Lupine Publishers | Prevalence of Anosmia and Ageusia in Patients with Covid-19 at a Primary Health Center, Doha, Qatar

 Lupine Publishers | Journal of Otolaryngology

Abstract

Background: Loss of smell and taste are common complaints in patients with the COVID-19 disease. These symptoms may present alone or with other symptoms. It is of utmost importance to know their rates of occurrence for better controlling of the infection.

Objectives: To detect the prevalence of anosmia and ageusia in individuals with COVID-19 in Al-Wajbah Primary Health Center, Doha, Qatar.

Materials and Methods: This retrospective cohort study was conducted at Al-Wajbah Primary Health Center, Doha, Qatar. The study covered the two-month period -May and June 2020. The proven cases of COVID-19 by real-time PCR (Polymerase Chain Reaction) were enrolled in the study. Data regarding the age, gender, symptomatology including anosmia and ageusia, history of recent travel, smoking, past history of nasal and paranasal diseases (NPND), and severity of the disease were taken from the patients’ records. IBM- SPSS version 22 statistical software was used for the analysis of the data.

Results: Out of 141, 35 (24.82%) subject presented with anosmia, ageusia or both. Most of the patients were from age group >30 year (n=104, 73.76%) with nearly equal gender. The majority of the individuals were without history of recent travel (92.2%) and smoking (80.14%). Three-quarters of the patients were asymptomatic, and 51.06% with a past history of NPND. The male sex, history of recent travel, smoking, and severe course of the disease were positive, highly significant association with anosmia or ageusia. All patients returned to their normal smell and taste sensations within a mean duration of 6.89 days.

Conclusion: Loss of taste and smell were common symptomatology of COVID-19 disease. The males, recent travel, smoking, and severe course of the disease were risk factors of the anosmia and ageusia in COVID-19 cases.

Keywords: Anosmia; Ageusia; Prevalence; COVID-19; Qatar

Introduction

On the last day of the year 2019, 41 patients with pneumonia of unidentified cause were detected in Wuhan City, Hubei province in China [1]. The identification of the causative microorganism was reached from the examination of the throat swab samples from the Chinese Centre for Disease Control and Prevention (CCDC) on 7thJanuary 2020. The causative agent was named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). The World Health Organization (WHO) in February 2020 named the disease as COVID-19 [2]. During the outbreak of COVID-19 infection, there were millions of infected people and hundreds of thousands of dead all over the world, and it remains a global threat [3].The source of coronavirus was found to be in a “wet market” in Wuhan, China, where meats from both live and dead animals are sold. The animal source of coronavirus is still debated, while most officials agree that the original host of the virus was a bat. Bats have also found to host other deadly viruses like Ebola, HIV etc. The coronavirus is a family of viruses that causes diseases in several animals. Seven of the viruses within this family and the new one has made the jump across the inter-species barrier and infected human, with most causing flu-like symptoms.The attention worldwide focused mainly on the infected cases and those with direct contact with patients. The asymptomatic carriers were not being tested because of the shortage in testing kits including all the suspicious cases even in developed countries with a good health system like the US and the UK [4]. So, it is of utmost importance to evaluate the number of predictive symptoms of this disease in order to decide for a selfisolation and prevent the spreading of the infection.

At the initial times of COVID-19 disease, the symptoms of the inpatient cases in China included fatigue, fever, dry and productive cough, shortness of breath, chest compression, myalgia, diarrhea, vomiting, anorexia, headache, sore throat, dizziness, palpitations, and, chest pain [5,6]. After that, there have been an increment in the scientific studies from various parts of the world about the significant increase in the cases number presenting with loss of smell alone. Gilani et al. from Iran reported 8 patients with anosmia, 5 of them were confirmed cases of COVID-19, and the remaining 3 cases were not tested owing to the shortage of testing kits in the pandemic period [7]. A European multicenter study concluded that olfactory (85.6%) and gustatory (88%) abnormalities are prevalent symptoms in European confirmed COVID-19 cases, who may not have other nasal complaints [8]. However, these cases do not meet the criteria of self-isolation or testing [9].Anosmia and/or ageusia might present alone or in mild confirmed cases of COVID-19. It is therefore necessary to test or quarantine those individuals with these complaints.We aimed to determine the prevalence of anosmia and ageusia in patients with COVID-19 in Al-Wajbah Primary Health Center, Doha, Qatar.

Materials and Methods

This retrospective cohort study was conducted at Al-Wajbah Primary Health Center, Doha, Qatar during May, and June 2020. Patients with proven COVID-19 infection by real-time PCR on nasopharyngeal and oropharyngeal swabs were enrolled in the current study. The PCR swabs were tested at the pathological laboratory of Hamad Medical Corporation, Qatar for the corona virus using the Abbot m2000 Real Time device patented in South Africa. Subjects with incomplete data, previous anosmia or ageusia, psychological disturbances, and those who lost to follow-up (not responding to 3 telephone calls) were excluded from the study. We had 180 covid-19 positive patients during our study period, out of which only 141 patients were included in this study.ICleanhcy Specimen Collection Flocked nylon swabs-Huachenyang (HCY) made in USA was used to collect the samples from all the individuals Data regarding the age, gender, history of recent travel, presenting symptoms (fever, myalgia, cough, dyspnea, fatigability, sore throat, anosmia, ageusia, diarrhea, etc.), past nasal and paranasal diseases (NPND), history of smoking, and the severity of the disease were taken from every patient who tested positive. The patients were divided into asymptomatic and symptomatic. The severity of the symptomatic diseases was classified into [10]:

a) Mild patients complained from only low-grade fever, mild cough, and slight fatigue.
b) Moderate patients complained from high grade fever and moderate respiratory symptoms. Findings of pneumonitis were seen in chest radiograph.
c) Severe patients had dyspnea, respiratory rate 30/min, blood oxygen saturation 93%, partial pressure of arterial oxygen to fraction of inspired oxygen ratio 300 mm Hg, or CT scans showing at least a 50% increase in infiltrate volume over 24-48 hours.
d) Critical patients had respiratory failure, septic shock, and/or multiple-organ dysfunction or failure.

IBM-SPSS statistical software version 22 was used for analyzing the data. Chi-Square test was used to compare between categorially variables. One sample T-test was used for the comparison of the means. P-value was considered a statistically significant difference if it is less than 0.05.

Results

Out of 180, 141 patients fulfilled the inclusion and exclusion criteria, were thus enrolled in the study. The prevalence rates of ageusia and anosmia, ageusia, and anosmia were 8.51%, 11.35%, and 4.96 respectively as shown in Table 1. The age of the patients ranged from 3-56 years with a mean age of 35.91year±10.069. The age range of the patients without anosmia 3-56 years was wider than those with anosmia 26-53 years, and there was a high statistically significant difference between the mean ages of both groups (p-value=0.000) Table 2. The highest age group affected by COVID-19 disease was >30 years (n=104, 73.76%). The males 71 (50.35%) was slightly more than females 70 (49.65%). Most of our patients were without history of recent travel 130 (92.2%). The majority of the cases were without history of smoking (80.14%). Three-quarters of the cases were asymptomatic as shown in Tables 2 & 3. There was a positively statistically significant difference between the 2 groups of patients (with and without anosmia) regarding the following factors the male sex, history of recent travel, smokers, and severe course of the disease. While, there was no statistically significant difference between both groups regarding the age group and past history of NPND (p-value>0.05) as shown in Table 2. The age ranged of the subjects without ageusia 3-56 years was wider than those with ageusia 10-53 years, and there was a high statistically significant difference between the mean ages of both groups (p-value=0.000) Table 3. There was a positively statistically significant difference between the 2 groups of patients (with and without ageusia) regarding the following factors the male sex, history of recent travel, smokers, past history of NPND, and severe course of the disease. While, there was no statistically significant difference between both groups regarding the age groups of the patients (p-value>0.05) as shown in Table 3. All patients were showed full recovery from the anosmia and ageusia with a resolution time of 3-12 days with a mean of 6.89 days±3.056. No death was reported in our study.The following tables show the variability indices of the symptoms of the covid-19 infected patients

Table 1: The distribution of 141 patients with COVID-19 disease.

Table 2: The relationship between socio-clinical characteristics and anosmia of 141 patients with COVID-19.

Table 3: The relationship between socio-clinical characteristics and ageusia of 141 patients with COVID-19.

Discussion

Chemosensory dysfunctions are common problems during the pandemic COVID-19 crisis. Smell and taste Abnormalities (STA) were the first and the only complaints in 10% of subjects, 19% experienced STA before other classical symptoms like fever and cough, as well as 25% of the children had only STA at the time of the presentation [10]. Therefore, these disorders are indicators of early cases of COVID-19 disease and necessary for screening and infection control. Our study design included a questionnaire for patients about anosmia, ageusia, or both only to overcome the bias due to unrecognized pre-existing chemosensory hypo-function, and the difficulties in catching these hypo-functions as they are highly subjected to personal variation in response to the questioner, and the stressful conditions of the patients. The prevalence rates of ageusia and anosmia, ageusia, and anosmia were 8.51%, 11.35%, and 4.96%, respectively, making the overall prevalence rate 24.82% Table 1. Qiu et al. multi-centric case series study found that 41% of the COVID-19 patients complained from STA [10]. Speth et al. reported that the prevalence rate of olfactory dysfunction was 61.2% [11]. Paderno et al. showed that the olfactory and gustatory dysfunctions were seen in 83% and 89% of patients, respectively [12]. In a systematic review and meta-analysis study by Tong et al. found that the prevalence rate of the 10 investigations which analyzed the olfactory dysfunction in patients with COVID-19 disease was 52.73%. While nine investigations reported that the prevalence rate of the gustatory dysfunction was 43.93% [13]. The study by Chary et al. found that the rate of STA without nasal complaints was 70% [14]. The variability among various studies might be attributed to the variation in the ethnicity, sample size, and type of the sample (children or adults or both, hospitalized, nonhospitalized or both, with or without nasal symptoms, subjective, objective or both assessment, and severity of the disease).There are no proved mechanisms for the STA. There is no prior investigation that studied the possible association between coronavirus and the appearance of taste alteration [15].

The study by Zhou et al. have been confirmed that COVID-19 uses the same receptor [cellular angiotensin-converting enzyme 2 (ACE 2)] as SARS-CoV[16]. The enzyme found in the mouth, particularly on the tongue. Therefore, it is possible that the COVID-19 causes taste dysfunction same as the ACE2 inhibitors [17]. Secondly, the taste disturbance in the presence of smell abnormality is that both chemosensory senses are intimately correlated [18]. The study by Brann et al. [19] suggested that the COVID-19 virus affects the nonneuronal olfactory epithelium causing anosmia and the associated taste dysfunctions. This is the most acceptable mechanism because most of the patients with COVID-19 infection are of the mild severity, outpatient cases, and most of the STA resolve within short period [8,20]. However, a large number of a cohort investigation with long term follow-up and objective measures of the assessment are needed to assess the exact time and rate of recovery of the STA in confirmed cases of COVID-19 infection.In a study by Vaira et al. [21] found that 66% of patients reported spontaneous resolution of STA on subjective self-reported questionnaire. While, 80% of these individuals were still revealed a slight disturbance in their chemosensory functions on objective evaluation measures. The authors revealed two possible causes for this observation. Firstly, the patients might be suffering from preexisting unnoticed chemosensory dysfunctions and secondly, the patients might consider the great improvement in these senses as normal. The present study was used the self-reported questionnaire on the evaluation of the anosmia or ageusia resolution in COVID-19 cases. Fortunately, all patients showed resolution with a mean of 6.89 days. This finding was higher than what was reported in the prior investigations [8,21]. However, self-reported evaluation was a shortcoming of the present study. we recommend a further study to use objective assessment of these chemosensory alterations in COVID-19 cases.

The study found that there was an equal gender distribution, but males with anosmia and ageusia were more prevalent than females (p-value<0.05). This finding was in contrast to the prior studies [8,10-12,14,21,22]. This difference between our study and the previous studies might be attributed to the differences in the social and cultural behaviors and geographical locations. Many investigations reported that younger patients had a positive impact on the resolution of the STA [11,14,21]. Despite, approximately 75 % of the patients were more than 30 years, our study found that the age was not considered a significant factor in relation with a resolution of anosmia and ageusia (p-value>0.05). Similar finding was reported by the previous study [12].In the early period of COVID-19 disease, recent travel is considered as an important factor for the transmission of the disease. But as the time progresses and the infection becomes a worldwide disease, recent travel becomes less important. Moreover, the contact with suspicious or proved COVID-19 cases is an important way of the transmission of the infection to healthy people. Our findings revealed that recent travel had a significant factor for those patients with anosmia, ageusia or both (p-value<0.05). However, the study did not find a cause for this difference. Smoking has adverse effects on the health state of the lungs and the human immune system. Therefore, smokers are more vulnerable to acquire infectious conditions. Previous investigations showed that the smokers are twice more infected with influenza than non-smokers as well as they are associated with a more severe course of illness. Besides, there were more deaths among smokers than the non-smoker during the MERS-CoV outbreak [23]. Moreover, smoking has a negative impact factor on the severity and clinical outcome in patients with the COVID-19 disease [23]. However, our study reported low prevalence of smokers (20%) in patients with the COVID-19 disease. This finding was similar to Speth et al. study [11] who they reported that 8.8% of their patients were current smokers. The current study and Speth et al. studies didn’t find an explanation of this contradiction. Despite, the low prevalence of smokers in the present study, the smoking was a highly statistically significant association with anosmia and ageusia (p-value=0.0000).

It is obvious that the nasal and paranasal problems like nasal polyposis have a drawback on the smell because they interfere with air current from reaching the olfactory epithelium in the roof of the nose. Besides, they might give some sort of taste hypofunction. The study by Paderno et al. [12] reported that nasal congestion is a risk factor for late recovery of the STA in the COVID-19 cases. Speth et al. [11] found that patients with this disease had also allergic rhinitis (35%), chronic rhinosinusitis (1%), and asthma (12.6%). Although, half of our cases gave NPNDs, but they were not considering a significant association with anosmia (p-value=0.104). The highly significant association between the NPNDs and ageusia was found in our study. Therefore, it is logical to ask in the history about these problems when one wants to manage a case of the STA. Olfactory dysfunction is generally a first symptom in COVID-19 disease [8,11,23]. The study by Yan et al. [24] reported that the mild disease had a statistically significant association with the STA. Severe disease type is usually not associated with the STA. Therefore, the STA can act as a major positive factor for the prognosis of Covid-19 disease. However, this theory is of limited in actual clinical practice because the hospitalized patients in the critical care unit are not able to give interview due to their bad health condition [14]. Fortunately, there was no patient in our study needed admission to the intensive care unit. The current study found a statistically significant association between anosmia and ageusia and severe disease type. This finding was in contrast with Yan et al.[20]. This may be attributed to the difference in the inclusion criteria (anosmia and ageusia in our study versus STA in Yan et al. s study). The limitations of the study included small sample size, did not register the time of onset of anosmia and ageusia, and the study was not used for objective measures of assessment.

Conclusion

The prevalence of anosmia and ageusia was 24.82%. They occur mostly in the age group >30 years with equal sex distribution. Most patients without history of smoking and recent travel. Half of the patients gave a past history of NPNDs. The majority of the cases were asymptomatic. The male sex, recent travel, smoking, severe type of the disease was considered risk factors of the anosmia and ageusia. Resolution of these symptoms occurred in 100% of the involved patients with a mean resolution time of 6.89 days.

Read More Lupine Publishers Otolaryngology Journal Articles:
https://lupine-publishers-otolaryngology.blogspot.com/

 

Lupine Publishers | The Second and Subsequent Sessions of the Med-El Cochlear Implant Fitting

 Lupine Publishers | Journal of Otolaryngology

 

Introduction

In the previous article [1], we briefly described the procedure for the first switch on and the first session of fitting of the Med-El cochlear implant. After the first session, the patient has 4 programs in the speech processor with increasing comfortable levels (C-levels) in the sequential MAPs. C-levels – comfortable levels - are the maximum current levels recorded in any channel of any program. The C-levels of the second program are based on the results obtained by the program SHCHUP [2,3]. The C-levels of the first program are three steps (step - 0.2-0.3 dB) lower than the second which in most cases are comparable to threshold levels of the stapedial reflex. Sometimes they can be higher. There is the explanation of this difference [4]. In the third and the fourth programs, the C-levels are simultaneously increased in all channels relative to the C-levels of the second program by 3 and 6 steps, respectively. The optimal (working, everyday) program is determined by parents in accordance with our explanation-instruction [5], by watching the behavior of the child on different programs in different sound environments. In this optimal program, C-levels are called Most Comfortable Loudness (MCL) levels. The child uses the program with MCL levels constantly, with the exception of places with a very loud environment (cinema, concert, performance, etc.), where he can switch to the program with C-levels lower than MCL levels. This article describes a work of an audiologist during the second and subsequent sessions of the CI fitting. Most of the articles in the bibliography were written specifically for the future “Guidelines for the cochlear implant fitting”. Links to the world literature are in the references to the above-mentioned articles.

Procedure

When parents come with a child to an audiologist, they may have the following discussion:
“How are you?” we ask parents about the results.
“Everything is fine.” mom replies.
“What is the optimal program?” we question. “How did you choose it?”
“We use the third.”
“And what about the second?” we ask.
“Child asks “What? Huh?” and asks to do better.”
“And the fourth?”
“Tried it, I don’t like it”
“Wonderful.”
We talk with the child, to evaluate the work program in a live voice, sometimes slightly increasing the loudness of the conversation. N.B. MCL levels in the working program are higher than the threshold C-levels of the stapedial reflex. We connect the processor to the DIB, place the antenna for fitting on the child’s head. “Is everything all right?” We carry out telemetry, save it. The next step is to open the work program selected by the parents (in our case MAP3), write the results of the new telemetry into it, and save this program. Let us assume that its number is 21. We increase and decrease the C-level by one step in any channel and save this program with the name Work21 for future use and comparison.
We open a program with the results of recording a threshold C-levels of the stapedial reflex. It was saved with the results of tympanometry in the first fitting session [6]. We write the results of the last telemetry into it and save this program at number 22. Later we will call it the reflex program. We compare C-levels of work program 21 and reflex program 22, so that in the further setup procedure we’ll monitor the approach of the C-levels of our test program to the C-levels of reflex program 22. We need to know this approach when we conduct categorical loudness scaling (CLS) [7] during the fitting. C-levels of electrical stimuli at which threshold stapedial reflexes are recorded have a loudness rating in the GOODLOUD range.

Parameters of Stimuli and Method of Stimulation

The duration of the electrical test stimuli is 300ms. In this work, we use stimulation with single pulses and stimulation of separate channels in SWEEP mode with an interval between sequential stimuli of 300 ms, as well as sequential stimulation of all channels in SWEEP mode with an interval between stimuli of 600 ms. Such an interval is used during registration of a stapedial reflex. The amplitude of stimuli is equal to the C-levels set in each channel. An amplifier, headphones, and stepped noises for conducting SHCHUP [2,3] are ready.

Fitting

We open the working (everyday) program 21. In the further fitting process, we will change the C-levels in this program and hereinafter we will call it a test program. We reduce the MCL levels of program 21 by 2 page down (according to C-levels, it will be less than reflex program 22). We remind (we show with gestures) to the child that when we will press the keys of the keyboard, he will hear either a single signal or their sequence. We demonstrate the child a single and SWEEP stimulation through separate channels. We give a single stimulus to the middle electrode with the number 5-7, where the patient hears the middle frequencies. We observe the child and ask: “How? Heard?” The child responds. It is very possible that he will agree. If everything is normal, then we apply single stimuli to other electrodes. “Is everything all right?” We apply stimulus sequences (SWEEP) to single electrodes. “Is everything all right?” We set the interval of 600ms and apply the SWEEP stimuli sequentially across all channels. We will sometimes use sequential SWEEP stimulation of all channels with an interval of 600ms - it is interesting for the child. We remind the meaning of the pictures used in categorical loudness scaling (CLS) [7] and ask the child to show how he hears? The child shows. We ask: “Can I increase loudness?” Child agree: “You can.” We increase by 3 steps and give single and SWEEP stimuli through separate channels. “Is everything all right?” By agreement with the child, we continue the parallel increase in the C-levels of the test program, conducting single and SWEEP stimulation on separate channels. We carefully monitor the reaction of the child. We ask to show the loudness in the pictures. When approaching the MCL levels of the old work program 21, we save the test program under No. 23.

Registration of Threshold Levels of The Stapedial Reflex

Next, we proceed to the measurement of threshold levels of the stapedial reflex in accordance with the previously described procedure [6]. We set the interval between stimuli to 600 ms. We equip the child for registration of the reflex and perform tympanometry. We open the reflex program 22 and reduce the C-levels in all channels by 3 steps. We provide SWEEP stimulation with interstimulus interval of 600ms across all channels. “Is everything okay?” Starting from these C-levels, we define the C-levels where the threshold values of the stapedial reflex are marked and save the program with these threshold C-levels under the number 24. Under the number 24CCPP, we save the reflexprogram with the parameters of the tympanogram; CC-compliance, PP-pressure at the point of max compliance [6]. For the history. We dismantle the registration unit, release, and praise the child. We compare the last results of registration of threshold levels of reflex and tympanometry with similar results obtained during the first fitting session. As a rule, the threshold levels of the reflex differ only slightly by 1-2 steps in some channels. Within the margin of error. The results of an old and new tympanometry are also quite close. The child safely tolerates the procedure of reflexometry as MCL levels of test program 23 are higher than the C-levels of the old reflex program 22. Very careful measurement of threshold levels of reflex (up to one step) is not required because the final profiles of MAPs are based on the result of the SHCHUP [2,3]. Now it is enough to make sure that the results of the current registration and the results obtained during the first (or previous) fitting session are close.

Categorical Loudness Scaling – CLS [7]

We open the test program 23. We again remind the meaning of the pictures used in the CLS [7]. Previously, the child has already shown his ability to evaluate the loudness. We conduct CLS in full. We present electrical stimuli in the SWEEP mode on a single channel with an interval between stimuli of 300 ms. Decrease-increase C-levels, the child shows their loudness ratings in accordance with our changes in C-levels of stimuli. We repeat the CLS on a few channels. Praise the child.

The final stage of fitting - SHCHUP [2,3].

As you know, objective measures, for example, threshold C-levels of the stapedial reflex, play a small role as indication of the optimal MAP profile [8] and therefore it is necessary to use subjective estimates to determine the MCL levels. As shown in the study of Sherlock P, Formby C [9] a simple loudness discomfort level estimate of loudness discomfort is an effective and valid clinical measure for characterizing the “threshold of discomfort”. This is why we developed our SHCHUP method in which we use special step noises [2,3]. With help of the SHCHUP, we determine the C-levels of electrical stimuli at which the child perceives sound stimuli of 106 dB SPL at the level of discomfort threshold, i.e. these C-levels are equal to the electrical upper tolerance levels. We open the test program 23 which is slightly lower in C-levels than the MCLs of the old working program 21. According to the results of our CLS the loudness of program 23 is in the area LOUD. Step noises are ready. Turn on the amplifier. We connect the antenna of the implant to a long wire, place it on the patient’s head, and the processor under the circumoral embouchure of the phone, to which we will apply SPL-controlled step noises. We activate the test program 23 and conduct the SHCHUP in accordance with the previously described procedure [2.3]. We compare the MCL levels of the old working program 21 and the C-levels of our test program, corrected according to the results of the SHCHUP. In those channels where C-levels of a test program are lower than the MCL levels of the old work program 21 we raise C-levels to the MCL levels of work program 21. We do not change C-levels of our test program where these C-levels above the C-levels of the old work program 21. We save the test program under number 25. Now it is a new work program and C-levels slightly differ from the old work program 21. we check the new work program 25 with a live voice, sometimes slightly increasing the loudness of the conversation. Setup is complete. We release the child from the equipment. Thank him. I shake his hand.

Creating of Configuration

Child clearly chose the working program after the first session of fitting (mother’s story). The difference in C-levels between consecutive MAPs of 1-2-3-4 was 3 steps. Now we have created a new working program 25 and considering the child’s auditory experience we are making new programs with a difference between MAPs’ C-levels of 2 steps. We write the program 25 as MAP2. It is configured on the results of the SHCHUP with correction for the MCL values of the old working program 21. We create the other MAP levels like this. We reduce the MCL levels of program 25 by 2 steps (program 26-MAP1), increase the MCL levels of program 25 by 2 steps - program 27 (MAP3), and increase the MCL levels of program 25 by 4 steps (program 28 (MAP4). We create a new configuration with these MAPs. Current thresholds levels (t-levels) are set at 10% of C-levels. You can set t-levels less than 10% [10]. It should be noted that for most children, the entire procedure described here is performed within one hour. And all the SWEEP, CLS, and SHCHUP methods are executed successfully. Parents are sent to evaluate new programs observing the child’s behavior on all programs for 2-3 days. The absolute goal is to provide the patient (child) with a comfortable program which ensures maximum performance [11]. If parents and the child choose the working program that is on MAP3, then you can create a new program 29, which is 2 steps higher than program 28 and then the last configuration will be as follows: MAP1 (program 25), MAP2 (program 27), MAP3 (program 28) and MAP4 (program 29).

As we wrote earlier, parents can adjust the MCL levels of the work program using the (+) and (-) buttons of the remote control. If subsequent fittings are made in other centers by another audiologist, then proceed as follows. Perform telemetry, ask which program is working, open it and at the suggestion of “Maestro” to change telemetry, agree and write the new values of the resistance of the electrodes in the working program. Save this program without changing the values of the MCL levels - only with the new telemetry. Then make the necessary adjustments to the threshold and C-levels in the work program and save it. From it, make the program quieter (MAP1) and louder (MAP3) and record the new working program as MAP2. Create a new configuration in which the old working program is written as MAP4. Explain to parents the position of programs on the buttons on the remote control. Give parents an instruction to compare the behavior and perception of the child on the previous and the new created working program and choose the best one. Should not be thoughtlessly (or thoughtfully?!) leave-save the program on the fourth MAP, which the child may not have used – not all patients choose the program at fourth MAP as optimal-working program.

Read More Lupine Publishers Otolaryngology Journal Articles:
https://lupine-publishers-otolaryngology.blogspot.com/