Craniofacial and cervical trauma in a pandemic context

Daniela Vrînceanu1,2, Adrian Ştefan1, Ioana Eftime1, Bogdan Bănică1, Mihai Dumitru1,2

1. ENT Department, Bucharest Emergency University Hospital, Romania

2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania


Introduction. Craniofacial and cervical trauma in the context of polytrauma is a major emergency that requires the prioritization of injuries and rapid therapeutic decisions. The context of the COVID-19 pandemic brings an additional difficulty in approaching these patients, especially those with indications for therapeutic maneuvers or with surgical indications. Materials and method. We present our experience in dealing with craniofacial and cervical trauma in the context of an emergency hospital, with a large number of admissions for polytrauma. Results. We detail the diagnostic and therapeutic algorithm, exemplified by complex clinical cases. We insist on the centrofacial traumas and on the open pharyngolaryngeal traumas, approached in mixed surgical teams. Discussion. Once the surgical indication has been established, the timing of the surgery and the approach are to be determined. In the case of complex craniofacial trauma or open laryngeal trauma that requires a laborious intervention in the aerodigestive sphere, it is very important to test fast RT-PCR for SARS-CoV-2 and to respect the circuits. Conclusions. Trauma in a pandemic context brings additional elements of difficulty, but the correct and complete balance of the injuries, the prioritization and the correct establishment of the surgical indication remain essential. The multidisciplinary approach to trauma is undoubtedly the ideal solution.

Keywords: trauma, COVID-19, diagnosis, surgery, multidisciplinary

ENT – a specialty with real difficulties in the COVID-19 pandemic

Celesta Drăgulescu, M. Chiţac, Anca Ciobotariu, Xenia Dolghii, Emanuela Onisâi, Andrada Nadoleanu, Mădălina Militaru, A. Ştefănescu, I. Zaharia

“Prof. Dr. Dorin Hociotă” Institute of Phonoaudiology and ENT Functional Surgery, Bucharest, Romania


The authors present a paper regarding the experience they and their patients have been through due to SARS-CoV-2 pandemic situation, focusing on the difficulties they have faced.

The limited access to health care services caused a delay of diagnosis, of paraclinical exams, treatment and of the follow-up of the patients.

Keywords: pandemic, SARS-CoV-2, ENT

Management of deep neck infections during the COVID-19 pandemic

M.D. Cobzeanu, D.O. Palade, Gianina Bandol, Gina Stegaru, Patricia Vonica, Florentina Severin, Liliana Gheorghe Moisii, Luiza Maria Cobzeanu, Gabriela Burlacu, B.M. Cobzeanu

“Sf. Spiridon” County Emergency Clinical Hospital, Iaşi, Romania


The authors conducted a prospective study based on the cases admitted with deep neck infection in the ENT Clinic of the “Sf. Spiridon” Emergency Clinical Hospital, Iaşi, over the last two years (2020-2021), during the COVID-19 pandemic. A total of 1859 cases were admitted, much less than in previous years due to the epidemiological context. A number of 43 deep neck infections were treated, 29 demanding surgical management. The late presentation, the coexisting organic strains and the SARS-CoV-2 infection led to difficulties in diagnosis and treatment of a pathology that often has a reserved prognosis due to the complexity and evolution of the lesions.

Keywords: deep neck infections, therapeutic management, COVID-19 

Considerations regarding the management of tracheobronchial foreign bodies – our experience

Cristina Bânţu1, Simona Strugariu1, Daniela Rusu2

1. ENT Department, “Sf. Maria” Emergency Clinical Hospital for Children, Iaşi, Romania

2. ENT Discipline, “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania


Foreign body aspiration is a common pathology in the pe­dia­tric population, representing a cause of morbidity and even mortality, especially in children aged 1 to 3 years old. In the context of the COVID-19 pandemic, the extraction of a tracheo­bronchial foreign body implies an increased risk of transmitting the SARS-CoV-2, due to the particularities of bronchoscopy and anesthesia. The ENT department within the “Sf. Maria” Emergency Clinical Hospital for Children, Iaşi, is the only one in the area of Moldova that manages this pathology. We will discuss the characteristics of foreign body aspiration and some cases from our experience.

Keywords: bronchoscopy, foreign body aspiration, COVID-19

Aerodigestive foreign bodies in SARS-CoV-2 pandemic

Elena Ioniţă1, Andrei Eduard Gheorghe2, Iulică Ioniţă3

1. Craiova County Emergency Clinical Hospital, Romania

2. Novaci City Hospital, Romania

3. Private Medical Practice ENT Dr. Ioniţă, Romania


Appeared two years ago and wreaking havoc worldwide both economically and health-wise, the COVID-19 pandemic in Europe, implicitly also in Romania, has imposed increasingly stringent measures taken by the authorities to prevent harmful effects on citizens and the economy. In the field of health, the infection with SARS-CoV-2 has forced the taking of rigorous hygienic-sanitary measures aiming, last but not least, to protect the medical staff exposed to the high risk of contamination. Foreign aerodigestive bodies are a major health problem, quite common, especially in children, with a range of complications marked by a significant risk of life. Although the clinical picture is often highly suggestive, the presence of the foreign body is not always confirmed on exploration. This outlines the need for a therapeutic management algorithm in the suspicion of a tracheobronchial foreign body. The aim of the paper. Highlighting the clinical changes of respiratory, dysphagic, patients with swallowed or aspirated foreign body. The objectives of the paper. The corroboration between the clinical-anamnestic, paraclinical, imaging, the positive diagnosis and the emergency therapeutic attitude. Materials and method. Between January 2020 and December 2021, 118 patients (aged between 1 year and 1 month old and 81 years old) with suspected foreign body aspiration/swallowing were presented to the emergency department of the Craiova ENT clinic. Endoscopic procedures of rigid tracheobronchoscopy and rigid esophagoscopy were performed under general anesthesia with muscle relaxants. We retrospectively reviewed patient data with the following variables: age, sex, clinical symptoms, radiological findings; location of the foreign body in the respiratory tract/digestive tract, the time elapsed between aspiration/swallowing and removal of the foreign body, possible incidents, accidents and intra- and post-procedural complications. Results. 90.67% (n=107) of the rigid endoscopic examinations were positive, with the removal of the foreign body aerodigestive. Foreign body suspicion was refuted in 9.33% (n=11) endoscopes. There were no major intra-/postprocedural complications. The nature of the foreign bodies that impacted the airway was predominantly organic. Conclusions. For foreign bodies, tracheobronchial asphyxiation accident is a sign of positive diagnosis, along with perioral cyanosis. For esophageal foreign bodies, retrosternal pain and salivation are suggestive.

Keywords: aerodigestive foreign bodies, rigid tracheobronchoscopy, rigid esophagoscopy

Surgical treatment of conductive hearing loss through implantable hearing aids

Cristian Mârţu1,2, Vlad Cozma1,2, Corina Butnaru1,2, Sebastian Cozma1,2, Oana Bitere Popa1,2, Dan Mârţu1, Ioan Piftor2, Luminiţa Rădulescu1,2

1. “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania

2. Clinical Rehabilitation Hospital Iaşi, Romania


Conductive hearing loss (CHL) is a relatively common disabling condition and can be caused by congenital disorders of the external and middle ear or through osicular chain fixation. Most commonly, however, it is caused by otomastoidian inflammatory pathology (polypoid otitis media and cholesteatoma) through chronic osteitic processes with irreversible damage to the tympanic-osicular transmission mechanism. CHL caused by congenital disease or fixation of the osicular chain can be recovered with active implantable hearing aids (HA) – fixed to the external cortex of the skull or anchored to the osicular chain, or by passive prostheses anchored to the osicular chain (TORP or PORP). In the case of chronic osteitic processes, the surgical principles involve the eradication of the pathological process in the first stage and in the second stage the functional restoration of hearing (during the same surgery or at a later revision intervention). Usually, the use of autologous materials is preferred as first intention, then, depending on the indication and the local status of the tympano-mastoid cavity and the Eustachian tube patency, TORP or PORP type prostheses or active HA with internal or external bone anchorage can be used with good results. Transmission hearing loss, a common condition in patients with chronic otologic pathology, currently benefits from a wide range of functional restoration possibilities, both through passive prostheses and active implantable HA, which can ensure a good hearing comfort and a proper quality of life. For each treatment type, there are specific and precise indications that have to be strictly followed.

Keywords: auditory rehabilitation, chronic hearing loss, bone anchoring, indications

Titanium prosthesis in cholesteatoma surgery

E.H. Ştefănescu

ENT Department, “Victor Babeş” University of Medicine and Pharmacy, Timişoara, Romania


Objectives. To determine whether a separate, staged procedure for ossicular chain reconstruction (OCR) results in significantly


different hearing results when compared to OCR performed concurrent with tympanomastoidectomy for cholesteatoma when using the same type of titanium prosthesis. Materials and method. We only included patients undergoing OCR for cholesteatoma within a five-year period (from January 2013 to December 2017). The intervention was OCR concurrent with tympanomastoidectomy (Group I) or OCR staged following tympanomastoidectomy for cholesteatoma (Group II). The staged procedure was performed within 16 months. The main outcome measures were mean postoperative air-bone gap (ABG), proportion achieving ABG closure to <20 dB and <30 dB for Group I and Group II overall and when controlling for the type of mastoid cavity created (open or closed) and the status of the stapes superstructure (TORP versus PORP). Results. Seventy-seven patients were included in the study. Thirty-four patients were included in Group I and 43 in Group II. The overall hearing results did not differ significantly in the two groups. When considering the status of the stapes and mastoid cavity, concurrent OCR resulted in improved mean postoperative ABG in a closed mastoid cavity with an intact stapes superstructure (p=0.043). Furthermore, a greater proportion of patients who had concurrent OCR within this group achieved ABG<20 dB and ABG<30 dB, although this difference did not reach statistical significance. By contrast, staged OCR resulted in improved mean postoperative ABG in open mastoid cavities with an absent stapes superstructure (p=0.046). A higher proportion also achieved ABG<20 dB and ABG<30 dB, but it was not statistically significant. Conclusions. Staged OCR is preferable in those with more severe disease, whereas those with least severe disease may benefit from a concurrent OCR.

Keywords: cholesteatoma, tympanomastoidectomy, ossicular chain reconstruction, titanium prosthesis

Controversies of the unilateral atretic ear

N. Balica, M. Poenaru, A.H. Marin, H. Ştefănescu, I.C. Mot, D. I. Horhat

ENT Department, “Victor Babeş” University of Medicine and Pharmacy, Timişoara, Romania


No one would argue that surgery for congenital aural atresia has the same potential for hearing restoration as does stapedectomy. Few middle ear procedures involving the middle ear ossicles do. But is the success rate so modest that unilateral cases are best observed, at least until the individual is an adult and can make his or her own decision? The routine use of the facial nerve monitor supplements the surgeon’s knowledge of temporal bone anatomy, the information provided by the preoperative HRCT, and provides another asset in making unilateral aural atresia repair safer for the patient. Most otologic surgeons would explore the middle ear of a child with a unilateral conductive hearing loss secondary to trauma, infection, or presumed ossicular fixation (e.g., malleus or stapes). Why, then, the reluctance – or controversy – regarding aural atresia, which, fortunately, is unilateral in most patients? Certainly, the hearing loss resulting from aural atresia is significant both in terms of severity (i.e., maximal conductive deficit) and in its potential impact on auditory and linguistic development. The concerns appear to focus on surgical risks and hearing outcome. Specifically, it has been documented in the literature that approximately 70% of patients will achieve a hearing threshold of at least 30 dB after surgery, and about 75% of these patients will maintain this level over a longer term. Just as all oto­laryn­gologists, or even otologists, are not equally trained in the various facets of major skull base surgery, the same must be acknowledged for atresia surgery. The optimal treatment for patients with unilateral aural atresia will be realized as more surgeons become trained in managing these patients and as referrals to centers experienced with this condition become a priority.

Keywords: congenital aural atresia, preoperative HRCT, trained surgeons, auditory and linguistic development

Tumorile glomice ale urechii medii

A. Maniu1, I. Asavinei2, A. Mihuţ2, S. Bota2, M. Dindelegan1

1. Departamentul ORL, Universitatea de Medicină şi Farmacie „Iuliu Haţieganu”, Cluj-Napoca, România

2. Departamentul ORL, Spitalul Clinic Judeţean de Urgenţă Cluj-Napoca, România


Tumorile glomice sunt tumori rare de origine vasculară care pot apărea la nivelul spaţiilor urechii medii. Originea acestor tumori poate fi la nivelul plexurilor vasculare care acompaniază nervul Jacobson (ramul timpanic al nervului IX) sau nervul Arnold (ram auricular al nervului X), în acest caz folosindu-se termenul de glomus timpanic. Termenul de glomus jugular sau jugulo-timpanic se referă la acele tumori care apar din celulele paraganglionare localizate la nivelul adventiţiei domului jugular sau la acele tumori care au originea în hipotimpan şi care invadează secundar bulbul jugular. Această lucrare prezintă câteva aspecte particulare legate de diagnosticul şi tratamentul acestor tumori, exemplificate prin cazuri clinice.

Cuvinte-cheie: glomus timpanic, clasificare, diagnostic, tratament

Auditory brainstem implants (ABI) in children

Ronen Perez1, J. Thomas Roland Jr.2, Riki Salem3, Nevo Margalit4, Jean-Yves Sichel1

1. Department of Otolaryngology – Head and Neck Surgery, Shaare Zedek Medical Center; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel

2. Department of Otolaryngology – Head and Neck Surgery, NYU School of Medicine, New York, USA

3. Department of Audiology, Shaare Zedek Medical Center; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel

4. Department of Neurosurgery, Shaare Zedek Medical Center; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel


Background. Auditory brainstem implants (ABI) directly stimulate the brainstem, bypassing the inner ear and auditory nerve. In recent years, ABI candidacy has been expanded to include children with deficient nerves or a non-implantable inner ear. The purpose of this paper is to give an overview on ABI in children and to present a series of ABI patients implanted and followed-up in our center in Jerusalem, Israel, including the country’s first ABI recipient. Methodology. Seven children implanted with an ABI are currently mapped and followed-up in the Cochlear Implant Center at Shaare-Zedek (five implanted at Shaare-Zedek and two at the New York University). Surgeries were conducted with collaboration between otologists, neurosurgeons and audiologists. All children were implanted with a cochlear AB541 device and the switch-on was conducted in the operating room under general anesthesia. The children’s age at implantation ranged between 2 and 8.6 years old; there were five boys and two girls. Results. Six of the seven children had deficient or hypoplastic auditory nerves and underwent cochlear implantation (CI) prior to receiving the ABI. One child had bilateral cochlear aplasia. Three children had CHARGE syndrome. The duration of the follow-up from surgery ranged from two to five years. The category of auditory perception (CAP) scores ranged from 0 to 8. The functional outcomes were highly variable, ranging from significant open set speech perception in the child with the longest duration of implant use to no auditory response in a child with CHARGE. The rehabilitation duration required for achieving functional results is significantly higher for this group of children with ABI compared to peers with CIs. Conclusions. Functional auditory and speech outcomes for children with ABI are highly variable and generally significantly poorer than those found with CIs. Nevertheless, most children showed a significant improvement, demonstrating that ABI may be the best and the only solution in this rare condition.

Keywords: auditory brainstem implant (ABI), cochlear nerve, cochlear aplasia, cochlear implant (CI), sensorineural hearing loss

Autoimmune inner ear disorders and the “case of Sjögren syndrome”

Patrizia Mancini1, Ginevra Portanova1, Francesca Atturo2, Roberta Priori3

1. Dipartimento Organi di Senso Università Sapienza, Policlinico Umberto I, Roma, Italia

2. UOC ORL, San Giovanni Addolorata, Roma, Italia

3. DH Sjogren, UOC Reumatologia Policlinico Umberto I Roma, Italia


Introduction. Autoimmune inner ear disease consists of a syndrome of rapidly progressive hearing loss (HL) and/or dizziness which is caused by antibodies or immune cells which are attacking the inner ear. There is no universally accepted set of clinical diagnostic criteria, and the audiological diagnosis is based on a loss of 30 or more dB in both ears at one or more adjacent frequencies (Harris, 2003). The cause of IMIED is generally assumed to be related to either B-cell antibodies or T-cells that cause damage to the inner ear. There are several theories: intolerance, genetic predisposition, cross-reaction and, finally, bystander damage. Immune-mediated inner ear disorders are classified as organ specific (Os-IMIED) and systemic (S-IMIED). Os-IMIED represent 1% of cases. The incidence of deafness in S-IMIED, as often data concern single-center reports. Deafness in Sjögren syndrome has been described in 46% of cases. Primary Sjögren’s syndrome is a chronic inflammatory autoimmune disease that affects the exocrine glands. Its key features are dry mouth, dry eyes, and other multisystem damage, including fatigue, fever, joint pain, skin lesions and kidney injury. More recently, neurological manifestations have been described, such as atypical facial pain, peripheral neuropathy (senso-motorial), CNS immune-mediated vasculitis, meningitis, migraine, and multiple sclerosis. Hearing loss might be therefore a central manifestation of the disease. Materials and method. The present study included patients who had undergone the first diagnosis of Sjögren syndrome at the immunology service of the Policlinico Umberto I of Rome. Only patients with positive biopsy were enrolled (n=25). Baseline audiological assessment – follow-up (minimum 18 months): medical history focusing on concomitant diseases and pharmacological therapy, pure tone audiometry, speech perception in quiet and in noise (It-Matrix), hearing handicap index (HHI). Results. HL was found in 36% of primary Sjögren, 44% of secondary presenting thyroiditis, and 20% of secondary with thyroiditis and other systemic disorders. Cochlear HL (measured as PTA) had a similar worsening over time in patients with or without systemic comorbidities. HHI was correlated to systemic clinical symptomatology, and emotional aspects of communication were more disabling than situational ones. It-Matrix improved over time in patients responsive to a correct therapeutic approach. In nonresponsive patients, central decoding of speech significantly worsened over time. Discussion. Data from the present study underlined a worst HL deterioration in patients with comorbidities. These patients presented a dissociation between PTA worsening and central decoding. Measure and monitor hearing in Sjögren syndrome cases (and in general in all autoimmune patients): it is of paramount importance in these patients to measure both peripheral and central processing, as the improvement in speech perception was shown to be linked to a correct systemic therapeutic approach.

Keywords: Sjögren’s syndrome, hearing loss, immune-mediated inner ear disorders

Spectrum of GJB2 gene mutations in Romanian patients with profound sensorineural hearing loss

Luminiţa Rădulescu, C. Mârţu, Corina Butnaru, B. Cobzeanu, B. Cavaleriu, Roxana Şerban, S. Cozma

“Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania; Clinical Rehabilitation Hospital, Iaşi, Romania


Introduction. Autosomal recessive mutations from the level of GJB2 gene remain the most frequent cause of profound congenital sensorineural hearing loss, therefore genetic tests can help establishing the degree of hearing impairment and the prognosis in children who do not pass the auditory screening tests from maternity. Materials and method. In this study, there were enrolled 310 subjects with congenital bilateral sensorineural hearing loss, candidates for cochlear implantation. All the study participants were submitted to an audiological assessment, using electrophysiological tests (PEA and ASSR) which allowed the determination of the hearing loss stage, and they were tested through GJB2 gene PCR sequencing for the detection of potential mutations. Results. Out of the 310 subjects, 39.67% presented different mutations at the level of GJB2 gene, responsible for hearing loss onset, and 10.96% were mutation carriers at the level of one of the alleles, but without these being the cause of hearing loss. Overall, there were found 18 different mutations at the level of GJB2 gene. The most frequent mutation was, as expected, 35delG, in 35.48% of cases, followed by c.71G>A in 6.77% of cases, and by c.551G>C in 2.25% of cases. Conclusions. Our results reveal the importance of an early identification of the genetic profile and, last but not least, the importance of an appropriate and informed genetic advice.

Keywords: hearing loss, GJB2, mutations

ENT endoscopic surgery – past, present and pandemic difficulties

Codruţ Sarafoleanu

Prof. Dr., “Carol Davila” University of Medicine and Pharmacy, Bucharest; ENT&HNS Department, “Sf. Maria” Clinical Hospital, Bucharest, Romania


The evolution from the external approach to rhinosinusal endoscopic surgery has provided important advances in the quality of medical practice and for the patients’ quality of life. Beyond the individualization of the treatment, it is very important to know the clinical, endoscopic and imaging anatomy, but especially the particular anatomical variants. It is not good to generalize the cases, because it is obvious that there are no simple cases. The correct diagnosis is essential, and endoscopic surgical treatment depends essentially on the endowment, personal and team skills and the ability to convert the endoscopic operation into an external approach. Imaging investigations are essential for both disease assessment and surgical planning. The introduction of ENT navigation has significantly improved the surgical approach and prevented the complications. A proper learning curve is an essential condition for performing ENT endoscopic surgery, and extensive operations at the skull base, orbit, lacrimal ducts and deep spaces are the rule at this time. The future is represented by surgical microrobots, gene therapy and individualized treatment. The ongoing COVID-19 pandemic determined important changes in the daily ENT practice and resources, due to the need to postpone the nonurgent medical or surgical procedures. These measures produced a limited access of the patients to the healthcare system. In our country, the surgical volume during pandemic decreased by more than 50%, with a frequent worsening of severe cases and the occurrence of fungal infections.

Keywords: endoscopic surgery, rhinosinusitis, rhinosinusal tumors, skull base

Sinusogenic ocular orbital complications in the context of COVID-19 – diagnostic and treatment issues

Daniela Vrînceanu1,2, Adrian Ştefan1, Ioana Eftime1, Bogdan Bănică1, Mihai Dumitru1,2

1. ENT Department, Bucharest Emergency University Hospital, Romania

2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania


Introduction. SARS-CoV-2 viral infection, responsible for COVID-19, is associated with generalized endotheliitis and vascular thrombosis, predominantly pulmonary. It should be noted that a preexisting inflammatory phenomenon in a given area increases the risk of vascular thrombosis, therefore chronic bacterial or fungal rhinosinusitis may be associated with an increased risk of ocular thrombosis in the territory of the central retinal or cerebral artery, such as cavernous sinus thrombosis. Materials and method. We present a series of cases with COVID-19 in the recent history (up to 30 days after diagnosis) that were admitted to the ENT department for sinusogenic ocular orbital complications. Results. We detail the diagnostic and treatment algorithm, insisting on the need for complete imaging exploration by CT and MRI of the brain, as well as the need for prompt surgery to remove the infectious focus that sustains thrombosis. Discussion. It is interesting to discuss the appearance of invasive fungal rhinosinusitis in these locally and systemically immunocompromised patients, as well as the benefit of combining voriconazole-type systemic antifungals with surgical treatment. Systemic and oral anticoagulant treatment for 3-6 months is mandatory. Conclusions. Oculo-orbital and cerebral complications in the context of COVID-19 represent a diagnostic and therapeutic emergency. The right therapeutic attitude influences the chances of recovery of vision that is severely affected, as well as the vital prognosis by stopping the evolution of cavernous sinus thrombosis.

Keywords: chronic fungal rhinosinusitis, COVID-19, ocular thrombosis

Obstructive sleep apnea syndrome – predictive factor for SARS-CoV-2 infection

Adriana Neagoş

Otorhinolaryngology Department, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, Târgu-Mureş, Romania


It is well known in the literature that when we talk about obstructive sleep apnea syndrome, we also discuss about the presence of the inflammatory and oxidative cellular phenomenon, also found in patients with asthma. Deprivation of sleep leads to the production of inflammatory cytokines. In patients with sleep disorders, there is also an associated pulmonary inflammatory process. Thus, the sleep disorders are associated with an inflammatory process in the lungs, for which some patients receive low or moderate doses of corticosteroids. It is believed that both obstructive sleep apnea syndrome and sleep disorders may be associated with an increase in the inflammatory phenomena in patients with COVID-19, even worsening the symptoms, if the type of patients at risk for severe COVID-19 pulmonary complications is taken into account: obesity, diabetes, with associated asthma with metabolic syndrome present. This is a common typology with that of patients with sleep disorders such as obstructive sleep apnea. In conclusion, the association of obstructive sleep apnea syndrome with SARS-CoV-2 infection is explained by the pathophysiological mechanisms, being important to solve the problem of sleep quality, to improve the results after SARS-CoV-2 infection, as well as the importance of vaccination against COVID-19 in patients with sleep apnea syndrome who have an increased risk of infection.

Keywords: obstructive sleep apnea, snoring, nasal breathing, arousal

Morphological and biochemical changes of the sinonasal mucosa in SARS-CoV-2 infection

Ionuţ Isaia Jeican1,2,3, Monica Muntean2,4, Veronica Trombiţaş1, Silviu Albu1

1. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca; ENT Clinic, University Clinical Hospital CFR Cluj-Napoca, Romania

2. Second Clinical Department, Clinical Hospital of Infectious Diseases Cluj-Napoca, Romania

3. Department of Anatomy and Embryology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

4. Department of Infectious Diseases, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania


Introduction. The upper respiratory tract mucosa is the site of the first step of infection with SARS-CoV-2 (ACE2 and TMPRSS2 receptors). Materials and method. Our studies included 36 deceased COVID-19 patients. Tissue samples were collected by curettage/craniotomy at 12 hours post-mortem and were subjected to investigations of molecular virology, histopathology-immunohistochemistry and scanning-transmission electron microscopy. The research was conducted after the approval of ethics committees and of the administrative boards of involved institutions. Results. Nasal mucosa (12 COVID-19 patients, five control patients). Positive tissue PCR for SARS-CoV-2 in 100% (n=12/12) of cases. Histopathological, stromal edema (lymphocytic inflammatory infiltrate), thickening of the basal membrane and viral cytopathic effect in 25% (n=3/12), 33.3% (n=4/12), respectively 8.3% (n=1/12) of cases. At electron microscopy – frequent microbial aggregates on surface (75%, n=9/12 versus control group – 20%, n=1/5), immune cells (58.3%, n=7/12), suggestive structures for SARS-CoV-2, and the abundance of the Golgi apparatus in the epithelial cells. The mean tissue IL-33 concentration was 52.77 pg/7 μg total protein (±6.869, n=12) (compared to 210 pg/7 μg total protein; ±8.327, n=25 CRSwNP tissue samples collected during FESS). Olfactory system (24 COVID-19 patients). CD3+ lymphocytes on the surface and in the thickness of the olfactory epithelium (33%, n=8/24). Frequent amylaceous bodies (66.6%, n=16/24), focal cerebritis (37.5%, n=9/24), CD3+ lymphocytes and softening in the olfactory bulb. Conclusions. The nasal mucosa of patients with COVID-19 responds to infection by dysbiosis and the involvement of the surface immune cells, suffering also cytopathic viral effects. The inflammatory histopathological changes are reduced in the rhinology region; olfactory bulb presents degenerative-inflammatory changes. The study of the initial host-virus interaction in the nasal microbiota may lead to an understanding of how the systemic inflammatory response occurs and modulates in COVID-19. Because the pulmonary viral insemination is secondary to the nasal one, further rhinological research in COVID-19 is necessary to study both local factors that may initiate systemic hyperinflammatory response, and the possibility of developing an intranasal vaccine.

Keywords: SARS-CoV-2, COVID-19, nasal mucosa, olfactory system, histopathology, electron microscopy

Smell and taste dysfunctions – diagnosis and functional recovery

Violeta Melinte1, Elena Pătraşcu1,2

1. ENT & HNS Department, “Sf. Maria” Clinical Hospital, Bucharest, Romania

2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania


Introduction. Even though smell and taste dysfunctions have been studied since the 19th century, the publications number concerning this subject has dramatically increased during the COVID-19 pandemic. The explanation is given by the multitude of patients accusing smell and taste affection during the confirmed SARS-CoV-2 infection, sometimes even as the only symptom. The diagnosis can be easily established, but the treatment, prognosis and recovery possibility are still considered a challenge for the specialists. Materials and method. Olfactory function evaluation is complex, requiring a detailed anamnesis, clinical and paraclinical ENT examination (nasal endoscopic exam, nasal swab test, imaging examinations focused on the olfactory bulb region), completed by specific subjective and objective investigations available (dynamic olfactometry with n-butanol, Snap and Sniff test, olfactory electrical evoked potentials). Taste testing is mandatory for all patients. In terms of treatment, the European Commission for Odor and Taste Disorders has proposed multiple drug therapies, such as topical and/or systemic administration of corticosteroids, systemic administration of neurotrophic medication, omega-3, intranasal vitamin A (using the “Kaiteki” position), intranasal sodium citrate, as well as performing olfactory training. Results. The odor impairment was confirmed by specific tests in most patients with SARS-CoV-2 infection who reported olfactory and taste disorders, but only half of them had a real impairment of taste. The recovery may be spontaneous within 7 to 14 days of onset. A duration of symptoms longer than 14 days requires treatment. There is no specific treatment for this condition. Olfactory training has been shown to be effective in treating olfactory disorders, as well as its association with the administration of systemic omega-3 and intranasal vitamin A. The prognosis is better for hyposmic patients than for those with anosmia. Conclusions. The severity of the olfactory impairment influences the prognosis of functional recovery. The association of parosmia decreases the quality of life of patients, despite the improvement of the results of subjective tests. Currently, sustained olfactory training, performed for at least three months, is the most effective method of treating smell impairment.

Keywords: anosmia, COVID-19, olfactory training

Novel aspects regarding tumors of the sphenoidal sinus

Gheorghe Mühlfay1,2, Adrian Bălaşa2,3, Beáta Kiss1, Mădălina Georgescu4, Karin Horváth2,5

1. Department of Otorhinolaryngology, County Emergency Clinical Hospital of Târgu-Mureş, Romania

2. “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology of Târgu-Mureş, Romania

3. Department of Neurosurgery, County Emergency Clinical Hospital of Târgu-Mureş, Romania

4. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

5. Department of Ophthalmology, Mureş County Clinical Hospital, Târgu-Mureş, Romania


Introduction. The tumoral pathology of the sphenoidal sinuses is not only increasingly various, but also numerous. Considered to be antechambers of the cranial box, these cavities constitute a complex border area, the treatment of their neoplastic pathology requiring, apart from an ever-growing level of competence, vast experience, adequate equipment and a team consisting of rhinologists, neurosurgeons, ophthalmologists, pathologists, radiologist and even interventionists, depending on the needs. Materials and method. The casuistry of the last five years of the Otorhinolaryngology Department of the County Emergency Clinical Hospital of Târgu-Mureş, including many such cases with complex locoregional variations, permits us to reach significant conclusions. The types of primary disease, complications and favorable outcomes reached not only by endoscopic nasal surgery (FESS), respectively combination but also compulsory conversion into a microscopic approach if needed, led to conclusions worthy of discussion. Results. From the selected and statistically processed sample, the majority of cases consisted of benign tumoral pathologies, with unfavorable clinical progress, compared to malignant tumors, simple forms, compared to forms with complex cranial base involvement, and male patients compared to female patients. In 34% of cases, only endoscopic surgery was needed, the rest needing microscope-assisted interventions in 46% of cases, or a mixed approach in 20% of cases at the Department of Neurosurgery. Most interventions required mixed teams. Discussion. A particular aspect deserves underlining, beyond the compulsoriness of the existence of complete endowment and necessary experience of the specialists, is the willingness and ability to collaborate within these teams. Furthermore, we emphasize the absolute necessity of openness from team members during the recovery of these difficult cases. In this regard, we underline the impossibility of building a surgical strategy without a competent radiologist and detailed imagistic exploration. Finally, we cannot overlook the importance of the pathologist in performing extemporaneous histopathology and immunohistochemistry. Functional recovery and esthetic expectations of patients were strictly respected. Conclusions. In all of these cases, the advantage of using combined CT and MRI imagistic was indisputable, as well as the importance of the navigation system, regardless of use of the FESS or microscopic approach. Postoperative care was relatively long, aiming the prevention of superinfection and optimal wound healing. For these reasons, mean hospitalization consisted of nine days. Interdisciplinary consultations were mandatory pre- and postoperatively, for example neurology exam or laboratory tests. In cases with major visual impairment, compensatory auditory or tactile possibilities were taken into account.

Keywords: tumor pathology, cranial base, medical imaging, FESS, interdisciplinarity

Management of voice disorders in COVID-19 pandemic

Rodica Mureşan

ENT Clinic Cluj-Napoca, Romania


The purpose of this study is to review the current literature and present our practical experience regarding the impact of COVID-19 on the management of voice disorders. Methodology. A comprehensive search of peer-review articles was completed using PubMed, Google Scholar and Web of Science. The search used many key terms, including “voice disorders”, “hoarseness”, “dysphonia”, “laryngoscopy”, and “voice therapy”. The analysis was also based on our experience in this field. Conclusions. Due to the COVID-19 pandemic, ENT and voice therapy practices had to make substantial changes to provide health services to patients with voice disorders. The study presents specific ways to reduce the transmission of the disease and the role of the phoniatrician and voice therapist in the management of voice disorders in this context.

Keywords: COVID-19, voice disorders, voice therapy

Characteristics of CO2 laser surgery in benign laryngeal diseases

Mihail Tuşaliu

“Prof. Dr. Dorin Hociotă” Institute of Phonoaudiology and Functional ENT Surgery, Bucharest; “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania


Lasers are a relatively recent acquisition in larynx surgery. The use of CO2 laser has seen rapid expansion in the approach of a large variety of benign and malignant laryngeal pathology. Transoral microscopic laser surgery became the method of choice for many of these pathologies of the glottic plane. This paper presents a series of relevant clinical cases and particular situations encountered that showcase the utility of this surgical technology in successfully addressing the most common benign laryngeal lesions. We evoked, commented on and highlighted the most important aspects regarding the chosen approach methods, the surgical details and the particularities of each case, the problems encountered, the benefits and disadvantages of using CO2 laser in these types of diseases and the solutions used to streamline the long-term results and to improve the patients’ quality of life.

Keywords: benign laryngeal diseases, CO2 laser surgery

Impact of COVID-19 pandemic on ENT oncology diseases

Magdalena Chirilă1,2, Alma Maniu1,2, Sever Pop1,2, Violeta Necula1,2, Doinel Rădeanu1,2, Cristina Ţiple1,2

1. ENT Department, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

2. ENT Department, Emergency County Clinical Hospital Cluj-Napoca, Romania


Objective. The COVID-19 pandemic has severely affected the diagnosis and treatment of patients with oncology diseases, with consequent delays and tumor upstaging. The aim of this study was to describe our experience on patients with head and neck tumors. Materials and method. This study retrospectively analyzed the clinical records (anatomical site of origin, TNM stage, and type of treatment) of patients diagnosed and treated for head and neck cancers in our ENT department between the 16th of March and the 31st of December 2020, and the 1st of January and the 31st of December 2021, and compared them with the clinical records of patients diagnosed between the 16th of March 2019 and the 15th of March 2020. Results. During the pandemic, we diagnosed and treated 211 patients with malignant tumor of the head and neck divided in 86 patients between the 16th of March and the 31st of December 2020, and 125 patients between the 1st of January and the 31st of December 2021. Those data were compared to those of 136 patients treated during the pre-pandemic period. The most common anatomical sites of origin of the neoplasms were larynx, hypopharynx and oropharynx, most of them in stage III or IV. Compared to the pre-pandemic data, we found a 32.05% decrease in the number of oncology patients undergoing surgery, while the rate of patients treated exclusively with nonsurgical approaches increased by 42.84%. Conclusions. The diagnostic and therapeutic procedures for patients affected by malignancy of head and neck region were severely impacted by the COVID-19 pandemic.

Keywords: COVID-19, head, neck, cancers

Respiratory intensive therapy of the critical patient with SARS-CoV-2 infection

Genoveva Cadar

Anesthesia and Intensive Care Department, “Marius Nasta” Institute of Pneumology, Bucharest, Romania


During the last year (2021), 391 patients were admitted in the COVID-19 intensive care unit (ICU) in our hospital for severe acute respiratory insufficiency due to SARS-CoV-2 infection. Out of those, approximately 65% were intubated and the rest were assisted with noninvasive ventilation (NIV) through different interfaces. The most frequently used interface was full-face mask, followed by facial (oronasal) mask. Helmet was used especially at the beginning of the pandemic, due to the fear regarding the aerosolized contamination of the personal, but with time it became less and less used, because of the difficulties of choosing the right ventilatory parameters to obtain the desired minute-volume (MV). High-flow nasal canula (HFNC) was used from the beginning, its use increasing over time, concomitant with the decrease of the panic regarding contamination and the rise in the number of the devices. The intubated patients were ventilated in pressure controlled or assisted modes and the majority of them were put in prone position (once or more times), especially in the second year of pandemic, when the new hired personnel gained experience. A small percentage of the intubated patients were tracheostomized, surgically, at the bedside. Tracheostomy didn’t significantly improve the rate of weaning and survival. The timing for intubation is still debated but, in our opinion, it should be probably correlated first of all with the clinical status of the patient.

Keywords: severe acute respiratory insufficiency, SARS-CoV-2 infection, intubation, noninvasive ventilation (NIV), Helmet tent

Prognostic factors in sudden hearing loss

V. Necula1,2, C. Blebea1, P. Ujvari1, M. Dindelegan1, D. Rădeanu1,2, A. Maniu1,2

1. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

2. Cluj County Emergency Clinical Hospital, Romania


Introduction. Sudden hearing loss is a sensorineural hearing loss that involves a more than 30 dB decrease of pure tone threshold on three consecutive frequencies, installed within three days. The rate of spontaneous recovery is very variable, between 47% and 63%, depending on the recovering criteria used. Age, dizziness, increased ESR and severity of hearing loss are some of the prognostic factors associated with the recovery of hearing thresholds. Materials and method. We studied a group of 44 adult patients, over the age of 18 years old, admitted in the ENT clinic between July 2017 and December 2021, referred to our department in the first 14 days after the onset. The patients referred after the first 14 days or treated as outpatients were not included in our study. Results. Under general corticosteroid therapy, in the study group 43.2% of patients had a complete hearing recovery, and 27% had a partial recovery, greater than 15 dB, but with a slight residual hearing loss. The initiation of the treatment in the first three days after the onset as well as the age of patients did not have a significant influence on recovery, while the association with vertigo negatively influenced recovery. Conclusions. The controversy over prognostic factors persists in sudden hearing loss. There is no standardized treatment and many patients do not seek for medical evaluation in time, so it is difficult to estimate what the actual cure rate is and what factors may influence the results exactly.

Keywords: sudden hearing loss, prognostic factors, corticotherapy

Unilateral deafness – a therapeutic challenge

Sebastian Cozma1,2, Luminiţa Rădulescu1,3, Cristian Mârţu1,3, Oana Bitere1,2, Raluca Olariu1

1. “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania

2. Audiology Department, Rehabilitation Clinical Hospital Iaşi, Romania

3. ENT Clinic, Rehabilitation Clinical Hospital Iaşi, Romania


Deep unilateral hearing loss is common in otological medical practice and therapeutic decisions are often difficult and conditioned by multiple factors. It can be congenital, in which case, in most patients, in the absence of postpartum hearing testing, it can remain unidentified for a long time, if this is not associated with a visible otic malformation, or it can be acquired, with various causes: infectious, traumatic, otological degenerative disorders, tumor etc. Lately, deep congenital unilateral hearing loss can be identified early due to the universal neonatal auditory screening which was introduced in Romania since 2019. When the diagnosis of this pathology occurs late, the ideal treatment of auditory recovery is compromised. The two directions of the functional recovery strategy are: (1) enabling or rehabilitating the diseased ear, on the condition of early intervention and providing binaural hearing, a possible result if treatment occurs as close as possible to the onset of deafness, and (2) restoration of the affected auditory field using the phenomenon of transcranialization that allows the projection of information to the uniquely functional contralateral ear. The main resources in the treatment of congenital or acquired deep unilateral deafness are: cochlear implant, for hearing with the affected ear, and conventional prostheses with bone vibrator or surgical prostheses with bone anchoring for hearing by transferring information to the functional ear. The treatment solutions can lead to ethical discussions, especially in the case of early-diagnosed unilateral congenital deafness, when the therapeutic success is conditioned by the rapidity of treatment.

Keywords: unilateral hearing loss, cochlear implant, bone anchoring hearing aids

Auditory rehabilitation through cochlear implant in COVID-19 pandemic conditions

Adriana Neagoş

Otorhinolaryngology Department, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, Târgu-Mureş, Romania


The sensorineural hearing loss has a multitude of causes and its incidence has increased lately in children and adults. Its etiology is under constant discussion, especially in the unilateral sensorineural hearing loss, with viral involvement being demonstrated. The determination of viral infection in the etiopathogenesis of unilateral sensorineural hearing loss is especially incomplete. An accepted element, however, is that, through the action of the virus, there are invaded the cochlear tissue and the cochlear nerve. In unilateral deafness, recovery may occur two weeks after infection, with a significant number of patients showing a complete recovery after this period. Hearing rehabilitation by cochlear implantation involves a multitude of postoperative medical care. During the pandemic period, a number of appointments for surgeries and rehabilitation program sessions were canceled, and there was a difficult access to the hearing rehabilitation processes. New sanitary methods have been implemented which have radically changed medical care and rehabilitation. In patients with cochlear implants, the use of a mask and excessive protection with social distancing have created problems that are very difficult to tolerate. Achieving a successful rehabilitation requires a fearless environment, by respecting hygiene in the COVID-19 era. A special emphasis is placed on the protection of medical staff who can safely resume cochlear implantation during this period without depriving patients (especially children) of cochlear implant surgery, mainly when there is a risk of cochlear ossification.

Keywords: cochlear implantation, pandemic, safe health care, difficult auditory rehabilitation

Organization of cochlear implant programs during the COVID-19 pandemic

Artur Lorens, Anita Obrycka, Piotr H. Skarzynski, Henryk Skarzynski

Institute of Physiology and Pathology of Hearing, Warsaw, Poland


For cochlear implant (CI) centers, the coronavirus pandemic has caused massive changes in working procedures. In many centers, following the so-called lockdowns, CI surgeries have been cancelled or postponed, outpatient services have been reduced, and rehabilitation programs shut down or severely curtail

ed. We will discuss the changes which were necessary in preoperative, intraoperative and postoperative CI protocol. To minimize resource exhaustion, good organization and preventive strategies are necessary. Resource usage should be carefully planned, and routine scheduled procedures should be reconsi­dered. Guidelines are urgently needed to prioritize procedures based on the risk versus benefit of performing them. According to our experience, cochlear implantation during these difficult times can be undertaken when safe measures and guidelines to prevent infection are implemented at every level.

Keywords: cochlear implantation, COVID-19 pandemic, undertaken

Development of a case history form for adults with audiovestibular conditions related to COVID-19

Aurelian Curcă

Audiology - Western University, Ontario, Canada


The novel coronavirus (SARS-CoV-2) has a wide symptomology that continues to evolve as its prevalence increases.  Several case reports outline the possibility of SARS-CoV-2 affecting the audiovestibular system with complications such as sensorineural hearing loss, ototoxicity, tinnitus, vertigo and dizziness. Thus, making documentation and tracking of audiovestibular conditions in patients who have had COVID-19 are important for an adequate care. As part of a larger project, an objective was the development of a case history form in order to establish good documentation practices regarding COVID-19-related cases for clinicians. Appraisal of the case history form was done through questionnaires by an expert panel which aimed to evaluate each item based on four criteria: appropriate amount of detail, novelty, relevance and appropriate health literacy level, so that patients would be able to fill out the form by themselves. The analysis of the appraisal used the e-Delphi method. The final product was a clinic-ready case history form that focused on the experiences of patients with SARS-CoV-2 infection and their subsequent audiovestibular conditions. As COVID-19 continues to evolve, so must the resources available to clinicians, and the development of this case history form will serve as a guide for clinicians to direct their care for patients who present with audiovestibular conditions after COVID-19. Attendees will receive up-to-date information on case history factors to consider when assessing patients who report having been infected with SARS-CoV-2.

Keywords: case history, COVID-19, audiovestibular

A team-based approach to action – rapid implementation of innovative virtual audiology services in response to COVID-19

Aurelian Curcă

Audiology - Western University, Ontario, Canada


During the COVID-19 pandemic, most audiology services in Canada are considered non-essential, resulting in a halt in the provision and maintenance of most services, including the provision of amplification technologies (e.g., hearing aids). These services are essential for the maintenance of communication abilities and in reducing the negative psychological effects (anxiety, depression and social isolation) that people with hearing loss can experience, which may be heightened when communicating with people wearing PPE. Recent technological innovation has enabled the application of virtual service delivery (also referred to as telepractice). Audiology practice is perfectly positioned to provide continuous patient care, using a virtual delivery model. This project brought together a multidisciplinary team of clinicians, researchers, industry-partners and highly qualified professionals to develop and implement a virtual audiology/hearing aid support framework at two clinical sites in London, Ontario. The project follows an evidence-based knowledge-to-action framework, which has been applied within this team’s research numerous times to achieve the following objectives: 1) bridge a research-to-practice gap related to virtual care delivery models in audiology and 2) to provide access to audiology patient services for all age groups specific to virtual hearing aid support to mitigate the immediate and wider effects of the pandemic. Attendees will receive up-to-date information on this project objectives, methodology, timelines and outcomes.

Keywords: team-based, virtual, telepractice

Remote Check – a digitalization project for the rehabilitation of CI users

Ioan-Alexandru Oltean

MSc, Associate, Clinical Support, MED-EL Vienna, Austria


What methods are there to remotely support the rehabilitation of cochlear implant (CI) users in the pandemic circumstances? How can technology monitor the development, the performance, and the success of CI users? We present an overview of a digitalization project for CI users in Romania – a method to assess the development and performance of CI users, without the need of costly travel to a specialized center. For the ENT doctors, the main benefit lays in the decrease of workload and reduced patient traffic. There will be more time for patients who need special care. For the CI users, the implementation of this project will bring shorter to no travel time, with a direct influence on cost reduction for both patients and ENT doctors.

Keywords: distance, verification, rehabilitation, cochlear implant, digitalization

Vestibular rehabilitation during the COVID-19 pandemic

Mădălina Georgescu

Audiology Department, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

Vertigo, dizziness and imbalance maintained their high incidence among acute or chronic symptoms that decrease the patient’s quality of life, but unfortunately the addressability has been significantly reduced during the COVID-19 pan­demic, both because of the restrictions imposed by the national management of the pandemic and due to patients’ reluctance to enter healthcare facilities, with a theoretically increased risk of infection. Under these conditions, the medical practice regarding the vestibular pathology has undergone continuous changes, depending on the restrictions – emergency state or alert state. Thus, at the beginning of the pandemic, we consulted online the patients who, at a telephone history, suggested a benign positional paroxysmal vertigo (BPPV) – using the WhatsApp video application, we monitored the patient while another family member, trained by phone, performed the repositioning maneuver. Subsequently, the consultations were performed in the office, but for patients with stable unilateral or bilateral peripheral vestibular deficit, we initiated a mixed vestibular rehabilitation program – the daily exercises were performed under video surveillance for the first 3-5 days and then monitored at two-week intervals, as the execution speed increases, to see the impact of the change. Weekly meetings on the platform or in virtual reality (Wii and Kinect) took place in the office, since this required specialized equipment. Also, for some patients, we also monitored online the development of vestibular rehabilitation exercises with virtual reality glasses, which we lent to the patients during the vestibular rehabilitation program (6-12 weeks, as needed). Clinical and paraclinical evaluation at the end of the vestibular rehabilitation program revealed similar results to those of patients included in the vestibular rehabilitation programs prior to the COVID-19 pandemic.

Keywords: peripheral vestibular syndrome, vestibular rehabilitation, telemedicine