eroc show daily - emirates rhinology & otology conference...published on behalf of mci middle...

Carefully selected vestibular function tests along with the hearing test are cost-e�ective �rst steps in the

laboratory evaluation of dizzy patients said Dr Kamran Barin in his presentation – Overview of Vestibular Function Tests and Their Clinical Usefulness in Evaluation of Dizzy Patients – at the EROC Congress in Dubai.

In his presentation he provided a description of test procedures and interpretation of �ndings for various vestibular tests including videonystagmography (VNG) / electronystagmography (ENG), vestibular-evoked myogenic potential (VEMP), video head impulse, and rotation chair – with an emphasis on VNG testing. The advantages, disadvantages, and clinical utility of each test was also discussed and guidelines were provided on how to use interdependencies among vestibular test �ndings to improve the clinical value of the tests and to avoid artifacts.

The goals of these tests are:1. To support the preliminary diagnosis that is derived from the history and physical examination. For example,

THE USEFULNESS OF VESTIBULAR FUNCTION TESTS FOR DIZZY PATIENTS

presence of a unilateral caloric weakness in VNG or an abnormal head impulse test (HIT) can support the diagnosis of vestibular neuritis and identify the side of lesion.

2. To identify subtle oculomotor abnormalities by providing a more sensitive and objective measure of eye movements. For example, internuclear ophthalmoplegia can be missed during a bedside clinical examination even by some experienced clinicians, but can be easily identi�ed during the saccade test in VNG.

3. To determine if additional diagnostic tests are needed. For example, patients with abnormal central �ndings in VNG should be referred for imaging studies for further evaluation.

4. To provide evaluation of vestibular function when procedures are planned that can potentially damage the labyrinth or the vestibular nerve. For example, information about the vestibular system prior to cochlear implantation or gentamycin therapy for Meniere’s disease can help with better management of the patient.

Traditional vestibular tests such as VNG, yield some type of abnormal �nding

in about 50% of patients with dizziness and balance complaints. Approximately half of those �ndings localize the lesion to either peripheral vestibular or central pathways. While the success rate for

the vestibular tests may appear to be low, it is signi�cantly higher than any other laboratory test that is used for the evaluation of dizzy patients. In addition,

There are advantages and disadvantages to vestibular function tests. Dr Kamran Barin, Assistant Professor Emeritus, Otolaryngology - Head & Neck Surgery, The Ohio State University discussed these and looked at the clinical utility of each test in a pre-conference workshop.

Continued page 3

EROC Show DailyShare the Knowledge. Stay Informed

18 January 2017 • ISSUE 1

2 THE OFFICIAL SHOW DAILY � 18 January 2017 7TH EMIRATES OTORHINOLARYNGOLOGY AUDIOLOGY AND COMMUNICATION DISORDERS CONGRESS

Published on behalf of MCI Middle EastUnited Arab EmiratesTel: +971 4 311 [email protected]

Congress ChairmanDr Hussain Abdul Rahman Al Rand

www.emiratesrhinologyandotology.ae

Published by Trident Communications102, Block C, Offices Land BuildingSheikh Rashid RoadDubai, UAETel: +971 4 3346609www.TridentComms.media

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EROC Show Daily: What is the main purpose / aim of the EROC Congress? n Dr Hussain Abdul Rahman Al Rand: The EROC conference aims to provide a platform for e�ective knowledge sharing by eminent experts in the �eld of Otorhinolaryngology from across the globe.

EROC Show Daily: Why is the EROC Congress important for healthcare in the region?n Dr Hussain: With the recent

and rapid developments in the �eld of medicine, there is now an enormous need, as well as expectation from society, for doctors and healthcare workers to keep abreast of the latest developments in medicine. This has resulted in the changing roles of doctors and healthcare workers in society. They are not only called upon to provide state of-the-art medical practice, but they are also expected to take part in teaching and research in order for them to keep up to date with the latest solutions to the challenges they face in medical practice. This conference aims to meet this need in the region by sharing knowledge of these new advances in the �eld of ENT.

EROC Show Daily: What are some of the more prevalent Otorhinolaryngology illnesses in the Middle East region?n Dr Hussain: The incidence of ear, nose and throat disorders in children is increasing in the Gulf countries which may be due to environmental factors related to the rapidly developing environment in which they are living.EROC Show Daily: Is the high prevalence

of these diseases unique to the region when compared to Europe, USA and Asia? If so, why?n Dr Hussain: The fast-developing cities in the region is to some extent a unique environmental factor – rapid urbanization. The desert vegetation and its e�ect on ENT disorders is also unique to the region.

EROC Show Daily: What is being done to reduce the prevalence of these diseases?n Dr Hussain: Neonatal hearing screening has been implemented for early detection and e�ective treatment.

EROC Show Daily: What do you think are the most pressing / urgent issues in this field of medicine in the region? What do you suggest should be done to improve the situation?n Dr Hussain: There is a lack of research and data. Solutions to this are investment in research and setting up research labs in the �eld of ENT.

EROC Show Daily: Can you tell us about some of the most recent breakthroughs in technological innovation in this field of medicine and explain how this is

helping patients? n Dr Hussain: Recent advances in cochlear implant technology is a major breakthrough for neonates with congenital hearing loss.

EROC Show Daily: Do you have any comments for congress delegates? n Dr Hussain: The congress is the biggest in the region and we bring in pioneers in the various �elds of ENT which will help delegates to get up-to-date knowledge in their respective specialties. n

Dr Hussain Abdul Rahman Al Rand, MSc (Cairo), German Board (Facharzt), FRCS, is Assistant Under Secretary, Health Centers and Clinics and Public Health, Ministry of Health and Prevention, UAE. He is Assistant Regional Secretary – IFOS (Middle East and Gulf region); President – ARABFOS; President – GCC ORL Head and Neck Society; President – Emirates ORL Head and Neck Society.

Challenges in managing chronic rhinosinusitis

On Day 1 of the 7th EROC Congress in Dubai, Dr Amin R. Javer, FRCSC

FARS, Endoscopic Sinus and Skull Base Surgery, Rhinology and Nasal Physiology, Director of St Paul’s Sinus Centre, begins his sessions by speaking on the salient features of endoscopic surgical anatomy of the paranasal sinuses. He will expand on the importance of anatomic landmarks to

carry out safe and e�ective functional endoscopic sinus surgery. He will also look at future management options that are in the

pipeline for the treatment of recalcitrant chronic rhinosinusitis (CRS) including antimicrobial PhotoDynamic Therapy (aPDT) and the use of Poloxomer 407 gel.

Dr Javer says one of the greatest challenges in CRS is the management of patients who fail advanced sinus surgery and are left with recalcitrant chronic in�ammation secondary to bio�lm formation within the sinus cavities.

He explains that antimicrobial photodynamic therapy is a non-invasive, non-antibiotic broad-spectrum antimicrobial treatment that is carried out by �rst instilling a photosensitizer into the infected and in�amed sinus cavity followed by the placement

of a balloon catheter within the sinuses. The sinus is illuminated with a 670nm non-thermal activating light using the sinuwave catheter.

He says: “In-vitro, this treatment modality has reduced polymicrobial bio�lm and planktonic bacteria and fungi by greater than 99.9% after a single treatment. In-vivo studies have also proven to be very successful with this novel therapy.

“Another advanced method of treating microbial bio�lm within the sinuses is by utilizing a thermoreversible gel with an ability to bind to more than one treating medication.”

Poloxamer-407 gel has unique thermoreversible properties that allow it to remain liquid in cold temperatures and turn solid in warmer environments. This makes it an ideal carrier to deliver medications into the sinus cavity where it can sit for prolonged periods as a semi-solid thereby allowing the medication to remain at the site where it is needed instead of immediately �owing out of the sinus.

In his presentation, Dr Javer also touches on the advances made in cytokine pro�ling of CRS patients that allows the physician to predict with certainty the correct medication that will work on a particular patient without guessing. It takes away the uncertainty and shotgun nature of prescribing medication that exists today in the treatment of recalcitrant CRS and allergic fungal sinusitis. n

Scenes from the EROC 2016 conference.

Experts invited to share their knowledgeDr Hussain Abdul Rahman Al Rand is the Chairman of the 7th Emir-ates Otorhino-laryngology, Audiology and Communica-

tion Disorders Conference. EROC Show Daily spoke to him about the conference and otorhinolaryn-gology in the region.

18 January 2017 � THE OFFICIAL SHOW DAILY 37TH EMIRATES OTORHINOLARYNGOLOGY AUDIOLOGY AND COMMUNICATION DISORDERS CONGRESS

the incidence of abnormal � ndings in vestibular tests increases to about 75% for otologic diseases.

ChallengesDespite their usefulness, vestibular tests face signi� cant challenges:

1. There is no direct access to the labyrinth or vestibular nerve activities. Instead, laboratory tests of vestibular function must rely on motor responses that originate from the vestibular system, namely eye or postural movements. This lack of direct access complicates interpretation of the test results.

2. Unlike auditory tests, it is di� cult to independently test each labyrinth by limiting the stimulus to one ear at a time. Head movements, which are the natural mode of vestibular stimulation,

generate responses from both labyrinths thus making it more di� cult to identify unilateral vestibular dysfunction. That is the reason a limited test such as the caloric

Cont’d from page 1

Videonystagmography (VNG) / electronystagmography (ENG) testing is used to assess the organs of balance (vestibular system) of the inner ear to determine if a person’s dizziness or loss of balance is caused by an inner ear abnormality.

The vestibular-evoked myogenic potential (VEMP) is a neurophysiological assessment technique used to determine the function of the otolithic organs (utricle and saccule) of the inner ear. It complements the information provided by other forms of vestibular apparatus testing.

The vestibular system helps a person maintain: balance, visual � xation, posture, and lower muscular control.

There are six receptor organs located in the inner ear: cochlea, utricle, saccule, and the lateral, anterior, and posterior semicircular canals. The cochlea is a sensory organ with the primary purpose to aid in hearing. The utricle and saccule are sensors for detecting angular or linear acceleration, and the three semicircular canals detect head rotation.

ENG / VNG / VEMP testing

Dr Kamran Barin’s other presentations include:1. Can the video head impulse test defi ne severity of bilateral vestibular hypofunction?

Rotary chair testing is considered the gold standard for evaluation of bilateral vestibular hypofunction. However, rotary chair testing is not readily available in many clinical settings. The purpose of this study is to determine if video head impulse testing (vHIT) can be used as a screening test to determine the presence and severity of bilateral vestibular hypofunction.

2. Canalithiasis, Cupulolithiasis, and Misdiagnosed BPPV

This presentation describes methods to di� erentiate between canalithiasis and cupulolithiasis in di� erent types of BPPV. We will also discuss methods to avoid misdiagnosing other vestibular disorders as BPPV.

l Check programme for details.

test, has served as the gold standard for evaluating vestibular function because it can limit the stimulation to one labyrinth. In recent years, other vestibular tests, such as VEMP and HIT, have become available that allow independent assessment of each labyrinth.

3. Currently, no laboratory test is capable of evaluating all of the structures within the labyrinth or the neural pathways that originate from these structures. As a result, many dizzy patients have to undergo multiple tests, and even then some components of the vestibular pathways are not adequately evaluated.

4. Vestibular tests are tests of function and with very few exceptions, they cannot identify the underlying disease. The results of the vestibular tests must be used along with the

history, physical examination, and other test � ndings to reach a � nal diagnosis.

The above issues as well as the complexity of the vestibular pathways make the interpretation of vestibular test � ndings challenging. n

Challenges in managing chronic rhinosinusitis

Middle ear cholesteatomasOn Day 1 Professor Olivier Sterkers, APHP, Hospital Pitié Salpêtrière; Otology, Auditory implants and skull base surgery, Paris, France; presents ‘Management of middle ear cholesteatomas in adults: Is mastoid obliteration useful?’

Prof Sterkers says, middle ear cholesteatomas in adults are surgically removed through either canal wall down or up techniques. Decision making depends mainly on the extension of the disease as suspected by otological evaluation under microscope, CT Scan and in some instances magnetic resonance imaging (MRI). The fact that bone substitutes have been proven to be safe and well tolerated (1,2,3) has changed the surgical techniques which could be adapted to each individual case based on an initial transmeatal attictomy.

Cholesteatomas with restricted extension to the attic are removed under microscope or endoscope and when necessary the ossicular chain reconstructed (4). In all the other cases, the cholestatomas extensions are followed through an enlarged transmeatal atticotomy associated to a mastoidectomy when necessary.

Obliteration of the mastoid cavity with bioactive glass (Bonalive) avoids the need to perform a radical cavity and provides well-tolerated support for cartilage reconstruction of the attical wall. Furthermore, aeration of the middle ear cavities will be restricted to the middle ear cleft which reduces the risk of recurrence (3). Follow up could be made then by either CT scan or MRI.

Management options for parapharyngeal space tumours

Parapharyngeal space tumours are uncommon and represent only 0.5% of tumours of the head and neck. Because

they are mostly benign – and tumours such as paragangliomas and schwannomas can generally be diagnosed by imaging studies – are slow growing and can be managed by watchful waiting, surgery, or radiation therapy, it is important to be able to counsel patients about the relative risks and bene� ts of the di� erent management options.

However, there are very few studies that report the complication rates of PPS surgery. No studies distinguish between surgical complications for pre- and poststyloid tumours despite the di� erent surgical approaches required, the di� erent pathology encountered and the fact that the poststyloid space contains key structures such as the internal carotid artery, internal jugular vein, lower cranial nerves and sympathetic trunk.

“I will present a personal series of the pathology and consequences and complications of surgery for 43 tumours of the pre- versus poststyloid parapharyngeal spaces in 41 patients,” says Prof Fagan. “A variety of surgical approaches were

Professor Johannes Fagan, of the University of Cape Town, South Africa, will present ‘Management Decisions relating to Parapharyngeal Space Tumours’ on Day 3, Session 2, Al Ras 2. He gives an outline of his talk.

employed depending on tumour location and pathology. All prestyloid tumours were benign, and predominantly of salivary origin. Of 25 poststyloid tumours, 4 were malignant, 14 were paragangliomas and 5 were schwannomas.

“There were no permanent surgical complications in prestyloid tumours. Permanent cranial nerve de� cits occurred in 20% of patients, 7% had >1 cranial nerve de� cit, and one patient had a stroke. Cranial nerve de� cits occurred only in paragangliomas.”

He says that the recommendations emanating from this study are that one should consider patients’ age and � tness, and the location and type of tumour when considering management options. Because the surgical approach should take into account the pathology and location of the tumour, the workup must include CT and/MR imaging and sometimes, FNAC.

“Prestyloid tumours can be safely resected. However, with poststyloid paragangliomas & vagal schwannomas, the options of watchful waiting vs radiation vs surgery should be carefully considered,” Prof Fagan says. n

What is a cholesteatoma?

1 – Bernardeschi et al. Eur Arch Otorhinolaryngol 20142 – Bernardeschi et al. Biomed Res. Int 20153 – Bernardeschi et al, Clin. Otolaryngol, 20164 – Bernardeschi et al, Eur Arch Otorhinolaryngol 2016

Vestibular function tests

A cholesteatoma is an abnormal, noncancerous skin growth that can develop in the middle section of the ear, behind the eardrum. Besides repeated infections, a cholesteatoma may also be caused by a poorly functioning eustachian tube.

When left untreated, a cholesteatoma will grow larger and cause complications that range from mild to very severe.

The dead skin cells that accumulate in the ear provide an ideal environment for bacteria and fungus to thrive. This means the cyst can become infected, causing in� ammation and continual ear drainage. Over time, a cholesteatoma may also destroy the surrounding bone. It can damage the eardrum, the bones inside the ear, the bones near the brain, and the nerves of the face. Permanent hearing loss may occur if the bones within the ear are broken.

The only way to treat a cholesteatoma is to have it surgically removed. The cyst must be removed to prevent the complications that can occur if it grows larger. Cholesteatomas don’t go away naturally. They usually continue to grow and cause additional problems.


From their humble beginnings in the mid-1980s, optical and electromagnetic (EM) systems have

undergone a fascinating transformation from experimental tools into highly reliable, sophisticated pieces of technology with excellent accuracy, providing valuable critical information to the surgeon.

While there is still an unchanged need for surgeons to thoroughly master the registration process and to understand the working mechanism of their systems – after all, it is always the surgeon who medicolegally is responsible to con� rm or doubt the precision, and correct for it, if necessary – signi� cant advances have been made over the past year.

Especially in EM-navigation, miniaturisation of the detector spools in submillimetric dimensions have enabled endoscopic surgeons to actually track the very tip of a navigated instrument, minimizing tracking errors – and allowing, for instance, malleable and � exible tools to be navigated with high precision.

The latest additions to the spectrum of user-friendly and surgeon-oriented navigational features we developed with Karl Storz Endoscope from Tuttlingen, Germany are the following:

1.) Highlighting danger areasOn the tri-planar navigational CT scans, the surgeon can set marks on potential danger areas (like a very “low hanging”, partially decalci� ed anterior skull base / ethmoidal roof in Fig. 1). When getting closer than a certain distance (which in our example was set at 6 mm), the navigated instrument´s display will turn from green to orange/amber on the screen (Fig. 2). When touching one of the (CT-) markers, the display turns full red and a warning peep is heard (Fig. 3). This is extremely helpful when during surgery the tip of the navigated tool cannot clearly be seen, like in cases of di� use

polyposis or bleeding.Of course, markers can be used to

highlight any potential danger area on the scans – anterior ethmoidal and/or internal carotid artery, optic nerve canal, medial orbital wall, nasolacrimal duct and others, as required by the surgeon.

2.) Planning and visualisation of a surgical path With this new software, the surgeon can draw his intended approach to any sinus on the navigational CT scans – it is his decision whether, for a frontal sinus approach for instance, he plans to go around or through an agger nasi or any other fronto-ethmoidal cell; this is his responsibility.

The system can even suggest a pathway on its own, based on only two points set by the surgeon: “start” and “� nish”. Again, it is the (medico-legal) responsibility of the surgeon, to control – and possibly modify – a system-suggested path.

This path then is displayed in the endoscopic view – like an Ariadne´s thread, leading the surgeon to his goal (Figs. 4, 5). Once the path has been veri� ed, there would even be no need to use navigated instruments – one just could follow the highlighted path visible in the endoscope and use one’s standard visual anatomical orientation.

l Examples of these features will be presented during the EROC Conference on January 18 from 14:00 – 14:25 in Session III in Al Ras 1.

Image-guided, computer-assisted intraoperative navigation has come a long way in endoscopic transnasal approaches to sinuses and skull base surgery, says Prof Dr Heinz Stammberger.

Heinz Stammberger, M.D. HonFRCS(Ed), HonFRCS(Engl), HonFACS, Endoscopic Sinus & Skull Base Surgery is Consultant, Interdisciplinary Skull Base Group, Professor Emeritus & Senior Excellence Faculty at the Medical University Graz, Austria.

Figure 1: Di� use recurrent eosinophilic polyposis. The low standing ethmoidal roof on the right has been marked (yellow dots). Note the navigated pointer is more than 1 cm away and hence, displayed green

Figure 3: The pointer is in contact with a danger point and has turned red ; in addition, a beep is heard.

Figure 2: The pointer turns orange, being less than 5 mm away from a danger point

Figure 4: Intraoperative endoscopic view into frontal recess on the left: clearly the path designed by the surgeon can be seen, leading into frontal sinus.

Figure 5: Path to frontal sinus displayed on CT scan ( note navigated endoscope with cone of vision indicated); corresponding endoscopic view with path right above endoscope.

New advances in navigational techniques in endoscopic sinus and skull base surgery


Obstructive Sleep Apnea (OSA) presents with recurrent upper airway obstructions

and desaturations during sleep terminated by arousals, leading to increased daytime sleepiness and risk for accidents. OSA causes elevated sympathetic tone associated with arterial hypertension and vascular inflammation. Studies have shown OSA increases the risk for cardio- and cerebrovascular incidents.

“Nasal CPAP-therapy is able to normalise sleep and breathing, restore sleep, and reduce cardiovascular risk. However, 20-50% do not use CPAP su� ciently,” says Prof Hörmann.

“In these patients surgery aims to improve CPAP compliance. This is mainly possible by nasal surgery of the valves, septum, turbinates, and paranasal sinuses.

“If CPAP use is de� nitively impossible or in mild OSA patients without CPAP necessity, surgery must eliminate or at least relevantly reduce OSA, but also snoring.”

Olympus recently introduced the VISERA 4K UHD

System enabling big screen surgery with 4K UHD endoscopy for ear, nose and throat (ENT) surgeons.

VISERA 4K UHD is the � rst of many products from the Sony Olympus Medical Solutions (SOMED) joint-venture. It delivers four times the resolution of HD with better light and a wider colour spectrum, promising to help surgeons operate with increased precision and con� dence.

The only fully integrated 4K imaging chain available for healthcare use, VISERA 4K UHD allows operating room personnel to get closer to the operating � eld as they view cases live on a 55-inch operative display that magni� es anatomical features to deliver more visual information to the entire surgical team. The VISERA 4K UHD System was created to address unmet needs in surgical imaging by improving the visual elements essential for Sinus surgery – light, colour and resolution – via an optimized 4K imaging chain that works seamlessly together to improve visibility.

Among the procedures identi� ed as potentially bene� ting from 4K UHD are

Prof Hörmann says that treatment is aimed at increasing the pharyngeal airway space as well as improving airflow dynamics on one hand and decreasing airway compliance by increasing pharyngeal muscle tone on the other hand. Nasal, soft palate, and tongue base surgery mainly increases airway size, whereas hypoglossal nerve stimulation directly strengthens airway patency.

“Even though surgery positively impacts sleep quality, daytime sleepiness, and cardiovascular risk its extent of improvement becomes more and more clear as shown on well-designed studies which have been published recently,” Prof Hörmann noted.

“Furthermore, considering that most surgeries inherit a compliance of 100%, mean disease alleviation is not per se inferior to conservative treatment options such as oral devices or CPAP. Therefore, therapeutic optimism and patient motivation are recommended even if CPAP is not possible,” he says. n

Surgery for OSA Olympus launches VISERA 4K UHD system for improved visualization during ENT procedures

Prof Dr Karl Hörmann, Director University HNO-Klinik (ENT Clinic), Medical University, Mannheim, Germany, will present ‘OSA Surgery’ on Day 3, Session 2, Snoring and Sleep Apnea, in Al Mawaj. He provides a brief outline of his talk.

Skull Base procedures and Functional Endoscopic Sinus Surgery (FESS), a surgical treatment of sinusitis and nasal polyps, including bacterial, fungal recurrent, acute and chronic sinus problems.

“As each specialty con� rms the improved experience that Big Screen Surgery delivers, we get closer to con� rming our predictions that this surgical modality could impact as many as 20 million procedures per year,” says Todd Usen,

President, Olympus Medical Systems Group

at Olympus Corporation of the Americas. “In the future months, we believe an increasing number of physicians will be excited

to see the bene� ts such technology advancement can bring toward improving quality of care, containing costs and enhancing patient satisfaction.”

l Big Screen Surgery with 4K HD for ENT will be demonstrated at the Olym-pus booth, at the 7th Emirates Otorhino-laryngology Audiology and Communica-tion Disorders Congress 2017 in Dubai, January 18-20. For more information, please visit www.olympus.eu/4K


TRIDENT COMMUNICATIONS

www.TridentComms.mediaTel: +971 4 334 6609 PO Box 117943 Dubai, UAE

l Specialist Writers / Editors – Medical, Financial, Travel, more… l Producers of professional on-site Show Daily newspapersl Contract Publishers

Obstructive Sleep Apnea (OSA) is one of the most prevalent disorders in adults. The estimated

prevalence of moderate to severe OSA is approximately 15 percent in men and 5 percent in women. Undiagnosed and untreated OSA is associated with high healthcare costs. Multiple OSA related health risks have been recognized, emphasizing the importance of diagnosis and treatment of the a�ected patients. Patients with OSA have increased risk for cardiovascular morbidities such as systemic hypertension, pulmonary arterial hypertension, coronary artery disease, cardiac arrhythmias, heart failure, and stroke. Patients with untreated severe OSA have a two- to threefold increased risk of mortality compared with individuals without OSA.

OSA is characterized by repetitive collapse of the upper airway during sleep. This recurrent airway obstruction is associated with hypoxemia and sleep

fragmentation. Airway obstruction often occurs at multiple levels and is thought to have multifactorial cause. It is still poorly understood why while awake individuals with OSA have no breathing problems, however, when asleep their airway loses neuromuscular tone and starts to obstruct. Continuous positive airway pressure (CPAP) is often the �rst line therapy. Despite the CPAP e�ectiveness, compliance with this therapy is low and patients often look for alternatives to CPAP treatment options.

Drug-induced sleep endoscopy The goal of sleep apnea surgery is to address the sites of the airway obstruction during sleep. Proper patient evaluation and individualized surgical treatment are important in order to achieve optimal OSA treatment results. Drug-induced sleep endoscopy (DISE) allows for examination of the nature of patient airway obstruction during sleep. Based on DISE �ndings a

Maria V. Suurna, MD, FACS, Otolaryngology – Head and Neck Surgery, Weill Cornell Medical College, New York, USA is presenting several Snoring and Sleep Apnea sessions at the EROC Congress. She provides an outline of some of the most recent developments in treatment.

Treatment for snoring

more individualized surgical procedure can be o�ered to a patient. Multiple surgical procedures have been developed to address various levels of airway obstruction by modifying soft tissues surrounding the upper airway either by tissue reduction or tissue stabilization and advancement. Upper airway surgery can be e�ective in properly selected patients, however, the surgical outcomes can be variable and are associated with painful post-operative recovery.

Traditionally sleep apnea surgery addressed patient’s skeletal anatomy and structural airway obstruction. However, non-anatomical factors, such as neuromuscular tone, have signi�cant contribution to pathophysiology of OSA. Hypoglossal nerve stimulation therapy is the newest surgical treatment option for patients with moderate to severe OSA who are unable to tolerate CPAP. Hypoglossal nerve stimulation activates genioglossus muscle leading to anterior

displacement of the tongue to open the lower pharyngeal airway. Coupling of the tongue and the palate leads to improvement of the upper pharyngeal airway obstruction. This therapy addresses the root cause of OSA and treats multiple levels of the airway obstruction without altering airway anatomy. Clinical trial and post FDA approval studies demonstrated great therapy compliance and signi�cant reduction of OSA burden.

Snoring and Sleep Apnea sessions at the CongressThere is a clear evidence of increased morbidity and high costs associated with untreated OSA. Snoring and Sleep Apnea sessions at the Congress will address the current state and future direction of OSA management. As Otolaryngologists we have a unique opportunity to o�er a comprehensive and individualized OSA treatment and make a drastic di�erence in patients’ quality of life. n

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Welcome to Dubai!

TRANSPORT OPTIONSThe Dubai Metro’s a great way to get around. You can buy a Nol Card (for use on the metro and buses) or a day pass at any Metro station. Remember don’t eat or drink on the Metro − it’s not allowed!

You can �ag a taxi down on the street or order one – call 04 208 0808 for Dubai Taxi. There is a meter and the minimum fare is Dhs12. The drivers speak English. Remember to have small change on you for taxi rides. There are pink taxis available especially for women.

Uber operates in the city as does Careem, a local and slightly cheaper version of Uber. You’ll need to download the Careem app to your smartphone or call +971 4 440 5222.

TAKE IN THE SIGHTSThe iconic Burj Khalifa in Downtown Dubai is the world’s tallest building. You can take a trip to the ‘At the Top’ observation deck, it’s best – and less expensive – to book in advance. It’s open seven days a week, from 8:30-22:00. We suggest you go up just before sundown so you get to see the city in the day and then watch the lights come as the sun goes down. For tickets visit https://tickets.atthetop.ae/atthetop

Why not enjoy a luxurious afternoon tea at the world’s only seven-star hotel, the Burj Al Arab. Booking is required. Visit www.jumeirah.com

The spectacular Dubai Fountain next to The Dubai Mall is impressive with its dazzling display − it’s a captivating water, music and light marvel! It’s free of charge to watch.

HIT THE SHOPS!There’s more than 1,000 stores in The Dubai Mall in downtown Dubai, including Bloomingdale’s, Marks & Spencer, Paris Gallery and Kinokuniya − Dubai’s largest bookstore.

You can see more than 300 sharks and lots of other marine creatures in the Dubai Aquarium on the ground level. The Dubai Mall also houses the Olympic-size Dubai Ice Rink and Reel Cinemas with 22 screens.

The Mall of the Emirates in Al Barsha has more than 500 shops and is home to the Middle East’s �rst indoor snow ski slope, Ski Dubai. You can even meet some penguins while you’re there!

Souk Madinat Jumeirah is an authentic recreation of a traditional Arabic marketplace – complete with winding waterways and abras (traditional Dubai water taxis). Souk Al Bahar is also a modern Arabic souk and has great views of the Burj Khalifa and the Dubai Fountain.

SEE THE DESERT Many visitors to Dubai take a desert safari. Most tour operators o�er this excursion. You set o� in the afternoon, drive through the dunes, watch a stunning sunset over the desert and end up at a Bedouin tent for a traditional Arabic dinner, before being dropped o� back at your hotel.

GO BACK IN TIMEDubai Museum is well worth a visit and a bargain at just Dhs3 admission. You can �nd out how Dubai came to be the thriving city it is today. The museum in Bur Dubai occupies the Al Fahidi Fort, built in the early 19th century it is one of the city’s oldest structures.

Dubai’s bustling souks are in Bur Dubai and Deira. The spice, gold and textile souks are great to wander around – and you may even pick up a bargain! The two main areas are separated by the Dubai Creek. You can hop on to an abra if you want to visit souks on the other side of the Creek − it will only cost you Dhs1.

The Al Fahidi Historical Neighbourhood, also known as Bastakiya, is nearby and well worth a visit to get a taste of what old Dubai was like. The Bastakiya has some interesting shops where you can pick presents for your family as well as tea houses, co�ee shops and traditional restaurants.

We hope you enjoy your time in this cosmopolitan city. You’re spoilt for choice with things to do in your free time. Here are a few tips and suggestions to help you get the most out of your visit.

TAKE A DIP!Cool o� at a waterpark. Wild Wadi is conveniently located next to the Burj Al Arab and o�ers 30 rides and attractions. Or enjoy the thrills and spills of Aquaventure Waterpark at Atlantis The Palm.

DINING OUTThere are many types of restaurants, but try some traditional Arabic eateries, such as Bait Al Wakeel set in a beautiful traditional house on the Dubai Creek. Ravi’s is a renowned Pakistani restaurant in Satwa, although basic it o�ers a�ordable but excellent food.

Fancy trying something di�erent? The Local House

Restaurant in the Al Bastakiya area of Bur Dubai has camel burgers and camel biryani on o�er.

Milas near the Ice Rink in The Dubai Mall serves grilled halloumi, chicken shawarma and fried ice cream. n

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