(11,16,27,33-40), while others were performed to evaluate 

the relationship between these measurements and OSAHS 

severity (17-20,22-24,32,40-45). 

In the current study, there was a significant correlation 

between age and AHI (Table 3), indicating that OSAHS is 

more severe in older patients. This is in agreement with the 

majority of previous studies (17,22-24,45,46), with the 

exception of those by Mayer et al42 and Schellenberg, 

Maisline, and Schwab (37). 

Table 4. Comparison between males and females for 

anthropometric/cephalometric data and AHI. 

Females (n = 39) Males (n = 54) p-value 

Age, years 49.77 ± 14.32 44.48 ± 15.99 p > 0.05 

BMI, kg/m 2 27.41 ± 4.50 27.88 ± 3.30 p > 0.05 

NC, cm 35.31 ± 2.27 40.91 ± 3.09 

** 

p < 0.01 

WC, cm 94.41 ± 10.79 99.89 ± 8.99 

** 

p < 0.01 

HC, cm 102.56 ± 8.65 105.19 ± 6.18 p > 0.05 

SNAº 82.74 ± 3.38 82.80 ± 4.56 p > 0.05 

SNBº 80.41 ± 4.35 81.35 ± 4.44 p > 0.05 

ANBº 2.33 ± 3.98 1.44 ± 3.83 p > 0.05 

MP-H, mm 15.04 ± 6.62 22.22 ± 8.00 

** 

p < 0.01 

PAS, mm 9.28 ± 3.44 10.59 ± 3.98 p > 0.05 

PNS-P, mm 37.82 ± 5.10 41.30 ± 5.12 

** 

p < 0.01 

AHI, events/h 31.02 ± 15.20 37.30 ± 18.53 p > 0.05 

Note: AHI = apnea-hypopnea index; BMI = body mass index; 

NC = neck circumference; WC = waist circumference; 

HC = hip circumference; SNA = angle formed by the junction 

of the sella (S), nasion (N), and point A; SNB = angle formed 

by the junction of the sella (S), nasion (N), and point B; 

ANB = difference between SNA and SNB; MP-H = distance 

between the mandibular plane and the hyoid bone; 

PAS = space between the base of the tongue and the posterior 

pharyngeal wall; PNS-P = distance between the posterior nasal 

spine and the tip of the soft palate 

It was observed that BMI was correlated with AHI, 

allowing us to infer that more severe OSAHS occurs in 

subjects with a higher BMI, which is concordant with most 

published studies (17,19,21-23,31,32,37,39,42,45-47). 

Nevertheless, this fact was not observed by Yucel et al (41) 

and Martinez-Rivera et al (24). 

NC is a simple measurement that is easily performed. 

Findings in the present study point to a positive correlation 

between NC and AHI, which is in agreement with other 

studies (19,20,22,24,31,32,37-39,41,46). A correlation with 

BMI was also observed previously (17-19,23,32,44), 

suggesting that obesity affects patients with OSAHS through 

fat deposition in the neck (20,23,30). In contrast to the 

majority of studies, Ogretmenoglu et al (17) stated that NC 

was more weakly correlated with AHI than BMI. 


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Table 5. Pearson correlation of AHI with age and anthropometric data for males and 

females. 

Age BMI NC WC HC 

M Pearson correlation 0.358 0.273 0.349 0.395 0.156 

p-value (two-tailed) 0.008 ** 0.046 * 0.010 ** 0.003 ** 0.259 

n 54 54 54 54 54 

F Pearson correlation 0.131 0.123 0.329 0.192 0.212 

p-value (two-tailed) 0.426 0.457 0.041 * 0.242 0.195 

n 39 39 39 39 39 

Note: AHI = apnea-hypopnea index; M = males; F = females; BMI = body mass index; 

NC = neck circumference; WC = waist circumference; HC = hip circumference; 

** p < 0.01; * p < 0.05. 

Table 6. Pearson correlation between AHI and cephalometric data for males and females. 

SNA SNB ANB MP-H PAS PNS-P 

M Pearson correlation -0.075 0.031 -0.125 0.229 -0.212 0.305 

p-value (two-tailed) 0.592 0.822 0.368 0.096 0.124 0.025 * 

n 54 54 54 54 54 54 

F Pearson correlation 0.020 -0.021 0.040 0.073 0.010 0.135 

p-value (two-tailed) 0.904 0.898 0.809 0.660 0.951 0.412 

n 39 39 39 39 39 39 

Note: AHI = apnea-hypopnea index; M = males; F = females; SNA = angle formed by the junction 

of the sella (S), nasion (N), and point A; SNB = angle formed by the junction of the sella (S), 

nasion (N), and point B; ANB = difference between SNA and SNB; MP-H = distance between 

the mandibular plane and the hyoid bone; PAS = space between the base of the tongue and 

the posterior pharyngeal wall; PNS-P = distance between the posterior nasal spine and the tip 

of the soft palate; * p < 0.05. 

WC also showed a positive correlation with AHI, in 

agreement with other studies (19,23,24,32,38,39,46).This 

correlation was weaker than that observed with NC, 

supporting the existing literature (19,23,39). The present 

study is also consistent with others (19,32) showing that 

the correlation of AHI with WC is greater than that with 

BMI. However, Davidson and Patel (32) observed that WC 

was more predictive than BMI as well as NC. 

Analyzing the relationship between cephalometric 

data and AHI showed a statistically significant correlation 

for MP-H and PNS-P, indicating an increased palatal length 

and an increased distance between the hyoid bone and the 

mandibular plane, which was consistent with other studies 

(29,42,43,46,48). According to Yucel et al (41), only MP- 

H measurement is related to AHI. The position of the hyoid 

bone, which has an impact on the shape and position of the 

tongue, affects hypopharyngeal airway patency (41). 

A study by Bharadwaj, Ravikumar, and Krishnaswamy 

conducted in India compared 10 OSAHS patients to a 

control group of 10 healthy subjects (mean age, 34.9 

years). These authors concluded that upright cephalometry 

demonstrated mandibular retrognathism, increased ANB 

angle, increased PNS-P length and increased soft palate 

thickness, increased tongue length, and decreased PAS in 

the group of OSAHS patients when compared to the 

control group (11). Other studies have shown that PNS-P 

and MP-H measurements are increased, while PAS is 

decreased, in patients with OSAHS, and these measurements 

were considered predictive of OSAHS (7,9,15). PAS 

measurement was correlated with severity of OSAHS 

assessed using the AHI (7,9). A study conducted in 

Strasbourg (France) in 1990, comparing 43 OSAHS patients 

to a control group of 40 asymptomatic individuals, showed 

that PNS-P measurement was increased in patients with 

OSAHS, while SNA, SNB, and ANB measurements did not 

demonstrate any alterations in either group (28). Other 

studies have shown increased MP-H measurement and 

decreased PAS measurement in comparisons between 

OSAHS groups and control groups (13,40). However, 

Mayer et al (42) found no correlation between PAS 

measurement and AHI. 

In a comparison between male and female patients 

in the present study, BMI and HC were similar. NC and WC 

were significantly higher in males than in females. These 

results are partially in agreement with findings by Millman 


325



et al (49), who described a higher NC for males, but no 

difference between the genders for BMI and WC. Another 

study demonstrated a significantly increased BMI in females 

(41). This fact reflects well-known characteristics concerning 

body fat distribution in men and women (49). 

In the current study, NC was more closely correlated 

with AHI than WC and BMI, both in the overall population 

and in male and female subjects, indicating that NC is the 

best anthropometric measurement for prediction of OSAHS 

severity, especially in males (18,19,23,39,41,44). 

Comparing cephalometry between male and female 

subjects showed a statistically significant difference in 

MP-H and PNS-P measurements, which were higher in 

male subjects. PNS-P measurement was correlated with 

AHI in males, while there were no significant correlations 

in females. 

In conclusion, the results of this study show a 

correlation of anthropometric (BMI, NC, and WC) and 

cephalometric (MP-H and PNS-P) measurements with the 

AHI, reinforcing their preparatory role and use as predictors 

of OSAHS. 

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DOI: 10.7162/S1809-977720130003000014 

Use of surface electromyography in phonation studies: an integrative 

review 

Patricia Maria Mendes Balata 1 , Hilton Justino da Silva 2 , Kyvia Juliana Rocha de Moraes 3 , Leandro de Araújo Pernambuco 4 , 

Sílvia Regina Arruda de Moraes 5 . 

1) Doctor in Neuropsychiatry and Behaviour Science of Adolescent Health; Speech and Language Pathologist; Voice Specialist ; (Speech and Language Pathologist of 

the Hospital dos Servidores do Estado de Pernambuco). 

2) Doctor of Nutrition; Speech and Language Pathologist; Master of Anatomy; Specialist in oral Motricity (Teacher in the Speech and Language Pathology Department 

of the Universidade Federal de Pernambuco). 

3) Master of Pathology; Physiotherapist (Teacher in the Physiotherapy Department of the Faculdade Estacio do Recife). 

4) Master of Pathology; Speech and Language Pathologist; Specialist in oral Motricity (Teacher in the Speech and Language Pathology Department of the Universidade 

Federal do Rio Grande do Norte; Doctoral Student in Public Health). 

5) Doctor of Sciences; Physiotherapist (Teacher in the Anatomy Department of the Universidade Federal de Pernambuco). 

Institution: Universidade Federal de Pernambuco. 

Recife / PE – Brazil. 

Mailig address: Patricia Maria Mendes Balata - Avenida Domingos Ferreira, 636, sala 208 - Pina - Recife / PE – Brazil - Zip Code: 51011-010 - Telephone: (+55 81) 

3326-9482 - E-mail: pbalata@uol.com.br. 

Financial support from National Council for Scientific and Technological Development with Edictal Universal Process MCT/CNPQ 14/2009, B, process: 476412/2009. 

Article received on October 4 th , 2012. Article accepted on January 18 th , 2013. 

SUMMARY 

Introduction: Surface electromyography has been used to assess the extrinsic laryngeal muscles during chewing and swallowing, 

but there have been few studies assessing these muscles during phonation. 

Objective: To investigate the current state of knowledge regarding the use of surface electromyography for evaluation of the 

electrical activity of the extrinsic muscles of the larynx during phonation by means of an integrative review. 

Method: We searched for articles and other papers in the PubMed, Medline/Bireme, and Scielo databases that were published 

between 1980 and 2012, by using the following descriptors: surface electromyography and voice, surface electromyography 

and phonation, and surface electromyography and dysphonia. The articles were selectedon the basis ofinclusion and exclusion 

criteria. 

Data Synthesis: This was carried out with a cross critical matrix. We selected 27 papers,i.e., 24 articles and 3 theses. The studies 

differed methodologically with regards to sample size and investigation techniques, making it difficult to compare them, but 

showed differences in electrical activity between the studied groups (dysphonicsubjects, non-dysphonicsubjects, singers, and 

others). 

Conclusion: Electromyography has clinical applicability when technical precautions with respect to application and analysis 

are obeyed. However, it is necessary to adopt a universal system of assessment tasks and related measurement techniques to 

allow comparisons between studies. 

Keywords: Electromyography; Phonation; Dysphonia; Laryngeal Muscles. 

INTRODUCTION 

The increased use of surface electromyography 

(SEMG) in speech and language pathology, not only in 

the literature but also in clinical practice, makes it 

important to investigate the current state of knowledge 

regarding this technique. This is true especially in the 

area of orofacial motricity, where SEMG is used as a tool 

for assessment and treatment. SEMG is also utilized in 

studies on the voice. When assessing the current 

knowledge regarding a particular subject area, it is 

important to identify and document the best evidence 

produced by quantitative and qualitative research on the 

topic in question. Then, through integrative review, it is 

possible to inventory gaps in the current knowledge that 

may constitute new challenges to the scientific 

community. 

Electromyography is a technique that measures the 

electrical activity (EA) of several muscles in the body in 

order to diagnose movement disorders, and can also 

contribute to the assessment of prognosis in motor alterations. 

It has been employed in the fields of neurology, orthopedics, 

physical therapy, and otorhinolaryngology. There are 2 

types of electromyographic examinations. Insertion 

electromyography (EMG) evaluates the action potentials 

of the motor units of deeper muscles; it is invasive and 

characterized by the use of needle electrodes fixed to the 

muscles under investigation. SEMG uses electrodes attached 

to the dermis to capture the myoelectric signals from 

muscles or muscle groups closer to the skin surface. 


329

Use of surface electromyography in phonation studies: an integrative review. 

Balata et al. 

In speech and language pathology, SEMG is used to 

aid in diagnosis and therapy, especially for the orofacial 

functions of chewing and swallowing. These functions 

have a close relationship with movement of the larynx; the 

main function of the larynx is protection of the upper 

airways during the act of swallowing. To understand the 

activity of the intrinsic muscles of the larynx, the field of 

otorhinolaryngology has used EMG mainly for investigating 

neurological voice disorders. However, there has been 

little research on the extrinsic laryngeal muscles. These 

muscles have their origin in extra-laryngeal structures, but 

modify phonation indirectly by either raising or lowering 

the larynx via the basic function of the suprahyoid (SH) 

muscles and infrahyoid (IH) muscles, respectively. The 

evaluation of these muscles by SEMG is a procedure 

considered feasible for clinical examination. 

The objective of this study was to investigate the 

current state of knowledge regarding the use of SEMG in 

assessing the EA of the SH and IH extrinsic muscles during 

phonation in order to help in understanding the complex 

phonatory phenomenon and its disorders, as well as to 

certify the use of this tool in vocal clinics. 

METHOD 

The integrative review is a method that belongs to 

the systematic review technique which, in turn, is focused 

on experimental studies that are preferably randomized 

with rigorous control of variables. This allows the safe 

development of evidence-based practice (1). As an 

alternative to narrative and systematic reviews, the 

integrative review involves a broader approach that allows 

the inclusion of studies which are not only experimental 

but also quasi-experimental or non-experimental. The 

process involved systematically follows pre-defined steps 

and allows a greater scope of theoretical and empirical 

sampling through a rigorous examination process. 

The following steps comprised the present study: 

(1) preparation of the guiding question; (2) literature 

search for the definition of descriptors; (3) selection of 

articles according to the criteria for inclusion and exclusion; 

(4) collection, data extraction, reading, and critical analysis; 

(5) interpretation and discussion of results; (6) knowledge 

synthesis and review presentation. 

Step 1) Preparation of the guiding question: the 

guiding question “what is the current state of knowledge 

regarding the use of SEMG in studies on the voice?” was 

defined from the theoretical and practical knowledge of 

the authors, with regards to the fact that SEMG is being 

increasingly used in studies on the area of speech and the 

voice, especially in Brazil. 

Step 2) Literature search for the definition of 

descriptors: articles were searched for on the Pubmed, 

Medline, and Scielo databases using the following descriptors: 

surface electromyography and voice, surface 

electromyography and phonation, and surface 

electromyography and dysphonia. 

Step 3) Selection of articles according to the criteria 

for inclusion and exclusion: articles and theses produced 

between 1980 and 2012 that complied with the criteria for 

inclusion and exclusion (Table 1) were included. Initially, 

we identified 48 articles on PubMed, 40 articles on Medline/ 

Bireme, and 2 articles on Scielo using the descriptor surface 

electromyography and phonation. Due to the quantitative 

difference between Pubmed and Medline/Bireme, a new 

search with the same descriptors was performed on the 

Pubmed Central database. This time, 114 publications 

were found with the first descriptor surface 

electromyography and voice. With the other descriptors, 

the amount of publications found was lower, and all other 

articles had already been identified in the initial search 

(Figure 1). 

Step 4) Collection, data extraction, reading, and 

critical analysis: these steps resulted in the development of 

an analytical matrix consisting of the following: article title, 

authors, country of origin, year of publication, type of 

study, study objective, sample, method (including vocal 

tasks and SEMG procedures), and conclusions (Table 

2).These variables were considered to respond to the 

objective of the current review. 

Steps 5) and 6) Interpretation and discussion of 

results and knowledge synthesis and review presentation: 

Table 1. Inclusion and exclusion criteria for study selection 

Inclusion criteria 

Exclusion criteria 

Articles and theses produced Studies involving functions 

between 1980 to 2012 in other than phonation 

English, Portuguese, and 

Spanish 

Experimental studies, 

Studies restricted to description 

quasi-experimental studies, and evaluation of the technical 

or non-experimental studies characteristics of equipment 

Studies addressing the use Studies addressing the use of 

of SEMG as an assessment SEMG as a training tool 

tool fornormal and abnormal (biofeedback) 

human voice 

Studies evaluating the 

Studies on patients with 

extrinsic muscles of the alterations that prevent 

larynx and cervical muscles phonation 

during vocal tasks 


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Balata et al. 

Researches published from 1980 to 2012 

(PubMed/Medline, Scielo and Bireme) N=90 

New search in PubMed 

Central N=76 

Selected studies for integral reading by three 

judges 

N = 38 

Select articles for abstract analyses N=114 

Themes other than the objective 

N=52 

Duplicity N=66 

Researches selected for complete reading 

N=36 

Researches selected to 

integrate this review 

N=27 

Themes other than the objective N=09 

Idiom inadequacy N=03 

Other procedures N=09 

Figure 1. Scheme for searching and selection of works 

according to the inclusion and exclusion criteria. 

analysis and discussion of the results were performed 

descriptively and integratively. This was followed by the 

sixth step that consisted of the synthesis of knowledge and 

review presentation. 

RESULTS AND DISCUSSION 

The final selection of studies using the inclusion and 

exclusion criteria resulted in 24 articles and 3 theses being 

included for review; the theses consisted of a dissertation 

and 2 doctoral theses. Most studies included in this review 

originated from the United States (14 studies), followed by 

5 articles from Brazil, 6 articles from European countries, 

and 1 article from Australia. This indicates the decentralization 

of interest in the use of SEMG technology to aid in 

understanding of the phonation phenomenon (Table 2). 

While the use of SEMG in studies on voice began in 

the 1980s (2 studies), the number of studies increased in 

the 1990s (5studies) and from the year 2000 onwards (20 

studies). From 2004, publications in this field had an annual 

frequency. This shows the growing interest of the scientific 

community in contributing more quantitative data on vocal 

assessment, which in turn has conferred greater objectivity 

to the parameters of this function, with the aim of 

understanding the behavior of the extrinsic muscles in 

various situations of phonation through the use of SEMG. 

The studies investigated had diverse methodology, 

which made it difficult to compare them. The studies 

differed with respect to the muscle groups investigated, 

the tasks performed, and the sample size. There were 

often less than 40 subjects distributed between cases and 

controls (n = 25) (2-11), and some studies did not include 

comparison groups (n = 15) (12-25). However, controlled 

studies did show differences between the EA of muscles 

evaluated in case and control groups, and attested to the 

quality of SEMG as a tool for clinical evaluation of the voice. 

Regarding the main objectives of the articles, there 

was a high frequency of articles studying hyperfunctional 

dysphonia (n = 7) (6,8,10,11,13,14,26), probably as a result 

of the muscle tension present in these frameworks and the 

need to bring greater objectivity to the assessment of these 

disorders. Other types of functional dysphonia, such as 

nodules and glottic chinks, were the subject of interest in 

5 studies (4,7,9,16,27), and laryngectomized patients were 

subject of 3 studies (5,15,21). The muscle activity involved 

in singing was also a subject of interest (n = 4) (4,17,19,24). 

SEMG was used in the cervical and extrinsic laryngeal 

muscles, and the findings were related to the evaluation of 

various phonatory tasks such as usual phonation in the 

emission of vowels, connected speech and reading, 

simulated phonation in hyperfunction and whisper, singing 

voice, and the voice at rest. 

Concerning electrode allocation, there was no 

normalization in the articles selected. Electrode allocation 

differed as a result of the objective of each study and the lack 

of an institutional recommendation regarding research 

procedures, especially for the muscles of small caliber that 

make up the SH, IH, and orofacial muscles (such as the lips 

orbicular (LO) and masseter (MA) muscle). Scientific 

organizations such as the International Society of 

Electrophysiology and Kinesiology (ISEK) and the group 

Surface EMG for the Non-Invasive Assessment of Muscles 

(SENIAM) integrate the basic research conducted in this area 

and enable exchange of data and experience with SEMG. 

These organizations have established appropriate criteria on 

electrode allocation and methods for captured signal 

processing, but make no reference to the muscle groups 

involved in phonation such as the SH and IH muscles. 

The reason for election of unilateral electrode 

allocation in 12 studies is not clear (4,6,10,12- 

15,18,19,21,22,25), especially when the equipment used 

had channels to support bilateral investigation of muscle 


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Balata et al. 

activity. Bilateral evaluation of muscle activity may have 

identified possible asymmetries, although it does not 

always produce clear findings, as shown by the results of 

8 studies (5,7,9,16,20,23,24,26). Therefore, the 

recommendation made in the study by Stepp (28) regarding 

compliance with the appropriate use of bipolar electrodes, 

which stated that they should be used in the body of the 

muscle of interest and never bilaterally, is apt. 

Among the studies aimed at understanding 

hyperfunctional behavior, most (n = 4) evaluated both the 

IH and SH groups, and regarded the cervical muscles as the 

sternocleidomastoid (SCM), scalene (SC), and trapezius 

(TR) muscles. Some works (n = 2) evaluated the thoracic 

respiratory muscles, including the rectus abdominis (RA) 

and major pectoralis (MP) (17,19),during singing, detecting 

differences in EA according to the tasks performed. Muscles 

of the orofacial region, such as the MA and LO, were also 

evaluated (8,15,25). 

It is interesting to mention that not all studies jointly 

assessed the SH and IH muscles, and investigators 

sometimes elected one or the other group for reasons that 

were not clarified in the methodology. However, 

investigation of the traction functions that such antagonistic 

muscles exert on the larynx during phonation and swallowing 

could extend the scope of projects studying the 

biomechanics of these functions. In addition, given the 

diversity of the tasks performed (emission of vowels, 

speaking, reading, and singing, with all of these tasks 

sometimes being requested in the same study), the reports 

investigated were too succinct in describing the occurrence 

of possible mechanical artifacts caused by the dynamics of 

emissions or difficulties associated with sustaining the 

electrodes in place during execution of these tasks. 

The first classical studies (10,11) using SEMG to 

assess phonation in people with dysphonia, as well as the 

findings of Silvério (7),Hocevar-Boltezar, Janko, andZargi 

(8), and Neli (27), showed differences in the EA of muscles 

between dysphonic and non-dysphonic subjects, with 

activity being higher in dysphonia. This indicates that 

dysphonic and non-dysphonic subjects actually differ in 

their muscular activities. However, the results of more 

recent studies (13,26) contraindicate the use of SEMG as a 

tool to assess vocal hyperfunction and indicate that it may 

not be used for diagnosis of muscle tension dysphonia 

(MTD).Even if SEMG has no sensitivity or predictive value 

for the diagnosis of hyperfunction, study results suggesting 

different responses among different groups, including 

dysphonic subjects, singers and laryngectomized patients 

(2,3,7-11,15-21,23,25,27), suggest that this procedure has 

the ability to evaluate behavior in an inter- and intra-subject 

manner, and may be used as a benchmark for clinical 

outcomes. 

Despite the methodological limitations of the studies 

analyzed, the technical evolution of SEMG measurement 

has involved some important factors that deserve 

consideration. For example, signal normalization is a technical 

recommendation that was used by 11 (40.7%) of the 27 

studies included in this review. During SEMG, it is 

recommended to use a benchmark of muscle contraction 

from each person evaluated; this is known as signal 

normalization and reduces inter- and intra-subject variability. 

There are several ways to normalize a SEMG signal: by 

using the maximum peak of electrical activity, by using the 

maximal voluntary contraction (MVC) or submaximal 

voluntary contraction (SMC), and through the mean EA. 

When evaluating muscles of low caliber such as the SH, 

IH,SC, LO, or MA muscles, the occurrence of crosstalk (i.e., 

interference by signals from adjacent muscles) must be 

minimized to allow greater reliability in the capture and 

normalization of signals. 

The articles studied in the current review used 

several methods of normalization, including maximal 

voluntary activation (MVA) or MVC (9,10,12,13,15,18,20), 

SMC (2,10), peak activity (14),and activity at rest (11). 

MVC was the most frequently used method. This was 

accomplished in most studies by means of manual counterresistance 

or resistance against a static object (with platform 

to support the chin), and aimed to provide maximum 

activation of the SH, IH, SC, and SCM muscles. The 

extensive work of Stepp (28), which characterizes the 

clinical use of SEMG in studies on speech and swallowing, 

proposes the standardization of the methodological steps 

for use of this tool. Stepp also reports the use of normalization 

through MVC by various maneuvers, emphasizing manual 

counter-resistance (4,6,12,15,28).Despite the evidence 

provided by these articles, it is pertinent to note that the 

use of manual counter-resistance or resistance against an 

object may introduce a possible bias, given the possibility 

of recruitment of muscles adjacent to those of interest and 

thus the unwanted occurrence of crosstalk. This possibility 

gains strength when antagonistic muscle groups are being 

evaluated, as in the case of the SH and IH muscles. 

According to the studies mentioned above, the same 

maneuver was used to normalize the signals of different 

muscles. However, the use of the same maneuver to 

normalize all muscles being tested should be questioned. 

If, for example, the SCM has greater EA because it is larger 

and more robust, using the same normalizing maneuver for 

smaller muscles may result in the possibility that the SCM 

and perhaps the SC are also recruited for the normalization 

task. One measure that could minimize this potential bias 

would be to seek the maximum activation of specific 

muscle groups; since specific muscle groups have distinct 

and physiologically defined functions, this seems feasible. 

For the SCM, this would only be reliably achieved through 

some kind of biofeedback control that ensured the level of 


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Balata et al. 

contraction performed was within the desired threshold 

(50% less than the maximum level), a precaution that was 

taken in 2 previous studies (2,10). 

Regarding normalization by the peak in speech 

emissions (reading, sentences, singing, and automatic 

sequences), this peak may be presented during the episode 

of respiratory pause and thus may not characterize the 

maximum phonation peak. In some situations, it may not 

even be present, as in the occurrence of an abrupt vocal 

attack for example. 

The studies investigated came to the conclusion 

that normality standards for the EA of the muscles involved 

in speech phonation could be established, but these 

standards were not identified in any of the studies.At first, 

the definition of these parameters of normality seemed to 

be important for consistency among studies, in order to 

allow safe evaluation of similar cases and even evaluation 

of those with different etiology. However, SEMG does not 

seem to allow the definition of such standards, as this type 

of electrophysiological evaluation of phonation is subject 

to individual variables such as muscle conditioning, fat, 

sagging dermis, and teeth arch conditions. These variables 

are better controlled through the use of proper 

normalization, whereby the subject becomes an internal 

reference. 

Although it has been advocated that the advent of 

high-density SEMG has contributed to the study of the 

action potentials of motor units, which was only possible 

previously using the invasive method of EMG, SEMG is not 

yet considered to be a tool for clinical implementation 

(29).Even so, it should be noted that despite the fact that 

methodological differences between studies hinder 

comparisons, the most recent studies, which are also the 

most numerous, use MVA normalization, which indicates a 

consistency in adopting this method. However, it should 

be assumed that normalization still constitutes a limitation 

of SEMG, since the maneuvers used for normalization did 

not differ between the muscles evaluated, which seems to 

create an important bias. 

allocation, tasks to be performed, forms of assessment, 

signal treatment and analysis, and especially the most 

appropriate method of normalization. Finally, while 

acknowledging that SEMG has limitations and requires 

technical care during its application and analysis, we 

believe that this is a procedure that provides quantitative 

information for vocal assessment and allows objective 

paradigms for understanding the muscles involved in this 

function. 

CONCLUSION 

The current state of knowledge regarding the use of 

SEMG for the assessment of phonation confirms the clinical 

applicability of this tool, as published studies demonstrate 

differences in EA between groups. However, SEMG appears 

to have no predictive value as a diagnostic test. The 

standardization of assessment techniques should be 

established in order to enable comparisons among future 

studies. 

ACKNOWLEDGEMENTS 

The researchers thank the National Council for 

Scientific and Technological Development for financial 

support. 

The current review identifies key gaps in the 

knowledge regarding use of SEMG for evaluation of 

phonation, and highlights the following challenges for 

future studies: normalization of electrode allocation by 

region and laterality; establishment of maneuvers for MVA 

to allow normalization by muscle (for antagonists in particular); 

and more robust studies with randomized control 

groups. However, the studies investigated point to a 

promising future regarding SEMG use. There is a mandatory 

requirement for the definition and adoption of an 

international system of assessment that establishes criteria 

for technical characteristics such as sites of electrode 


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339



DOI: 10.7162/S1809-977720130003000015 

Middle ear adenoma with neuroendocrine differentiation: relate of two 

cases and literature review 

Aline Gomes Bittencourt 1 , Robinson Koji Tsuji 2 , Francisco Cabral Junior 3 , Larissa Vilela Pereira 3 , Anna Carolina de Oliveira Fonseca 1 , 

Venâncio Alves 4 , Ricardo Ferreira Bento 5 . 

1) Otolaryngologist, Ph.D. Student. Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil. 

2) M.D., Ph.D. - Associated Doctor. Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil. 

3) M.D., Otolaryngology Resident. Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil. 

4) M.D. Ph.D. Professor and Chairman - Department of Patology, University of São Paulo School of Medicine, São Paulo, Brazil. 

5) M.D. Ph.D. Professor and Chairman - Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil. 

Institution: Departamento de Otorrinolaringologia, Hospital das Clínicas, Universidade de São Paulo. 


Mailing address: Aline Gomes Bittencourt - Departamento de Otorrinolaringologia - Hospital das Clínicas - Universidade de São Paulo - Av. Dr. Enéas de Carvalho Aguiar, 

255, 6º andar/sala 6167 - São Paulo / SP – Brazil / Zip code: 05403-000 - Telephone: (+ 55 11) 3088 0299 - E-mail: alinebittencourt@hotmail.com 

Article received on December 20 th , 2012. Article accepted on February 18 th , 2013. 

SUMMARY 

Introduction: Adenomas with neuroendocrine differentiation are defined as neuroendocrine neoplasms, and they are rarely 

found in the head and neck. 

Objective: To describe two cases of a middle ear adenoma with neuroendocrine differentiation, with a literature review. 

Case Report: Patient 1 was a 41-year-old woman who presented with a 3-year history of left aural fullness associated with 

ipsilateral “hammer beating” tinnitus. Patient 2 was a 41-year-old male who presented with unilateral conductive hearing loss. 

Conclusion: Adenoma with neuroendocrine differentiation of the middle ear is a rare entity, but it should be considered in 

patients with tinnitus, aural fullness, and a retrotympanic mass and remembered as a diferential diagnosis of tympanic paraganglioma. 

Keywords: Neuroendocrine Tumors; Hearing Loss; Adenoma. 

INTRODUCTION 

Neuroendocrine cells are generally present in the 

respiratory epithelium as well as in the bronchial and 

intestinal mucosa. A few of these cells are also associated 

with epithelial structures found throughout the body, 

including the head and neck. Adenomas with 

neuroendocrine differentiation are defined as 

neuroendocrine neoplasms, and they are rarely found in 

the head and neck. When they occur in this region, they are 

more commonly found in the larynx (1). They usually grow 

in the lungs or gastrointestinal tract (1, 2). 

CASE REPORTS 

Patient 1 was a 41-year-old woman who presented 

with a 3-year history of left aural fullness associated with 

ipsilateral “hammer beating” tinnitus. Over the following 8 

months, the patient developed left-side otalgia and was 

treated with systemic antibiotics but without any 

improvement. 

The patient consulted a colleague who raised the 

possibility of a tympanic paraganglioma. Computed 

tomography (CT) of the temporal bones revealed a material 

with a soft tissue density that diffusely obliterated the 

left mastoid cells, but with no signs of ossicular chain 

erosion (Figure 1). Angiography of the temporal bone 

showed a lobulated solid lesion with defined limits and 

contrast uptake within the left middle ear and the 

epitympanic recess. 

The patient consulted our institution when her 

symptoms persisted. She had no complaints of hearing loss 

or otorrhea. On examination, the patient was found to be 

in good general condition and without neurological deficits. 

Otoscopy of the right ear was normal, but a retrotympanic, 

non-pulsatile mass was detected in the left ear (Figure 2). 

Figure 3 demonstrates her puretone audiometry, with a 

10dB-gap in the left ear. She subsequently underwent a left 

radical mastoidectomy with total resection of the lesion. 

Intraoperatively, the tumor had a fibrous aspect and filled 

the antrum and the entire tympanic cavity, involving the 

ossicular chain. The histopathological study was compatible 

with middle ear adenoma with neuroendocrine 

differentiation. 

Patient 2 was a 41-year-old man who presented 

with unilateral conductive hearing loss. CT scan showed a 

middle ear mass in the promontory mimicking a tympanic 


340

Middle ear adenoma with neuroendocrine differentiation: relate of two cases and literature review. 

Bittencourt et al. 

A B C 

Figure 1. Computed tomography of the temporal bones revealed a material with a soft tissue density that diffusely obliterated 

the left mastoid cells, but with no signs of ossicular chain erosion. A. Coronal B. Axial C. Transverse 

Figure 2. Otoscopy of the left ear demonstrating a retrotympanic 

non-pulsatile mass. 

Figure 3. Pure tone audiometry showing a gap in the left ear. 

A 

B 

Figure 4. Computed tomography of the temporal bones revealing a small soft tissue 

density material in the left tympanic cavity. A. Coronal B. Axial 

paraganglioma (Figure 4). Magnetic ressonance imaging 

(MRI) of the temporal bones revealed a small mass in the 

left tympanic cavity with isosignal in T1 and post-contrast 

enhancement on T2 sequences(Figure 5). The patient 

underwent surgical intervention through a supra-meatal 

approach that completely removed the mass. The tumor 

was brownish and elastic, involved the ossicles and extended 

to the promontory. Histology and immunohistochemical 

reactions were also compatible with middle ear adenoma 

with neuroendocrine differentiation (Figure 6). 


341



A 

B 

Figure 5. A: MRI of the temporal bones revealing a small mass in the left tympanic 

cavity with isosignal in T1 (A) and post-contrast enhancement on T2. 

. 

A 

B 

C 

D 

Figure 6. A: Well-differentiated papillary/trabecular/solid epithelial neoplasm composed of medium-sized cells. Central 

nuclei presented salt-and-pepper – like chromatin, and granular eosinophilic cytoplasm. Some neoplastic cells were seen 

amidst a fibrotic stroma. HE stain, original magnification x200. B-C: Immunohistochemical identification keratins marked 

by the antibodies AE1+AE3 and most of them were reactive for neuroendocrine markers chromogranin and 

synaptophysin. Original magnification x100. D: Ki-67 Ag was expressed in very low level (< 1 % of the cells). Original 

magnification x400. 

REVIEW OF THE LITERATURE 

In 1980, Murphy et al. first reported a middle ear 

adenoma with neuroendocrine differentiation, also called 

carcinoid tumor, as various denominations are used for 

these neoplasias, reflecting the controversy between its 

presumed histogenesis and differentiation (3). The lesion 

had adenomatous histological characteristics, but with 

ultrastructural neuroendocrine differentiation (1, 4). Since 


342



then, approximately 40 cases have been described in the 

English literature (1). 

The incidence of this tumor in the middle ear is 

difficult to establish since it may be confused with 

adenomatous tumors, ceruminomas, and even with other 

tumors, such as paragangliomas (1). 

Clinically, it presents with conductive hearing loss 

and ear fullness. Less frequently, patients may complain of 

tinnitus, headache, and even facial paralysis (5). In most 

cases, otoscopy demonstrates an intact tympanic membrane 

with a retrotympanic mass, as occurred in this case. 

Carcinoid syndrome (flushing, sweating, and diarrhea) is 

not found in these patients because of the small production 

of vasoactive peptides. Distant metastases are rare events 

(1, 5). Imaging studies consistently show a locally infiltrative 

mass and may show invasion of the ossicles (4). 

Middle ear adenoma with neuroendocrine 

differentiation can be distinguished from adenomatous 

tumors (adenomas, adenocarcinomas, and adenoid cystic 

carcinomas), ceruminomas, and paragangliomas by their 

light microscopic appearance, argyrophilic granules, and 

ultrastructural evidence of neurosecretory granules, as well 

as by immunohistochemical detection of various 

neuroendocrine markers. These include neuron-specific 

enolase, chromogranin, synaptophysin, serotonin, glucagon, 

insulin, gastrin, vasoactive intestinal polypeptide, pancreatic 

polypeptide, and calcitonin (4). 

DISCUSSION 

We reported two cases of middle ear adenoma with 

neuroendocrine differentiation wich presented with 

unspecific clinical manifestations. In both cases, the 

radiological features were very similar to tympanic 

paraganglioma, wich is the most frequent tumoral lesion of 

the middle ear. The final diagnosis was provided by 

histological and immunohistochemical analysis of the tumor. 

The recommended treatment is complete surgical 

excision of the lesion and the technique used is determined 

by the size and involvement of adjacent structures (1). 

Radiotherapy is not indicated since the tumor has poor 

radiosensitivity (1). The prognosis is good, however, a 

rigorous postoperative follow-up is indicated for all patients 

(3). 

Our patients underwent surgical treatment and 

clinical follow-up in conjunction with the Oncology 

department. One of the patients (patient 1) had imaging 

studies performed 18 months after surgery, wich confirmed 

that there were no signs of disease recurrence. 

FINAL COMMENTS 

Middle ear adenoma with neuroendocrine 

differentiation is a rare entity, but it should be considered 

as a possible diagnosis in patients with hearing loss, tinnitus, 

aural fullness, and a retrotympanic mass. 

REFERENCES 

1. Ferlito A, Devaney K, Rinaldo A. Primary carcinoid tumor 

of the middle ear: A potentially metastasizing tumor. Acta 

Otolaryngol. 2006;126(3):228-31. 

2. Pellini R, Ruggieri M, Pichi B, et. al. A case of cervical 

metastases from temporal bone carcinoid. Head Neck. 

2005;27(7):644-47. 

3. Becker CG, Barra IM, Pimenta HHO, Crosara PFTB, Ribeiro 

CA, Castro LPF. Adenoma da orelha média: relato de caso. 

Rev Bras Otorrinolaringol. 2004;70(4):551-4. 

4. Knerer B, Matula C, Youssefzadeh S, et al. Treatment of 

a local recurrence of a carcinoid tumor of the middle ear by 

extended subtotal petrosectomy. Eur Arch Otorhinolaryngol. 

1998;255(2):57-61. 

5. Shibosawa E, Tsutsumi K, Ihara Y, et al. A case of carcinoid 

tumor of the middle ear. Ausis, Nasus, Larynx. 2003;30 

Suppl:S99-S102. 


343

Case Report 


DOI: 10.7162/S1809-977720130003000016 

Bullous Systemic Lupus Erythematosus: Case report 

Ivan Dieb Miziara 1 , Ali Mahmoud 2 , Azis Arruda Chagury 3 , Ricardo Dourado Alves 4 . 

1) Associate Professor in the Department of Otorhinolaryngology, School of Medicine, University of São Paulo, São Paulo, Brazil. 

2) Otolaryngologist in the Department of Otorhinolaryngology, School of Medicine, University of São Paulo, São Paulo, Brazil. 

3) Specialist in Otolaryngology, School of Medicine, University of São Paulo, São Paulo, Brazil. 

4) Resident in Otolaryngology, School of Medicine, University of São Paulo, São Paulo, Brazil. 

Institution: Study from the Division of Clinical Otorhinolaryngology, Clinic of Stomatology, Hospital of the Faculty of Medicine, University of São Paulo. 


Mailing address: ENT Hospital - Azis Arruda Chagury - Avenue Dr. Enéas de Carvalho Aguiar, 155 - São Paulo / SP - Brazil - Zip code: 05403-000 - Telephone: 

(+55 11) 3069-6226 - E-mail: azischagury@gmail.com 

Article received on September 17 th , 2011. Article accepted on February 5 th , 2012. 

SUMMARY 

Introduction: Bullous systemic lupus erythematosus (BSLE) is an autoantibody-mediated disease with subepidermal blisters. 

It is a rare form of presentation of SLE that occurs in less than 5% of cases of lupus. 

Case Report: A 27-year-old, female, FRS patient reported the appearance of painful bullous lesions in the left nasal wing 

and left buccal mucosa that displayed sudden and rapid growth. She sought advice from emergency dermatology staff 15 

days after onset and was hospitalized with suspected bullous disease. Intravenous antibiotics and steroids were administered 

initially, but the patient showed no improvement during hospitalization. She displayed further extensive injuries to the trunk, 

axillae, and vulva as well as disruption of the bullous lesions, which remained as hyperemic scars. Incisional biopsy of a 

lesion in the left buccal mucosa was performed, and pathological results indicated mucositis with extensive erosion and the 

presence of a predominantly neutrophilic infiltrate with degeneration of basal cells and apoptotic keratinocytes. Under direct 

immunofluorescence, the skin showed anti-IgA, anti-IgM, and anti-IgG linear fluorescence on the continuous dermal side 

of the cleavage. Indirect immunofluorescence of the skin showed conjugated anti-IgA, was anti-IgM negative, and displayed 

pemphigus in conjunction with anti-IgG fluorescence in the nucleus of keratinocytes, consistent with a diagnosis of bullous 

lupus erythematosus. 

Discussion: BSLE is an acquired autoimmune bullous disease caused by autoantibodies against type VII collagen or other 

components of the junctional zone, epidermis, and dermis. It must be differentiated from the secondary bubbles and vacuolar 

degeneration of the basement membrane that may occur in acute and subacute cutaneous lupus erythematosus. 

Keywords: Lupus Erythematosus, Systemic; Stomatitis; Mucositis 

INTRODUCTION 

Bullous systemic lupus erythematosus (BSLE) is an 

autoantibody-mediated disease with subepidermal blisters. 

It is a rare presentation of SLE occurring in less than 5% of 

lupus cases (1). A study conducted in 3 regions of France 

reported an incidence of 0.2 cases per million inhabitants 

(2). Although the disease affects both men and women 

regardless of race or age, it occurs more frequently in 

black women between the second and third decades of 

life. 

Clinically, BSLE presents as tense bullous lesions 

that can be serous or hemorrhagic and spread rapidly to 

all parts of the body, although lesions are mainly found on 

the trunk and in sun-exposed areas; they can also affect 

mucous membranes. These lesions often indicate lupus 

manifestation (1). However, they must be differentiated 

from other bullous dermatoses such as epidermolysis 

bullosa acquisita (EBA), dermatitis herpetiformis, bullous 

pemphigoid, and linear IgA bullous dermatosis (3). 

In this paper, we report the case of a young female 

patient who suddenly developed bullous disease and was 

admitted to hospital because of severe oral lesions. After 

immunofluorescent examination, a diagnosis of bullous 

lupus erythematosus was made. 

CASE REPORT 

Here, we report a 27-year-old, single, catholic, 

female, born in Sierra Taboão and raised in Embu. The 

patient reported emergence of painful bullous lesions on 

the nasal ala and left buccal mucosa that displayed sudden 

and rapid growth (Fig. 1). She sought advice from the 

emergency dermatology staff 15 days after the onset of 

symptoms and was hospitalized with suspected bullous 

disease. General examinations were normal and her 

leukocyte levels were unchanged. Upon hospitalization, 

intravenous steroids were introduced but the patient showed 

no clinical improvement. She displayed further extensive 

injuries to the trunk, axillae, and vulva as well as rupture of 

the bullous lesions, which remained as reddened scars. 


344

Bullous Systemic Lupus Erythematosus: Case report. 

Miziara et al. 

Figure 1. Bullous lesion in the right lower lip. 

Figure 2. Predominantly neutrophilic inflammatory infiltrate 

with hydropic degeneration of the basal layer and apoptotic 

keratinocytes. 

Figure 4. Lack of oral lesions, without mucosal scarring. 

Figure 3. Direct immunofluorescence of the skin showing 

linear fluorescence on the continuous dermal side of the 

cleavage. 

We performed an incisional biopsy of a lesion in the 

left buccal mucosa. The pathology results indicated mucositis 

with extensive erosion and the presence of a predominantly 

neutrophilic inflammatory infiltrate with degeneration and 

apoptosis of basal layer keratinocytes (Fig. 2). Direct skin 

immunofluorescence showed anti-IgA, anti-IgM, and anti- 

IgG linear fluorescence on the continuous dermal side of 

the cleavage (Fig. 3). 

Indirect immunofluorescence of the skin showed 

conjugated anti-IgA, was anti-IgM negative, and indicated 

pemphigus. It also displayed anti-IgG conjugated with 

fluorescence in the nucleus of keratinocytes, confirming 

the diagnosis of bullous lupus erythematosus. 

As initial treatment, we administered 100 mg 

dapsone, 250 mg chloroquine, 50 mg azathioprine, and 

50 mg prednisone. Although this resulted in improvement 

of the lesions, there was persistence of some scarring 

plaques on the trunk and lower lip. The patient was 

followed up for 6 months. During this period, she remained 

clinically stable, without active lesions in the oral mucosa 

and lips (Fig. 4), and we gradually reduced her dose of 

prednisone. 

DISCUSSION 

In 1973, Pedro and Dahl (4) described the first case 

of BSLE. After this, several cases with similar characteristics 

were reported. BSLE patients produce autoantibodies that 

recognize type VII collagen, a major component of anchoring 

fibrils, which play an important role in dermoepidermal 

adhesion. 


345

Bullous Systemic Lupus Erythematosus: Case report. 

Miziara et al. 

Chan and colleagues (5) identified further 

autoantibodies reacting to multiple basement membrane 

components including bullous pemphigoid antigen 1, 

laminin-5, and laminin-6 in patients with BSLE. This 

hyperimmune state seems to be associated with the gene 

for major histocompatibility complex HLA-DR2 (4). 

The clinical manifestations of BSLE are characterized 

by vesicles, serous blisters, or hemorrhagic content in the 

face, neck, and trunk. Lesions can be located in areas both 

exposed and unexposed to the sun. They may be 

accompanied by mild to severe itching and can affect 

mucous membranes. BSLE lesions may heal completely, or 

result in hypo-or hyperpigmentation or scarring (6). 

The clinical picture of BSLE is similar to bullous 

pemphigus, being distinguished by indirect 

immunofluorescence. Histologically, the condition presents 

as subepidermal blisters accompanied by neutrophil 

microabscesses in the papillary dermis and dermal edema. 

There are also large deposits of mucin and the absence of 

eosinophils, which helps to differentiate between dermatitis 

herpetiformis Duhring, linear IgA dermatosis, and EBA (6). 

In BSLE, direct immunofluorescence shows deposits 

of immune complexes (IgG, IgA, IgM, and complement) 

along the basement membrane that can be granular to 

linear (7). 

Using indirect immunofluorescence, and according 

to the autoantibodies present, BSLE can be classified into 

3 subtypes: type 1, which reacts against collagen VII; type 

2, where the location of the antigen is undefined or the 

dermal antigen is one other than type VII collagen; and 

type 3, where the antigen is epidermal (6). 

BSLE responds well to treatment with dapsone, 

which differs from EBA. In some cases where high doses of 

corticosteroids alone were used for control of visceral 

manifestations, there was no improvement of skin lesions 

until the introduction of dapsone. It is expected that within 

24–48 h of the introduction of dapsone, the emergence of 

new bubbles will be stopped, and total regression should 

occur within weeks. In cases that do not respond to 

dapsone, the use of prednisone and azathioprine is 

suggested. BSLE may regress completely and independently 

of systemic involvement without recurrence (8). 

REFERENCE 

1. M Tincopa, Puttgen KB, Sule S, Cohen BA, Gerstenblith 

MR. Bullous lupus: an unusual initial presentation of systemic 

lupus erythematosus in an adolescent girl. Pediatr Dermatol. 

2010 Jul-Aug;27(4):373-6. 

2. Bernard P, Vaillant L, Labeille B, et al. Incidence and 

distribution of subepidermal autoimmune bullous skin 

diseases in three French regions. Bullous Diseases French 

Study Group. Arch Dermatol. 1995;131(1):48-52. 

3. Vieira FMJ, Oliveira ZNP. Bullous systemic lupus 

erythematosus. An Bras Dermatol. 1998;73:143-7. 

4. Peter SD, Dahl MV. Direct immunofluorescence of Bullous 

systemic lupus erythematosus. Arch Dermatol. 

1973;107:118-20. 

5. Chan LS, LaPiere JC, Chen M, Traczyk T, Mancini AJ, Paller 

AS, et al. Bullous systemic lupus erythematosus with 

autoantibodies recognizing multiple skin basement 

membrane components, bullous pemphigoid antigen 1, 

laminin-5, laminin-6, and type VII collagen. Arch Dermatol. 

1999;135:569-73. 

6. Obermoser G, Sontheimer RD, Zelger B. Overview of 

common, rare and atypical manifestations of cutaneous lupus 

erythematosus and histopathological correlates. Lupus. 2010 

Aug;19(9):1050-70. 

7. Cato, Ellen Erie et al. Bullous systemic lupus erythematosus 

associated with lupus nephritis: report of two cases. An Bras 

Dermatol. 2007;82(1):57-61. 

8. Vassileva S. Bullous systemic lupus erythematosus. Clin 

Dermatol. 2004 Mar-Apr;22(2):129-38. 


346

Case Report 


DOI: 10.7162/S1809-977720130003000017 

Eagle’s Syndrome 

Thaís Gonçalves Pinheiro 1 , Vítor Yamashiro Rocha Soares 2 , Denise Bastos Lage Ferreira 3 , Igor Teixeira Raymundo 3 , 

Luiz Augusto Nascimento 4 , Carlos Augusto Costa Pires de Oliveira 5 . 

1) MD. Fellowship in Laryngology, Department of Otorhinolaryngology, University of Sao Paulo. 

2) MD. Ph.D. Student in Health Sciences, Department of Otorhinolaryngology - Head and Neck Surgery, University of Brasilia. 

3) MD. Attending Physician, Department of Otorhinolaryngology - Head and Neck Surgery, University of Brasilia. 

4) MD, PhD. Adjunct Professor, Department of Otorhinolaryngology - Head and Neck Surgery, University of Brasilia. 

5) MD, PhD. Full Professor, Department of Otorhinolaryngology - Head and Neck Surgery, University of Brasilia. 

Institution: University of Brasilia – University of Brasilia Hospital, Department of Otorhinolaryngology - Head and Neck Surgery. 

SGAN, Via L2 Norte, Quadra 604/605, Asa Norte - Ambulatório II, Brasilia/DF – Brazil, ZC: 70.840-050. 

Mailing address: Vítor Yamashiro Rocha Soares - SGAN, Via L2 Norte, Quadra 604/605 - HUB - Anexo III, Apart. 20 - Asa Norte - Brasília/DF - Brazil, Zip code: 

70840-050 - E-mail: vyrsoares@gmail.com 

Article received on October 5 th , 2011. Article accepted on November 16 th , 2011. 

SUMMARY 

Introduction: Eagle’s syndrome is characterized by cervicopharyngeal signs and symptoms associated with elongation of the 

styloid apophysis. This elongation may occur through ossification of the stylohyoid ligament, or through growth of the apophysis 

due to osteogenesis triggered by a factor such as trauma. Elongation of the styloid apophysis may give rise to intense facial 

pain, headache, dysphagia, otalgia, buzzing sensations, and trismus. Precise diagnosis of the syndrome is difficult, and it is 

generally confounded by other manifestations of cervicopharyngeal pain. 

Objective: To describe a case of Eagle’s syndrome. 

Case Report: A 53-year-old man reported lateral pain in his neck that had been present for 30 years. Computed tomography 

(CT) of the neck showed elongation and ossification of the styloid processes of the temporal bone, which was compatible with 

Eagle’s syndrome. Surgery was performed for bilateral resection of the stylohyoid ligament by using a transoral and endoscopic 

access route. The patient continued to present pain laterally in the neck, predominantly on his left side. CT was performed again, 

which showed elongation of the styloid processes. The patient then underwent lateral cervicotomy with resection of the stylohyoid 

process, which partially resolved his painful condition. 

Final Comments: Patients with Eagle’s syndrome generally have a history of chronic pain. Appropriate knowledge of this 

disease is necessary for adequate treatment to be provided. The importance of diagnosing this uncommon and often unsuspected 

disease should be emphasized, given that correct clinical-surgical treatment is frequently delayed. The diagnosis of Eagle’s 

syndrome is clinical and radiographic, and the definitive treatment in cases of difficult-to-control pain is surgical. 

Keywords: Neck Pain; Osteogenesis; Oral Surgical Procedures. 

INTRODUCTION 

Eagle’s syndrome is characterized by 

cervicopharyngeal signs and symptoms associated with 

elongation of the styloid apophysis (1). The styloid 

apophysis consists of a bone projection originating in the 

tympanic portion of the temporal bone, which is 

approximately 25 mm in length (2). Elongation of the 

styloid apophysis may occur through ossification of the 

stylohyoid ligament, or through growth of the apophysis 

due to osteogenesis triggered by a factor such as trauma 

(1). 

Elongation of the styloid apophysis or calcification 

of the stylohyoid ligament may give rise to intense facial 

pain, headache, dysphagia or odynophagia, otalgia, buzzing 

sensations, and trismus (1-4). Precise diagnosis of the 

syndrome is difficult. It is generally confounded by 

temporomandibular joint dysfunction, chronic tonsillitis, 

migraine, cluster headache, glossopharyngeal and trigeminal 

neuralgia, myofascial pain dysfunction syndrome, pain 

secondary to unerupted or impacted third molars, neck 

arthritis, and tumors of the base of the tongue. Finger 

palpation of the palatine tonsil increases the pain associated 

with Eagle’s syndrome and corroborates its diagnosis. In 

addition to a clinical history and physical examination, 

radiological evaluation is also important for diagnosis (4). 

The aims of this study were to describe a case of 

Eagle’s syndrome followed up at the Otorhinolaryngology 

- Head and Neck Surgery Service and to conduct a critical 

review of the literature. 

CASE REPORT 

The patient was a 53-year-old man who reported 

having had dysphagia as well as a stabbing pain laterally 

in his neck and bilateral cervical pain in his 


347

Eagle’s Syndrome. 

Pinheiro et al. 

temporomandibular joint for 30 years. The pain extended 

to the deltoid region and, although intermittent, occurred 

every day along with hardening of the left side of the neck 

and episodic frontal headache. The condition had 

progressively worsened over the preceding 10 years, in 

terms of both intensity and frequency. The patient 

reported that the pain worsened with heat, especially 

with exposure to sunlight, and when lying down on his 

back. Clinical treatment using analgesics, anti-inflammatory 

agents, or muscle relaxants did not alleviate the pain. The 

patient said that he had not had any previous pathological 

conditions, except for an appendectomy 32 years earlier. 

There were no palpable enlarged lymph nodes in the 

neck region. Oral examination showed a hardened lesion 

in the posterior tonsillar pillar measuring 15 mm and a 

retromolar bone spur on the left side. 

Radiography and computed tomography of the 

neck showed elongation and ossification of the styloid 

processes of the temporal bone. The right styloid process 

measured 5.7 cm and the left measured 4.9 cm, which 

was compatible with Eagle’s syndrome (Figures 1A and 

1B). 

Surgery was performed for bilateral resection of the 

stylohyoid ligament by using a transoral endoscopic access 

route. However, the patient continued to present 

preauricular pain with a burning sensation irradiating to the 

sides of the neck and temporal region, predominantly on 

his left side. Another computed tomography scan was 

produced, which showed elongation and ossification of the 

styloid processes of the temporal bone, with the right side 

measuring 4.4 cm and the left side measuring 3.9 cm. This 

suggested that the base of the styloid process continued to 

be present bilaterally. The patient then underwent lateral 

cervicotomy with resection of the stylohyoid process, 

which partially resolved his painful condition (Figures 1C 

and 1D). 

FIGURE 1. (A) Computed tomography (CT) scan of the neck showing elongation and ossification of the styloid 

processes of the temporal bone. The right styloid process measures 5.7 cm and the left measures 4.9 cm, which 

is compatible with Eagle’s syndrome. (B) CT scan of the neck after intraoral styloidectomy, showing ossification 

of the styloid processes. The right styloid process measures 4.4 cm and the left measures 3.9 cm, thus suggesting 

that the base of the styloid process is present on both sides. (C) Surgical specimen after extraoral styloidectomy: 

right and left styloid processes. (D) CT scan of the neck after extraoral styloidectomy, showing the absence of 

elongation of the styloid processes on both sides. 


348



DISCUSSION 

Eagle’s syndrome is directly related to calcification 

of the stylohyoid ligament or elongation of the styloid 

process. These processes trigger symptoms such as recurrent 

facial pain, foreign body sensation, dysphagia, otalgia, and 

trismus (4). The styloid process, stylohyoid ligament, and 

lesser cornu of the hyoid bone form the stylohyoid complex, 

which originates embryologically in Reichert’s cartilage of 

the second branchial arch (1,2). Reichert’s cartilage has 4 

portions: the upper portion, from which the styloid process 

develops; the central portion, from which the stylohyoid 

ligament forms; the lower portion, from which the lesser 

cornu of the hyoid bone originates; and the basal portion, 

which gives rise to part of the hyoid bone (1,4). 

The reported sizes of the normal styloid process in 

the literature show a high degree of variability. Moffat et al 

conducted studies on cadavers and showed that the normal 

range of lengths of the styloid process was from 1.52 cm 

to 4.77 cm (5). In most radiographic studies, styloid 

processes are considered normal when they are shorter 

than 2.5 cm and elongated when they are longer than 4.0 

cm. In the latter situation, Eagle’s syndrome is very likely 

to be present (1). It seems that there is little correlation 

between the extent of ossification and the severity of 

symptoms (6). 

Several theories have been proposed to explain the 

elongation of the styloid process in Eagle’s syndrome, 

including congenital elongation resulting from persistence 

of a mesenchymal embryonic leaf, with the capacity to 

produce bone tissue in adults; reactional ossifying 

hyperplasia due to osteitis, periostitis, or tendinitis, caused 

by surgical trauma or chronic local irritation; and ossification 

of the stylohyoid ligament related to endocrine disorders in 

women at menopause, accompanied by ossification of 

other ligaments. Some authors have affirmed that the 

syndrome frequently correlates with tonsillectomy (1). 

However, Prasad et al did not observe this relationship in 

a series of 58 cases (2). The patient in the present case did 

not have any previous pathological history of tonsillectomy. 

The prevalence of elongation of the styloid process 

is variable. Some reports have shown that this abnormality 

occurs in 4% of the population, but that only 4% of such 

individuals present symptoms (2,4). In 1970, Kaufman et 

al confirmed this low rate of correlation, reporting that the 

styloid process was elongated in 7.3% of their patients (7). 

In 1979, Correl et al reported that calcification of the styloid 

complex or elongation of the styloid process was present 

in 18% of the 1700 panoramic radiographs that they 

examined, and observed low concordance with the presence 

of symptoms (8). Thus, the majority of patients with an 

elongated styloid process are asymptomatic (4). Greater 

prevalence of the disease has been found in women (3:1) 

(2,4). 

The main symptoms of the syndrome include 

nonspecific neck pain, foreign body sensation in the 

pharynx, odynophagia, otalgia, pain in the 

temporomandibular joint, and trismus (2). Painful palpation 

of the tonsillar fossa, together with suggestive clinical and 

radiological signs, corroborates the diagnosis of Eagle’s 

syndrome. In addition, pain relief achieved through 

infiltration of local anesthetics into the tonsillar fossa is 

suggestive of the disease (3,6). 

Radiological examination can confirm the syndrome. 

Radiography can show the increased length of the styloid 

process. Currently, computed tomography is considered to 

be the best examination for defining the length and 

angulation of the styloid process, and also enables an 

evaluation of the anatomical relationships between the 

stylohyoid complex and adjacent structures (1,3,4). 

According to some authors, panoramic or lateral radiographs 

are sufficient for diagnosing the disease (2). 

The other conditions identified in differential 

diagnosis for the syndrome include temporomandibular 

joint dysfunction, pain secondary to unerupted or impacted 

third molars, glossopharyngeal and trigeminal neuralgia, 

migraine, neck arthritis, cluster headache, myofascial pain 

dysfunction syndrome, and tumors (4). Neuralgia of the IX th 

and V th cranial pairs consists of sudden sharp pain of short 

duration that arises through stimulation of the trigger zone, 

which is unlike that observed in Eagle’s syndrome, where 

the pain is dull and persistent. Disorders of the 

temporomandibular joint and third molar pain are confirmed 

through radiological examinations (1). 

Treatment for Eagle’s syndrome can be surgical, but 

is not always. Pain control may be achieved in some 

patients by means of oral analgesics. Some authors have 

suggested that transpharyngeal infiltration of steroids and 

local anesthetics in the tonsillar fossa should be used (1,2). 

The treatment of choice is styloidectomy, which can be 

performed transorally or extraorally. The transoral route 

consists of an incision in the tonsillar fossa, after tonsillectomy 

if necessary, which is followed by identification, separation, 

and excision of the styloid process. In the external technique, 

an incision is made in the neck, in the region proximal to 

the sternocleidomastoid muscle, into the hyoid bone, 

followed by identification, separation, and removal of the 

styloid process. This technique makes it possible to view 

the structures better, thus enabling greater resection of the 

styloid process (1) with less chance of deep infection in the 

neck (2). However, the extraoral technique requires a 

longer surgical recovery and it involves greater morbidity 


349



(relating to drains, sutures, risk of facial nerve lesions, and 

scarring of the neck). 

FINAL COMMENTS 

Patients with Eagle’s syndrome generally have a 

history of chronic pain treated by several physicians. 

Appropriate knowledge of this disease is necessary for 

adequate treatment to be provided. The importance of 

diagnosing this uncommon and often unsuspected disease 

should be emphasized, given that correct clinical-surgical 

treatment is frequently delayed. The diagnosis of Eagle’s 

syndrome is clinical and radiographic, and the definitive 

treatment in cases of difficult-to-control pain is surgical. 

REFERENCES 

1. Fini G, Gasparini G, Filippini F, Becelli R, Marcotullio D. 

The long styloid process syndrome or Eagle’s syndrome. J 

Craniomaxillofac Surg. 2000;28:123-7. 

2. Prasad KC, Kamath MP, Reddy JM, Raju K, Agarwal S. 

Elongated styloid process (Eagle’s syndrome): a clinical 

study. J Oral Maxillofac Surg. 2002;60(2):171-5. 

3. Beder E, Ozgursoy OB, Ozgursoy SK, Anadolu Y. Threedimensional 

computed tomography and surgical treatment 

for Eagle’s syndrome. Ear Nose Throat J. 2006;85(7):443- 

5. 

4. Mendelsohn AH, Berke GS, Chhetri DK. Heterogeneity 

in the clinical presentation of Eagle’s syndrome. Otolaryngol 

Head Neck Surg. 2006;134:389-93. 

5. Moffat DA, Ramsden RT, Shaw HJ. The styloid process 

syndrome: aetiological factors and surgical management. J 

Laryngol Otol. 1977;91(4):279-94. 

6. Diamond LH, Cottrell DA, Hunter MJ, Papageorge M. 

Eagle’s syndrome: a report of 4 patients treated using a 

modified extraoral approach. J Oral Maxillofac Surg. 

2001;59:1420-6. 

7. Kaufman SM, Elzay RP, Irish EF. Styloid process variation. 

Radiologic and clinical study. Arch Otolaryngol. 

1970;91(5):460-3. 

8. Correl R, Jensen J, Taylor J, et al. Mineralization of the 

stylohyoid-stylomandibular ligament complex: A 

radiographic incidence study. Oral Surg Oral Med Oral Pathol. 

1979;48:286-91. 


350

Case Report 


DOI: 10.7162/S1809-977720130003000018 

Retrolabyrinthine approach for cochlear nerve preservation in 

neurofibromatosis type 2 and simultaneous cochlear implantation 

Ricardo Ferreira Bento 1 , Tatiana Alves Monteiro 2 , Aline Gomes Bittencourt 3 , Maria Valeria Schmidt Goffi-Gomez 4 , 

Rubens de Brito 5 . 

1) Otolaryngologist, PhD. Professor and Chairman. Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil. 

2) Otolaryngologist. Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil. 

3) Otolaryngologist, PhD student. Neurotology Fellow. Division of Otorhinolaryngology, University of São Paulo Medical School, São Paulo, Brazil. 

4) Audiologist, PhD in Human Communication Disorders (Speech Pathology). Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, 

Brazil. 

5) Otolaryngologist, PhD. Associate Professor. Department of Otolaryngology, University of São Paulo School of Medicine, São Paulo, Brazil. 

Institution: Division of Otorhinolaryngology, University of São Paulo Medical School. 

São Paulo / SP – Brazil. 

Mailing address: Dra. Aline Gomes Bittencourt - Departamento de Otorrinolaringologia - Hospital das Clínicas - Universidade de São Paulo - Av. Dr. Enéas de Carvalho 

Aguiar, 255, 6º andar/sala 6167 - São Paulo / SP – Brazil – Zip code: 05403-000 Telephone: (+ 55 11) 3088-0299 - E-mail: alinebittencourt@hotmail.com 


SUMMARY 

Introduction: Few cases of cochlear implantation (CI) in neurofibromatosis type 2 (NF2) patients had been reported in the 

literature. The approaches described were translabyrinthine, retrosigmoid or middle cranial fossa. 

Objectives: To describe a case of a NF2- deafened-patient who underwent to vestibular schwannoma resection via RLA with 

cochlear nerve preservation and CI through the round window, at the same surgical time. 

Resumed Report: A 36-year-old woman with severe bilateral hearing loss due to NF2 was submitted to vestibular schwannoma 

resection and simultaneous CI. Functional assessment of cochlear nerve was performed by electrical promontory stimulation. 

Complete tumor removal was accomplishment via RLA with anatomic and functional cochlear and facial nerve preservation. 

Cochlear electrode array was partially inserted via round window. Sound field hearing threshold improvement was achieved. 

Mean tonal threshold was 46.2 dB HL. The patient could only detect environmental sounds and human voice but cannot 

discriminate vowels, words nor do sentences at 2 years of follow-up. 

Conclusion: Cochlear implantation is a feasible auditory restoration option in NF2 when cochlear anatomic and functional 

nerve preservation is achieved. The RLA is adequate for this purpose and features as an option for hearing preservation in NF2 

patients. 

Keywords: Neurofibromatosis 2; Cochlear Implantation; Hearing Loss. 

INTRODUCTION 

Neurofibromatosis type 2 (NF2) is an autosomal 

dominant disease consequent to mutation of both alleles of 

a suppressor tumor gene in the long arm of chromosome 

22 (1,2). Bilateral vestibular schwannoma is typical, occurring 

in 90% of the gene carriers (1). Progressive sensorineural 

hearing loss is almost certain, accompanied or not with 

dizziness and tinnitus. 

The first attempt at auditory restoration in a patient 

with NF2 and profound hearing loss was conducted by 

House and Hitselberger in 1979 (3). Auditory brainstem 

implant (ABI) has been the standard surgical treatment for 

these patients, to recover some degree of auditory capability 

and to enhance lip reading. In the 1990s, the promising 

idea of using a cochlear implant for auditory restoration 

became feasible. Auditory results of cochlear implantation 

are far better than those reported after ABI (4). 

The aim of this study is to describe a ase of a NF2- 

deafened-patient who underwent to vestibular schwannoma 

resection via retrolabyrinthine approach, with cochlear 

nerve preservation and cochlear implantation through the 

round window, at the same surgical time. 

CASE REPORT 

A 36-year-old woman with NF2 presented with a 

complaint of bilateral progressive sensorineural hearing 

loss for 10 years, which was similar in both ears. In 2009, 

the hearing loss became severe and communication 

problems aggravated. In 2006 she had undergone to 

partial tumor resection for facial nerve preservation on 

the left side at another institution. After surgery, the 

treatment was complemented with gama-knife radiation. 

She scheduled an appointment with our team seeking for 

a treatment for hearing rehabilitation. The tumor on her 

right side measured 1.5 cm (Figure 1). 


351

Retrolabyrinthine approach for cochlear nerve preservation in neurofibromatosis type 2 and simultaneous cochlear implantation. 

Bento et al. 

Due to the size of the tumor we believed it would 

be more convenient to attempt hearing preservation in 

the right ear and to try a cochlear implant. After counseling 

she agreed with and accepted surgery. In March 2010, the 

patient underwent retrolabyrinthine approach with complete 

tumor resection and anatomic preservation of the 

cochlear and facial nerves. 

The retrolabyrinthine approach was performed 

with the patient placed in the classic supine position with 

the head rotated away from the surgeon. A retroauricular 

incision was made three centimeters posterior to the 

auricular sulcus extending to the mastoid tip. A muscle 

flap was placed anteriorly, allowing for the posterior 

retraction of the periosteum in order to drill the place into 

which the receiver/stimulator was lodged. A wild 

mastoidectomy was performed, exposing the entire posterior 

fossa dura mater, the sigmoid sinus and the jugular 

bulb. The posterior semicircular canal was partially drilled 

and obliterated, and the meatal plane was skeletonized. 

The vestibule was not opened. The posterior dura was 

opened from the base of the IAM to the anterior edge of 

the jugular bulb, extending to the edge of the sigmoid 

sinus. After cisternal drainage of cerebral spinal fluid the 

meatal plane was longitudinally opened and the tumor 

removed (Figure 2 A). 

The functional assessment of the cochlear nerve 

was evaluated through electrical promontory stimulation, 

which demonstrated present responses with poor 

morphology an unreliable reproducibility. Subsequently, 

cochlear implantation of a Nucleus 24RE Contour Advance 

(Cochlear Ltd., Lane Cove, Australia) through the round 

window was performed. The electrode array was partially 

inserted (6 active electrodes out) (Figures 2 B, 3). 

Impedances of electrodes measurements were adequate. 

The patient had absent intraoperative neural response 

telemetry (NRT) in Electrodes 1, 22, 11, 6 and 16 with 

25μs (Figure 4 A) and also in electrodes 11 and 15 with 

50μs (Figure 4 B). No complications or additional deficts 

occured. 

Figure 1. Coronal magnetic resonance imaging of the temporal 

bone showing bilateral cerebellopontine angle tumors 

with homogeneous enhancement after gadolinium injection 

on T1-weighted sequence, measuring 1.5 cm on the right side 

and 3.0 cm on the left side. 

Figure 2.View of the retrolabyrinthine approach with vestibular schwannoma being removed (arrow) (A). View 

of the posterior tympanotomy approach with electrode array inserted in the coclea via round windown (arrow 

head) (B). (MFD, middle fossa dura-mater; PFD, posterior fossa dura-mater; PSC, posterior semi-circular canal; 

LSC, lateral semi-circular canal). 


352


Bento et al. 

Figure 3. High-resolution coronal (A) and axial (B) CT scans of the temporal bones showing insertion of the electrode array 

into the middle and basal turns of the cochlea. 

The cochlear implant was activated four weeks 

after surgery, with a Freedom speech processor with 

hearing sensation in 5 electrodes with advanced 

combination encoders (ACE) speech coding strategy 

900Hz of stimulation rate and 5 maxima, with 75μs pulse 

width. All other electrodes elicited visible facial nerve 

stimulation. Two months after activation she was referred 

to auditory training with a speech pathologist. With the 

increase in pulse width (150μs), 11 electrodes elicited 

auditory response with very little or no facial stimulation. 

Sound field hearing threshold improvement was achieved 

(Figure 5). The mean tonal threshold was 46.2 dBHL. 

Despite the auditory training and the improvement in 

hearing thresholds, the patient could only detect 

environmental sounds and human voice but cannot 

discriminate vowels, words nor do sentences at 2 years of 

follow-up. 

Figure 4. Intra-operative NRT showing absent evoked potentials 

on electrodes 1, 22, 11, 6, and 16 at 25-μs pulse width (A) and 

on electrodes 11 and 15 at 50-μs pulse width (B). 

DISCUSSION 

Cueva et al. (5) elicited auditory sensation through 

electrical promontory stimulation in 6 patients with NF2 

who underwent tumor removal with cochlear nerve 

preservation. Since then, about 31 cases of cochlear 

implantation in NF2 patients have been reported in the 

literature (6-16). The timing of implantation varied from 

simultaneously to 10 years after tumor resection. 

Regardless of the time of cochlear implantation or the 

approach used, these studies have reported a diverse 

range of speech perception outcomes, from no benefit to 

significantly better speech discrimination (14). 

Figure 5. Sound field hearing threshold before and 48 months 

after surgery with the cochlear implant in the right ear. 

The previously described approaches for CI in 

these patients were translabyrinthine, retrosigmoid or 


353


Bento et al. 

middle cranial fossa. The translabyrinthine approach for 

schwannoma removal is a highly destructive method, and 

degenerative changes in the cochlea such as fibrosis or 

ossification are more pronounced and occur in a short 

time (13). Thus, we hypothesized that the RLA with 

simultaneous cochlear implantation could bring better 

results. 

Cochlear implantation offers advantages over ABI 

as reliable tonotopic stimulation of the auditory system. 

It is also less technically demanding and reduces the risk 

of major complications (16). As an attempt to avoid the 

overall poor hearing results of ABI and to limit the 

adverse effects of direct brainstem stimulation, cochlear 

implantation has been proposed and successfully 

performed in this case. 

Surgical tumor resection may result in mechanical 

or thermal injury to the cochlear nerve or labyrinthine 

artery and traction on the eighth nerve may cause 

avulsion of delicate auditory fibers at the habenula perforata 

(16). Some studies demonstrate that hearing preservation 

is achieved in only 32%-67% of cases (16). Nevertheless, 

more than 80% of such patients are left with an anatomically 

intact auditory nerve (16). Thus, although anatomic 

conservation of the cochlear nerve is fundamental, if the 

functional preservation is not achieved, the auditory 

results may be poor. The use of electrical promontory 

stimulation testing is controversial as positivity does not 

guarantee cochlear implant performance. Our patient´s 

test showed present responses and cochlear implant was 

performed with improvement in hearing thresholds, but 

she cannot discriminate speech. 

CONCLUSION 

Cochlear implantation is a feasible auditory restoration 

option in NF2 when cochlear anatomic and functional 

nerve preservation is achieved. The RLA approach was 

adequate for this purpose and presents an option for 

hearing preservation in NF2 patients. 

REFERENCES 

1. Kanowitz SJ, Shapiro WH, Golfinos JG, Cohen NL, Roland 

JT Jr. Auditory brainstem implantation in patients with 

neurofibromatosis type 2. Laryngoscope. 2004;114:2135- 

46. 

2. Vincenti V, Pasanisi E, Guida M, Di Trapani G, Sanna M. 

Hearing rehabilitation in neurofibromatosis type 2 patients: 

cochlear versus auditory brainstem implantation. Audiol 

Neurootol. 2008;13:273-80. 

3. Hitselberger WE, House WF, Edgerton BJ, Whitaker S. 

Cochlear nucleus implants. Otolaryngol Head Neck Surg. 

1984;92(1):52–4. 

4. Tran Ba Huy P, Kania R, Frachet B, Poncet C, Legac MS. 

Auditoryrehabilitation with cochlear implantation in patients 

with neurofibromatosis type 2.Acta Otolaryngol. 

2009;129(9):971–5. 

5. Cueva RA, Thedinger BA, Harris JP, Glasscock ME 3rd. 

Electrical promontory stimulation in patients with intact 

cochlear nerve and anacusis following acoustic neuroma 

surgery. Laryngoscope. 1992;102:1220–24. 

6. Tono T, Ushisako Y, Morimitsu T: Cochlear implantation 

in an intralabyrinthine acoustic neuroma patient after 

resection of an intracanalicular tumor. J Laryngol Otol. 

1996;110:570–73. 

7. Graham J, Lynch C, Weber B, Stollwerck L, Wei J, Brookes 

G: The magnetless Clarion cochlear implant in a patient 

with neurofibromatosis 2. J Laryngol Otol. 1999;113:458– 

63. 

8. Temple RH, Axon PR, Ramsden RT, Keles N, Deger K, 

Yucel E: Auditory rehabilitation in neurofibromatosis type 

2: a case for cochlear implantation. J Laryngol Otol. 

1999;113:161–63 . 

9. Ahsan S, Telischi F, Hodges A, Balkany T: Cochlear 

implantation concurrent with translabyrinthine 

acoustic neuroma resection. Laryngoscope. 

2003;113:472–74. 

10. Nolle C, Todt I, Basta D, Unterberg A, Mautner VF, Ernst 

A: Cochlear implantation after tumor resection in 

neurofibromatosis type 2: impact of infra- and postoperative 

neural response telemetry monitoring. ORL. 2003;65:230– 

34. 

11. Aristegui M, Denia A: Simultaneous cochlear implantation 

and translabyrinthine removal of vestibular schwannoma in 

an only hearing ear: report of two cases (neurofibromatosis 

type 2 and unilateral vestibular schwannoma). Otol Neurotol. 

2005;26:205–10. 

12. Lustig LR, Yeagle J, Driscoll CL, Blevins N, Francis H, 

Niparko JK. Cochlear implantation in patients with 

neurofibromatosis type 2 and bilateral vestibular 

schwannoma. Otol Neurotol. 2006;27:512-18. 

13. Vincenti V, Pasanisi E, Guida M, Di Trapani G, Sanna M. 

Hearing rehabilitation in neurofibromatosis type 2 patients: 

cochlear versus auditory brainstem implantation. Audiol 

Neurootol. 2008;13:273-80. 


354


Bento et al. 

14. Celis-Aguilar E, Lassaletta L, Gavilán J. Cochlear 

implantationin patients with neurofibromatosis type 2 and 

patients with vestibular schwannoma in the only hearing 

ear. Int J Otolaryngol. 2012;2012:157497. 

16. Carlson ML, Breen JT, Driscoll CL, Link MJ, Neff BA, Gifford 

RH, Beatty CW. Cochlear implantation in patients with 

neurofibromatosis type 2: variables affecting auditory 

performance. Otol Neurotol. 2012;33(5):853-62. 

15. Belal A. Is cochlear implantation possible after acoustic 

tumor removal?Otol Neurotol. 2001;22(4):497–500. 


355

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