International Rhinologic Society Rhinology 0300-0729 60 6 2022 12 1 36417572 Improving routine clinical practice - a daily challenge 401 401 EN B.N. Landis Department of Otolaryngology, University of Geneva Medical School and Geneva University Hospitals, Geneva, Switzerland 3043 10.4193/Rhin22.906

International Rhinologic Society Rhinology 0300-0729 60 6 2022 12 1 36150160 Recurrence rates of de-novo versus inverted papilloma-transformed sinonasal squamous cell carcinoma: a meta-analysis 402 410 EN J.L. Birkenbeuel Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, CA, USA K. Goshtasbi Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, CA, USA N.D. Adappa Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA J.N. Palmer Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA C.C.L. Tong Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA E.C. Kuan Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, CA, USA 3018 10.4193/Rhin22.187 Background: There is a paucity of reporting on recurrence patterns of de-novo sinonasal squamous cell carcinoma (DN-SCC) and inverted-papilloma-transformed sinonasal squamous cell carcinoma (IP-SCC). Method: A systematic literature review queried studies comparing recurrence patterns in patients with both DN-SCC and IP-SCC. Primary outcomes included local and regional recurrence and rates of distant metastasis. Of the 595 studies screened, eight were included. Results: Patients with DN-SCC had significantly higher rates of positive margins, advanced T classification (T3/T4), treatment with chemotherapy and radiotherapy. There were no significant differences in local recurrence or regional recurrence. Overall risk of distant metastasis was lower in IP-SCC. DN-SCC, compared to IP-SCC, is more likely to present with advanced TNM classification and have positive margins after surgical resection, which may affect rates of distant metastasis and recurrence. Conclusions: The findings in this study suggest IP-SCC may be a less aggressive malignancy compared to DN-SCC, with the possibility of a reduced role for adjuvant therapy in IP-SCC. Further studies are required to better understand differences in tumor biology and treatments strategies between IP-SCC and DN-SCC.

International Rhinologic Society Rhinology 0300-0729 60 6 2022 12 1 36150153 Septoplasty versus septoplasty with turbinate reduction for nasal obstruction due to deviated nasal septum: a systematic review and meta-analysis 411 420 EN G. Bin Lajdam College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia K. Alaryani College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia A.A. Ghaddaf College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia A. Aljabri College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia A. Halawani College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia M. Alshareef Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, King Abdulaziz Medical City, Jeddah, Saudi Arabia M. Algarni College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia; Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, King Abdulaziz Medical City, Jeddah, Saudi Arabia H. Al-Hakami College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia; Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, King Abdulaziz Medical City, Jeddah, Saudi Arabia 3026 10.4193/Rhin22.157 Introduction: Compensatory inferior turbinate hypertrophy is a common accompanying manifestation in patients with nasal obstruction due to deviated nasal septum (DNS). The grounds for inferior turbinate reduction (ITR) in this population are still not well established. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of septoplasty with ITR versus septoplasty alone. Methods: Computerised search in Medline, Embase, and CENTRAL was performed. Eligible for inclusion were randomised controlled trials (RCTs) comparing septoplasty to septoplasty with unilateral, contralateral, ITR in adults with DNS. Primary outcomes were health-related quality of life and nasal patency. The secondary outcome was the occurrence of adverse events. Standardised mean differences (SMD) and odds ratios (OR) with 95% confidence intervals were calculated. Results: Twelve RCTs that enrolled 775 participants were found eligible. Data were reported at follow-up periods ranging from 1 month to 48 months. The pooled effect estimate showed a statistically significant improvement with unilateral, contralateral, ITR in Nasal Obstruction Symptom Evaluation scale (NOSE) scores. The rate of adverse events was significantly higher with ITR. Conclusions: Unilateral reduction of the hypertrophied contralateral inferior turbinate during septoplasty resulted in better subjective relief of nasal obstruction in adults with DNS than septoplasty alone. However, caution is warranted since only few well-designed RCTs were identified.

International Rhinologic Society Rhinology 0300-0729 60 6 2022 12 1 36346392 Intraoperative intraorbital bleeding: considerations from a collaborative and retrospective Italian study with a management algorithm proposal 421 426 EN I. Dallan ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy M. Picariello ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy G. Fiacchini ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy R. Canevari Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy M. Rigante ENT Department, University of Perugia, Perugia, Italy E. Pasquini ENT Department, Ospedale Bellaria, Bologna, Italy E. Emanuelli ENT Unit, Padova, Italy E. Alexandre ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy L. Cristofani-Mencacci ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy P. Castelnuovo ENT Department, Fondazione Marchi, Varese, Italy 3022 10.4193/Rhin22.068 Background: Intraoperative intraorbital bleeding is a rare but potentially catastrophic event that can lead even to blindness, if not treated promptly. The goal of surgery is to quickly reduce intraorbital pressure thus restoring normal visual function. Aim of our work is to propose a practical algorithm helping the surgeon in the setting of this critical event. Methodology: An Italian multi-institutional retrospective study was conducted. All the cases of intraoperative intra-orbital bleeding requiring at least some form of surgical management were analyzed. Cases simply managed conservatively were excluded from this analysis. Results: Sixteen cases were collected. Of these, 12 were initially treated with a medial wall orbital decompression, while 4 were treated via a lateral canthotomy and inferior cantholysis (LCC). Ten patients recovered completely. Four patients presented post-op sequelae (diplopia, enophthalmous and/or eyelid malpositioning). Two major negative outcomes (blindness) were observed. Conclusions: Timely surgical intervention is critical. According to the setting in which the bleeding occurs, different options are available. LCC is probably the most rapid maneuver that can be done to reduce intraorbital pressure. Anyway, if the patient is still in the OR and a complete ethmoidectomy yet done we advise, as first step, to perform a medial orbital wall decompression.

International Rhinologic Society Rhinology 0300-0729 60 6 2022 12 1 36150158 Rhino-orbito-cerebral mucormycosis: patient characteristics in pre-COVID-19 and COVID-19 period 427 434 EN L.M. Cherian Department of ENT, Christian Medical College, Vellore, Tamil Nadu, India L. Varghese Department of ENT, Christian Medical College, Vellore, Tamil Nadu, India V. Rupa Department of ENT, Christian Medical College, Vellore, Tamil Nadu, India R.R. Bright Department of ENT, Christian Medical College, Vellore, Tamil Nadu, India L. Abraham Department of ENT, Christian Medical College, Vellore, Tamil Nadu, India R. Panicker Department of ENT, Christian Medical College, Vellore, Tamil Nadu, India N. R. Department of ENT, Christian Medical College, Vellore, Tamil Nadu, India J. Peter Department of Ophthalmology, Christian Medical College, Vellore, Tamil Nadu, India A. Nayak Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India A. Shyam Department of Radiodiagnosis, Christian Medical College, Vellore, Tamil Nadu, India G.M. Varghese Department of Infectious diseases, Christian Medical College, Vellore, Tamil Nadu, India A. Manesh Department of Infectious diseases, Christian Medical College, Vellore, Tamil Nadu, India R. Karuppusami Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India K. George Department of Internal medicine, Christian Medical College, Vellore, Tamil Nadu, India T. George Department of Internal medicine, Christian Medical College, Vellore, Tamil Nadu, India A. Lenin Department of Internal medicine, Christian Medical College, Vellore, Tamil Nadu, India S.G. Hansdak Department of Internal medicine, Christian Medical College, Vellore, Tamil Nadu, India R. I. Department of Internal medicine, Christian Medical College, Vellore, Tamil Nadu, India J.S. Michael Department of Microbiology, Christian Medical College, Vellore, Tamil Nadu, India M. Ninan Department of Microbiology, Christian Medical College, Vellore, Tamil Nadu, India M. Thomas Department of Pathology, Christian Medical College, Vellore, Tamil Nadu, India R. Kurian Department of Pathology, Christian Medical College, Vellore, Tamil Nadu, India S. Mammen Department of Virology, Christian Medical College, Vellore, Tamil Nadu, India R. Kurien Department of ENT, Christian Medical College, Vellore, Tamil Nadu, India 3019 10.4193/Rhin22.099 Background: Rhino-orbito-cerebral-mucormycosis (ROCM), a rare and potentially fatal disease was seen in increasing numbers during the COVID-19 pandemic. This study describes and compares the patient characteristics and outcomes in COVID-19 associated mucormycosis (CAM) and non-COVID-19 mucormycosis (non-CAM). Methodology: CAM patients (24 cases) were recruited from the COVID-19 period and non-CAM (24 controls) from the pre-COVID-19 period. Clinical data of the CAM group was collected retrospectively with 3 month outcomes prospectively. The non-CAM group data was collected retrospectively. Patient characteristics were compared and risk factors for mortality in ROCM were assessed. Results: Orbital symptoms [altered vision, restricted eye movements, ptosis] and intracranial involvement were higher in CAM patients on presentation. Similarly, the radiological involvement of orbit (orbital apex, superior orbital fissure) and intracranial cavity (intracranial thrombosis, cavernous sinus) was also higher in CAM patients. Newly detected diabetes was found only in CAM patients (29.2%). Although univariate analysis suggested an increased mortality risk in ROCM patients with orbital involvement, the multivariate analysis showed no increased risk with any of the parameters assessed, including COVID-19 positivity. Conclusions: Compared to the non-CAM, the disease presentation was severe in CAM with higher frequency of orbital and intracranial involvement. However, with early detection and treatment, the short term survival was comparable in both groups.

International Rhinologic Society Rhinology 0300-0729 60 6 2022 12 1 36150163 Real-world-effectiveness of biological treatment for severe chronic rhinosinusitis with nasal polyps 435 443 EN B.R. Haxel Department of Otolaryngology, Head and Neck Surgery, Schwarzwald-Baar Klinikum Villingen-Schwenningen, Germany; Department of Otolaryngology, Head and Neck Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Germany T. Hummel Smell and Taste Clinic, Department of Otorhinolaryngology, Technische Universität Dresden, Dresden, Germany K. Fruth HNO-Zentrum Mainz, Mainz, Germany K. Lorenz Department of Otorhinolaryngology, Technische Universität Dresden, Dresden, Germany N. Gunder Department of Otorhinolaryngology, Technische Universität Dresden, Dresden, Germany P. Nahrath Department of Otorhinolaryngology, Technische Universität Dresden, Dresden, Germany M. Cuevas Department of Otorhinolaryngology, Technische Universität Dresden, Dresden, Germany 3020 10.4193/Rhin22.129 Background: During the last two years, three different monoclonal antibodies have been approved in many countries for the treatment of patients suffering from severe chronic rhinosinusitis with nasal polyps (CRSwNP). Their efficacy has been demonstrated through large double-blind placebo-controlled clinical studies. Until now, only very limited reports on real-world data regarding this therapy have been published. Methods: This per protocol analysis included patients with an indication for biological treatment because of uncontrolled CRSwNP, despite long-term nasal steroid treatment, systemic steroid use and/ or endonasal sinus surgery. Baseline data on demographics, medical history and comorbidities, polyp score, quality of life and sense of smell (using Sniffin´ Sticks) were assessed and a treatment with either dupilumab or omalizumab was started. The patients were followed up after three and six months. The changes in polyp score, quality-of-life measures and olfaction were noted. Results: 70 consecutive patients were evaluated during the study. Of the patients, 49 were treated with dupilumab and 21 with omalizumab. The polyp score decreased significantly after three and six months, and the quality-of-life parameters and olfaction increased. More than 90% of patients showed a moderate to excellent response to the therapy and there was no difference in the overall response between the two treatments. Olfaction improved in two thirds of the patients, but one third was still anosmic after six months treatment. Conclusions: This real-world study shows the effectiveness of the monoclonal antibodies dupilumab and omalizumab in the treatment of severe CRSwNP. Nasal polyp scores and quality-of-life parameters as well as measured olfactory function were improved after just three months. The response after guideline-based criteria was insufficient only in 5 patients of this cohort.

International Rhinologic Society Rhinology 0300-0729 60 6 2022 12 1 36150161 Discordance of chronic rhinosinusitis disease control between EPOS guidelines and patient perspectives identifies utility of patient-rated control assessment 444 452 EN A.R. Sedaghat Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, United States of America K.W. Singerman Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, United States of America K.M. Phillips Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, United States of America 3023 10.4193/Rhin22.160 Background: The objective of this study was to determine concordance of patient-reported chronic rhinosinusitis (CRS) disease control with CRS disease control assessed according to European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) criteria. Methods: In 421 participants, CRS disease control was determined using EPOS criteria which include the burden of 5 symptoms measured on a binary scale, use of rescue medications in the prior 6 months and presence of diseased mucosa on nasal endoscopy. Symptom severity was also assessed using a visual analogue scale (VAS). Participants rated their CRS disease control as “controlled�, “partly controlled� or “uncontrolled�. Results: Patient-reported and EPOS-based CRS disease control ratings agreed for 49.6% of participants. Amongst cases of disagreement, EPOS guidelines assessed worse CRS disease control relative to 92.9% of patients. Facial pain/pressure and impaired sense of smell distinctly associated with patient agreement with EPOS guidelines on having “uncontrolled� CRS. Higher VAS symptom scores were associated with worse patient-reported CRS disease control (i.e., agreeing with EPOS guidelines). Removal of the nasal endoscopy criterion improved agreement between patients’ and EPOS control assessments, and replacement of this criterion with patient-reported control further aligned EPOS guidelines with patient perspectives. Conclusions: EPOS guidelines regularly assess worse CRS control than assessed by patients. The lack of more gradated symptom severity criteria and inclusion of nasal endoscopy may contribute to discordance of EPOS guidelines with patient-reported CRS control. Replacement of nasal endoscopy findings with a measure of patient-reported CRS disease control better aligns EPOS CRS disease control guidelines with patients’ perspectives.

International Rhinologic Society Rhinology 0300-0729 60 6 2022 12 1 36173184 Loss of p16 expression is a risk factor for recurrence in sinonasal inverted papilloma 453 461 EN M. Menéndez Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain V.N. Cabal Department of Head and Neck Oncology, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain B. Vivanco Department of Pathology, Hospital Universitario Central de Asturias, Oviedo, Spain L. Suárez-Fernández Department of Head and Neck Oncology, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain F. López Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain J.L. Llorente Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain M.A. Hermsen Department of Head and Neck Oncology, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain C. �lvarez-Marcos Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain 3029 10.4193/Rhin22.143 Background: The purpose of this study was to evaluate p16, p53, EGFR, pEGFR protein expression and HPV infection as possible markers of tumor progression in a series of sinonasal inverted papilloma (SNIP) and sinonasal squamous cell carcinoma (SNSCC). Methods: A series of 49 SNIP, 11 SNSCC associated with SNIP (SNIP-SNSCC) and 52 SNSCC not associated with SNIP were analyzed for p16, p53, EGFR, and phosphorylated EGFR (pEGFR) expression by immunohistochemistry. Human papillomavirus (HPV) infection status was evaluated by DNA-PCR. Results were correlated to clinical and follow-up data. Results: Reduced or loss of p16 expression was observed in 18% SNIP, 64% SNIP-SNSCC and 87% of SNSCC. Reduced or loss p16 staining in SNIP correlated with shorter recurrent SNIP-free follow-up. In contrast, p16 expression was not predictive of recurrent SNSCC in cases with SNIP-SNSCC and SNSCC. P53, EGFR, and pEGFR expression did not differ between the tumor groups, nor were they related to recurrent SNIP-free follow-up or recurrent SNSCC. Oncogenic HPV types 16 and 18 were detected in 5% of SNIP and 18% of SNIP-SNSCC, but not in SNSCC. There was no correlation between HPV infection and >70% p16 immunostaining. Conclusions: HPV infection appears to play a minor role in SNIP and SNSCC and p16 immunostaining does not appear a valid surrogate marker for HPV. However, reduced or loss p16 expression may have prognostic value as a risk marker for recurrent SNIP.

International Rhinologic Society Rhinology 0300-0729 60 6 2022 12 1 36259682 Effectiveness of the lateral pedicled endonasal flap for prevention of restenosis in frontal sinus drillouts 462 470 EN R. Fischer Department of Otorhinolaryngology, University of Regensburg, Regensburg, Germany C.T. Seebauer Department of Otorhinolaryngology, University of Regensburg, Regensburg, Germany F. Zeman Centre for Clinical Studies, University of Regensburg, Regensburg, Germany C. Bohr Department of Otorhinolaryngology, University of Regensburg, Regensburg, Germany W. Hosemann Helios Clinic Stralsund, Stralsund, Germany R. Weber Städtisches Klinikum Karlsruhe, Department of Otorhinolaryngology, Karlsruhe, Germany C. Rohrmeier Faculty of Medicine, University of Regensburg, 93042 Regensburg, Germany and ENT medicinal office, Straubing, German T.S. Kuehnel Department of Otorhinolaryngology, University of Regensburg, Regensburg, Germany 3031 10.4193/Rhin22.178 Background: Frontal sinus median drainage according to Draf is an established procedure for achieving maximum drainage of the frontal sinus. Despite great efforts and several modifications, restenosis of the neo-ostium is still a persistent problem. This study presents an approach by implementing local mucosal flaps to prevent restenosis and compares it with the conventional technique without using the flap. Methods: Description of endonasal, lateral pedicle mucosal flap. A Draf III procedure was performed on 156 patients between 2012 and 2021. Data for 123 of the included patients were retrospectively analyzed in terms of surgical indication, technique, postoperative aftercare and patency of the drainage pathway. The follow-up observation period was between 3 and 24 months. Results: Treatment with the pedicle mucosal flap took place in 86 cases. 37 patients were treated as a control group without this flap. The analysis showed a significant association to the event "total closure of the drainage pathway" for surgical technique, as well as in the case of the presence of an allergy and the existence of Samter’s triad. Furthermore, there was a significant association between the onset of "near total closure of the frontal sinus ostium" and Samter’s triad, CRS and revision surgery was involved. Conclusions: Use of an endonasal lateral pedicle flap for reconstruction of mucosal defects in frontal sinus surgery improves the long-term chances of a patent drainage pathway. Bone exposed by drilling was covered with a local mucosal flap for a faster epithelialization, healing and less scarring.

International Rhinologic Society Rhinology 0300-0729 60 6 2022 12 1 35403179 Gendered differences in relative ACE2 expression in the nasal epithelium 471 473 EN J.H. Juratli Smell and Taste Clinic, Department of Otorhinolaryngology, TU Dresden, Dresden, Germany A. Joshi Smell and Taste Clinic, Department of Otorhinolaryngology, TU Dresden, Dresden, Germany S. Füssel Department of Urology, TU Dresden, Dresden, Germany T. Hummel Smell and Taste Clinic, Department of Otorhinolaryngology, TU Dresden, Dresden, Germany 2990 10.4193/Rhin21.484

International Rhinologic Society Rhinology 0300-0729 60 6 2022 12 1 Mepolizumab improves quality of life and reduces activity impairments in patients with CRSwNP 474 478 EN C. Bachert Ghent University and Ghent University Hospital, Belgium; University of Stockholm, Stockholm, Sweden P.W. Hellings Ghent University and Ghent University Hospital, Belgium; University of Leuven, Leuven, Belgium; Academic Medical Center, Amsterdam, the Netherlands V.J. Lund University College London, London, UK; Royal National Throat Nose and Ear Hospital, UCLH, London, UK W.J. Fokkens Academic Medical Center, Amsterdam, the Netherlands C. Hopkins Guys and St Thomas' Hospital, King's College, London, UK B. Mayer Clinical Statistics, GSK, GSK House, Brentford, Middlesex, UK R.H. Chan Respiratory Patient-Centred Outcomes, Value Evidence and Outcomes, GSK, Brentford, Middlesex, UK S.G. Smith Respiratory Therapeutic Area, GSK, Research Triangle Park, NC, USA A.R. Sousa Respiratory Patient-Centred Outcomes, Value Evidence and Outcomes, GSK, Brentford, Middlesex, UK R. Alfonso-Cristancho Respiratory Therapeutic Area, GSK, Research Triangle Park, NC, USA S. Yang Value Evidence and Outcomes, GSK, Collegeville, PA, USA on behalf of the SYNAPSE Study Group 3021 10.4193/Rhin22.053

International Rhinologic Society Rhinology 0300-0729 60 6 2022 12 1 36150157 Nasal disorders and cardiovascular damage: flow-mediated dilation and intima-media thickness as risk parameters 479 480 EN M. Gelardi Department of Otolaryngology, University Hospital of Foggia, Foggia, Italy R. Giancaspro Department of Otolaryngology, University Hospital of Foggia, Foggia, Italy L. Iannuzzi Otolaryngology Unit, Department of Biomedical Sciences, Neuroscience and Sensory Organs, University of Bari Aldo Moro, Italy S. Taliente Otolaryngology Unit, Department of Biomedical Sciences, Neuroscience and Sensory Organs, University of Bari Aldo Moro, Italy K. Piccininni Otolaryngology Unit, Department of Biomedical Sciences, Neuroscience and Sensory Organs, University of Bari Aldo Moro, Italy N. Quaranta Otolaryngology Unit, Department of Biomedical Sciences, Neuroscience and Sensory Organs, University of Bari Aldo Moro, Italy G. Bulzis Department of Emergency and Organ Transplantation - Cardiovascular Disease Unit, University of Bari Aldo Moro, Bari, Italy N. Sasso Department of Emergency and Organ Transplantation - Cardiovascular Disease Unit, University of Bari Aldo Moro, Bari, Italy R. Carbonara Department of Emergency and Organ Transplantation - Cardiovascular Disease Unit, University of Bari Aldo Moro, Bari, Italy M.M. Ciccone Department of Emergency and Organ Transplantation - Cardiovascular Disease Unit, University of Bari Aldo Moro, Bari, Italy M. Cassano Department of Otolaryngology, University Hospital of Foggia, Foggia, Italy 3024 10.4193/Rhin22.155