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OBJECTIVE Cultural adaptation of the tinnitus handicap inventory questionnaire to the Moroccan dialect version. METHOD We conducted a prospective study over a 3 years period (January 2017-January 2020) in the Otolaryngology Department of Casablanca University hospital. Translation was produced by a forward-backward procedure with analysis of the psychometric properties of the Moroccan version of the tinnitus handicap inventory. RESULTS The final Moroccan version of Tinnitus Handicap Inventory (THI) was given to 83 otosclerosis patients suffering from tinnitus. They filled the questionnaire twice before surgery and 1 year after surgery.The item-total correlations are all statistically significant (p

Melkersson-Rosenthal syndrome (MRS) is a rare disease, with unknown etiology characterized by oro-facial oedema, fissuring tongue and peripheral facial palsy. The mainstay treatment is corticosteroids. We report the case of a 38-year old female, who presented six recurrent episodes of left peripheral facial palsy associated with simultaneous oedema of the median frontal area, treated successfully by short course oral corticosteroids with neuromuscular facial re-education. However, the recovery of the last episode was incomplete and the patient kept a left House-Brackmann grade II facial palsy at six months. The median frontal area was slightly inflammatory, being the location of simultaneous repetitive oedema and the tongue was fissured. These cardinal symptoms realise the complete triad of Melkersson-Rosenthal syndrome (MRS). The histopathological examination of the lip biopsy showed lymphocytic inflammation around the blood vessels. Since the residual facial palsy was graded as mild dysfunction, the frontal oedema fully recovered and the fissured tongue was not painful, the treatment consisted on appropriate neuromuscular re-education. The 6 months follow-up showed no recurrence with a stable grade II left facial palsy. We present this case to supplement the rare literature data concerning the management of this rare entity. Patients should be prepared to the risk of recurrent episodes with longer duration of symptoms and more incomplete recoveries, which may indicate other therapeutic options.

Various pathological entities may manifest on imaging as unilateral or bilateral nasal and/or sinus opacity. The vast majority is represented by inflammatory pathologies, tumors are rare, but they are dominated mainly by benign tumors. Malignant diseases are uncommon, accounting for 3% of tumors of the head and neck. Advances in imaging using preoperative computed tomography and magnetic resonance imaging have been significantly marked in the diagnostic approach to sinonasal pathologies. Surgical modalities are influenced by preoperative knowledge of the nature and topography of the tumor. The aim of this work is to describe the clinical, radiological, and anatomopathological characteristics of sinonasal pathologies expressed by unilateral sinonasal opacity in imaging, to identify the clinicoradiological variables likely to predict malignancy, and to make a correlation between the radiological images and the anatomopathological result.

Skull base osteomyelitis (SBO), also referred to as malignant otitis externa (MOE) in its typical form, is usually a complication of otitis externa and severe uncommon and life-threatening condition requiring early diagnosis and long-term treatment in order to avoid its neurologic sequelae. We report the case of 69 years old female with a history of uncontrolled type 2 diabetes, who presented refractory and chronic right-sided purulent otorrhea with temporal headaches for 6 months, treated with no improvement by multiple attempts of ambulatory empiric therapy. After the appearance of grade III facial palsy and painful swelling in the right periorbital and zygomatic areas, the patient consulted in our department where a CT scan showed massive cortical and trabecular destruction of the right petrous bone and the mastoid extended to the lateral orbital wall, the zygomatic arch and the greater sphenoid wing realising extensive osteomyelitis of the skull base and the lateral face. The treatment was started immediately based on intravenous broad-spectrum antibiotics. Despite aggressive long-term treatment, the patient passed away, underlying the increased SBO morbidity and mortality secondary to delayed diagnosis.

Laryngotracheal stenosis (LTS) is a severe condition with a high morbidity rate, described as the narrowing of the upper airway diameter. The etiology of acquired LTS is dominated by prolonged tracheal intubation. The diagnosis is based on endoscopic examination and computed tomography scan imaging providing an exact analysis of the lesion, with precise measurements.We report a descriptive retrospective review based on the analysis of the medical records of a cohort of 18 patients, treated between January 2015 and January 2018 for an acquired LTS.The results showed predominance in young males. The majority (73%) was hospitalized in a reanimation unit under tracheal intubation while the others (27%) underwent a tracheostomy. The location of the stenosis was tracheal in 69% of the patients, laryngeal in 23%, and laryngotracheal in 8%, and the degree of obstruction exceeded 70% in 11.2%. The endoscopic treatment was based on dilatation and endoluminal calibration by the Montgomery T-tube in 77.7% of our patients, circumferential resection by CO2 laser in 11.1%, and endoscopic posterior cordectomy in 11.1% of the cases. The surgical treatment relied on the resection of the stenosis followed by T-tube calibration in 61.1% of our patients, the resection with a termino-terminal anastomosis in 11%, and supraglottic partial laryngectomy in one patient. The follow-up showed major improvement in the clinical symptomatology, but the biggest challenge in LTS remains the occurrence of restenosis.LTS is a severe condition and needs to be always considered in patients with inspiratory dyspnea and a medical history of tracheal intubation. It requires exhaustive endoscopic and imaging exploration with multidisciplinary management and long-term follow-up to prevent and detect the early signs of an eventual recurrence.

The aim of this study was to translate and verify the psychometric properties of the CES (Chronic Ear Survey Score) in the Moroccan Arabic dialect as well as the evaluation of the quality of life of patients suffering from suppurative chronic otitis media. A cross-sectional study was carried out between 1st April 2016 and 10 January 2017 in ENT department of the 20 August hospital Casablanca. The data were collected using an anonymous questionnaire administered by the physician. The CES scale used has been translated according to international recommendations. Internal Reliability was evaluated by the Cronbach alpha coefficient and validity was calculated through the Spearman coefficient of correlations. Statistical analysis was done using SPSS 20.0. A total of 107 patients were enrolled in the study with an average age of 35 years (standard deviation = 13 years) with a sex ratio of 0.70. About 35.5% of patients perceived their disease as severe. The mean CES was 48 (standard deviation = 15) indicating a significant decrease in the quality of life of patients suffering from CSOM. Good internal reliability was noted (alpha = 0.72). CES scores increased significantly with perceived severity (p

Squamous cell carcinoma (SCC) of the tongue is one of the most common cancers in the oral region, most frequently associated with lymph nodes metastases which influence the most the prognosis. The identification of predictive factors of occult cervical nodal metastases for N0 tumors will allow to adapt the treatment to the patient, avoiding over or under management. From 2014 to 2019, a cohort of 26 patients with SCC of the mobile tongue was reviewed by analysing the medical history, the epidemiological and clinical parameters, the tumor sites, aspects, diameters, depths of invasion, pathological degree, degree of differentiation, T classification and results of neck dissections. The incidence of occult cervical nodal metastases was up to 26,92% and a significant correlation was only found with the tumor depth invasion and the muscular invasion (p, Highlights • The tongue is the most deadly location of oral SCC and most commonly associated with nodal metastases. • The depth of invasion and muscular infiltration seem to influence the occurrence of nodal metastases. • Elective dissection (level I, II, III) with tumour excision is the effective treatment of N0 SSC of the tongue.

Tympanoplasty is one of the most performed procedures in ENT. The aggressiveness of its microscopic approach has led otologists to adopt the endoscopic approach as a less invasive alternative. The purpose of this work is to appreciate the advantages and disadvantages of this surgical technique. We conducted a prospective descriptive cross-sectional study on 20 interventions within the ENT department of August the 20th 1953 Hospital of Casablanca from April 2019 to June 2019. The average age of operated patients was 36.3 years. Perforations were unilateral in (71%) of the cases with a predominance of the anterior (29%) and subtotal (36%) locations. The tympanoplasties were performed by 3 different senior otologic surgeons, and were left in (57%). The mean operating time was (59.5 min) and the mean anesthesia duration was 75.1 min. Intraoperative vision allowed us to fully visualize the margins of all perforations (100%) and anatomical structures of the middle ear in almost all interventions. The first procedures carried out were filled with difficulties whose management of intraoperative bleeding was the main one in (42.8%) of the cases. (57%) procedures were described as easy. No complication was detected intraoperatively or immediately postoperatively. Endoscopic tympanoplasty has several advantages, including: Minimally invasive approach to the middle ear; panoramic perioperative vision; Gain of operating time; decrease in the duration of anesthesia; Valuable educational tool; postoperative comfort; Decrease in hospital stay and early return to daily activities; Better aesthetic rendering; cost and transportability. However, we also note a number of disadvantages of endoscopic tympanoplasty, particularly: performing the procedure with one hand; difficulty passing through the EAC; 2D vision that alters the perception of depth; management of intraoperative bleeding; fogging; learning curve.

Background Intraparotid facial nerve neurofibromas are benign neoplasms, extremely rare, difficult to diagnose and to manage. Only three pediatric cases have been reported in the literature. Case presentation We report the 4th case of a 7-year-old child admitted for a parotid mass without facial palsy, for whom the surgical indication was the increase in volume of this mass, as well as the aesthetical impairment, the surgical exploration found the tumor attached to the lower branch of the division of the facial nerve. The excision of the mass was performed with the sacrifice of the inferior branch of the facial nerve, the trunk and the upper branch of the facial nerve was preserved, the pathological study was in favor of a plexiform neurofibroma. The patient has presented postoperatively a grade 5 facial palsy in the inferior territory of the facial nerve with a slight recovery 1 year after surgery. Conclusion Even though plexiform neurofibromas in the parotid gland are extremely rare, and their diagnosis are not often primary evoked in front of any growing mass of this region, the surgeon must keep in mind the existence of these neoplasms as a differential diagnosis of a parotid tumor., Highlights • Neurofibromas are non-encapsulated tumors that grow inside the nerve that surrounds each nerve fascicle and lengthen them, locally invasive, non-metastatic, highly vascularized, and slow-growing. • Our patient is the 4th isolated case of intraparotid facial nerve plexiform neurofibroma without neurofibromatosis type 1. • Preservation of the nerve during surgery is almost impossible and its excision can lead to significant morbidity. • It is essential that the surgeon keep in mind the existence of these tumors as a differential diagnosis of a parotid tumor.

Background lymph node tuberculosis is the most common form of extra pulmonary tuberculosis. Although diagnosis is usually difficult, therapeutic management remains a challenge and a subject of national and international debate. Materials and methods the medical records of patients with cervical lymph node tuberculosis who were treated at 20 August Hospital, Casablanca, Morocco, between May 2017 and November 2018 were reviewed. The results of the treatment were analyzed retrospectively. The aim of our work was to identify all causes of medical treatment failure in cervical lymph node tuberculosis, and to propose indications for the use of surgery in cervical lymph node tuberculosis in Morocco. Results Out of a total of 104 patients, the mean age was 24 years, the sex ratio was 0.51 (women: 66.3%), twenty (19.2%) patients received medical treatment alone, and 84 (80.8%) patients required medical and surgical treatment. Surgery was required when the size of the lymphadenopathies was greater than or equal to 3 cm (p = 0.005), when the patient presented with an abscess and/or fistula(p = 0.005), when the patient presented with resistance to antibacillary drugs(p = 0.032), or developed a paradoxical upgrading reactions (p = 0.001), or when the patient had a recurrence of lymph node tuberculosis(p = 0.008) on multivariate analysis. Conclusion antibiotic therapy remains the main treatment for all patients in lymph node tuberculosis, but the results of our work show the value of surgery in some indications., Highlights • Our goal in this study was to identify causes of the failure of medical treatment in lymph node tuberculosis, to propose indications for surgery. • The study has compared patients who were reported to be cured under medical treatment alone after a lymph node biopsy, and patients who required surgery after failure of medical treatment in lymph node tuberculosis. • We recommend surgery when we have: adenopathies ≥3 cm in diameter, abscesses, and fistulas, recurrence, resistance to antibacillary drugs, and paradoxical upgrading reaction.

The relationship between the location of otosclerotic zones and hearing thresholds has been evaluated in several studies and has generated different conflicting reports. This study was carried out in order to evaluate the relationship between otosclerotic zones extension on CT scan and pure tone audiometry (PTA) thresholds, before and after stapedotomy. Materials and Methods: 108 patients with a positive surgical diagnosis of otosclerosis, operated by the same surgeon, were enrolled in this retrospective study, performed in a tertiary referral hospital between 2015 and 2018.PTA thresholds were significantly poorer in cases of extensive otosclerosis (peri cochlear, peri vestibular, or internal auditory canal hypodensities, p = 0,001). However, for cases with hypodensity extending to the endosteum of cochlea (Type III), we have noted a significant improvement in postoperative PTA thresholds (Mean AC (air conduction) = 32,8 ± 8,16/62,97 ± 12,28 dB), Mean BC (bone conduction) = 18,3 ± 8,56/26,25 ± 15,93 dB). Conclusions: In our study, extensive and multifocal otosclerosis lesions had a statistically significant negative impact on postoperative AC and BC threshold; however, type III lesions tend to be associated with a very good prognosis.

Cystic lymphangiomas are rare dysembrioplasias that occur mostly in children. Although benign, these tumors remain potentially life-threatening, due to the possible compression of the upper airway. The management of cystic lymphangiomas is still somewhat controversial, with surgery generally being the first-line treatment.17 patients were included in this retrospective study, all aged less than 18 years old and treated for head and neck cystic lymphangiomas at our department between 2007 and 2017. All these patients had received surgical treatment alone. The relevant data were analyzed with SPSS software.17 patients were included, with a sex ratio M/F of 1,4, and an average age of 4 years old. Complete resection of the tumor could only be completed in 12 patients. No postoperative complications were observed in our series. All the patients were followed for a minimum of 2 years after treatment.Cystic lymphangiomas are rare tumors of mysterious origins. The main symptom is swelling of the affected area. In our series, the results of the surgery were promising and consistent with results reported in the literature. A follow-up study with a larger population could be interesting, to further examine potential prognostic factors.

Introduction The cervical lymphoepithelial or branchial cleft cyst are benign dysembryologic cystic tumors developing in the anterolateral region of the neck. They are relatively uncommon anomalies. The aims of this study are to analyze the anatomoclinical features and to discuss the modalities of care for the management of this disease. Presentation of case We report a case of a 70 years-old woman who was admitted to our department with a complaint of painless mass in the right supraclavicular region. Clinical examination and radiological investigations found a mass compatible with cervical cyst. Treatment consisted of the complete resection of the cyst. histopathological examination found a Cervical lymphoepithelial cyst. Conclusion The cervical lymphoepithelial can be easily misdiagnosed. It is imperative that clinicians make an accurate diagnosis for appropriate treatment (that is, surgical excision)., Highlights • The cervical lymphoepithelial or branchial cleft cyst are relatively uncommon anomalies. • The branchial cleft cyst, or cervical lymphoepithelial cyst, is a pathological entity whose etiology has yet to be delineated. • The cervical lymphoepithelial can be easily misdiagnosed. • The surgery is the treatment of choice.

Highlights • Cervical lymph node SmCC as a primary tumor’s location, was never described in the literature according to what we know. • AC neuroendocrine carcinoma of the tonsil has never been described in the literature up to our knowledge. • A review of the literature was performed, indicating treatment and disease’s prognosis. • In 2012, the 2005 WHO classification of neuroendocrine tumors of the head and neck region was modified by adding the ranges of the Ki-67 and suggested that LCNEC should be considered a distinct disease entity and be separated from AC., Introduction Primary neuroendocrine carcinomas are uncommon head and neck malignancies. Their classification is still debated. We report four cases of unusual primary locations of neuroendocrine carcinomas of head and neck region emphasizing two entities and rare sites that were never described in the literature to the best of our knowledge. Presentation of cases We reported four different cases of neuroendocrine carcinomas (nasal cavity, larynx, lymph nodes and tonsil) treated in our institution. The diagnosis was made by biopsy and confirmed by Immunohistochemical study. We underscored 2 atypical and rare entities in their location and anatomo histopathological type. Chemotherapy and radiotherapy were proposed for patients with nasal’s and laryngeal locations. This latter had also undergone surgery. For lymph node location, the patient received decompressive radiotherapy alone. The patient diagnosed with neuroendocrine carcinoma of the tonsil didn’t get any treatment except initial tonsillectomy for diagnosis purposes. Regarding the evolution in our case series, 2 patients had a relapse with local and regional metastasis. Among the 4 patients, 50 % passed away, one is still alive with deterioration of his general status and one is lost to follow-up and refused undergoing further investigations. Discussion There is confusion in the literature regarding the classification of neuroendocrine carcinomas. According to the 2005 WHO, these lesions, can be subdivided into TC, AC (including LCNEC), SmCC, combined SmCC with nonsmall cell carcinoma, and paraganglioma. Their treatment is still debated. Through an overview of the literature, we have gathered the main studies and 2 meta-analysis summarizing the mainstay treatment and disease’s outcome. Conclusion Neuroendocrine carcinomas of head and neck region are aggressive tumors with poor prognosis, low incidence and their diagnosis is not obvious. The treatment protocol depends on the type, the site of the lesions, and metastasis status. It’s still not well codified.

A cystic mass that rapidly increases in volume in a dangerous anatomical region, notably the supraclavicular region, which contains important neurovascular elements, must be considered at high risk. A vascular study is mandatory before biopsy. Neoadjuvant chemotherapy can be a treatment option in high‐risk synovial sarcoma.

Introduction Abnormalities of the fourth branchial arch are less common than those of the second arch and usually present with inflammation of the left thyroid lobe. Case presentation We report the case of a 10 years old girl who presented to our department with recurrent cervical cellulitis, and who was diagnosed, upon endoscopic exploration, with a left sinus pyriform fistula. The patient was treated using mini-invasive surgery by electrocoagulation, with good clinical outcome. Conclusion Branchial arch malformations are rare congenital malformations. The diagnosis is mainly based on clinical examination, imaging and, endoscopic investigations. The conservative attitude may be the treatment of choice, especially if the cervical mass is not well individualized., Highlights • The fourth arch anomaly is very rare, and few reports are available in the literature • This congenital anomaly manifests as recurrent cervical abscesses or acute suppurative thyroiditis in most cases. • Recently, minimally invasive endoscopic surgery has revolutionized the management of the pyriform fossa sinus in children.

Head and neck paragangliomas are rare vascular tumors derived from the paraganglionic system, located at the carotid body, jugular vein, tympanic cavity and vagal nerve. From 2010 to 2020, a cohort of 26 patients divided in two groups, 15 with cervical paragangliomas and 11 with temporal bone paragangliomas, was reviewed by analysing the medical history, the epidemiological and clinical parameters, the imaging results and classification, the modality of treatment and outcome. Cervical paragangliomas present as firm and pulsatile mass with the characteristic aspect of “salt and pepper” on MRI T1 weighted sequences. The most common type on Shamblin classification was the type II. Total surgical resection was performed in 93,33% of cases. The sensitivity of MRI in the diagnosis of vagal paragangliomas was up to 75%, with a specificity of 90,91% and the correlation of the MRI results and the findings of surgical exploration is significant with p ⩽ 0.02. Temporal bone paragangliomas appear as pulsatile mass behind the tympanic membrane, causing variable hearing loss in 90,90% of the cases. The facial nerve is the most frequently affected cranial nerve, in 36,36% of the cases. The main type according to FISH classification is the type B. Embolization was performed in all type C tumors. Surgery was the first line treatment while the inoperable patients were considered for radiotherapy. The aim of this study is to report the main clinical features of head and neck paragangliomas, the imaging tools and findings evaluating their sensitivity and specificity and the treatment protocol and outcome., Highlights • Head and neck paragangliomas are rare, usually benign hypervascular tumors, characterized by slow growth over time. • Typical clinical manifestations and imaging evaluation should be considered together to establish the treatment protocol. • MRI is efficient to detect vagal paragangliomas. • Surgery provides excellent control of the tumor while radiation therapy is considered for surgery contraindication.

Esophageal perforation following an impacted foreign body (FB) is a rare and potentially life-threatening condition. Early clinical suspicion and imaging are important for a targeted management to achieve a good outcome. Endoscopic extraction of esophageal FB is a good and safe treatment alternative while the surgical procedure remains a necessary option for many patients. We present the case of a 50 years old woman, with no relevant medical history, who accidently ingested a chicken bone during a meal causing mild dysphagia. The patient consulted immediately but was reassured after normal clinical examination. We received the patient 9 days later with severe dysphagia and cervicomediastinal cellulitis. The cervical CT scan showed the significant collection and the FB impacted in the cervical esophagus wall. A first endoscopic exploration drained the pus and allowed the placement of a nasogastric tube. However, the removal of the FB required an open cervical surgery with the evacuation of the collection and the suture of the esophageal perforation followed by the placement of a drainage tube. The patient medical state improved rapidly and no further incidents were noted. The diagnosis of esophageal FB should be meticulous in order to avoid such life-threatening complications., Highlights • Esophageal perforation secondary to an impacted foreign body is a rare and potentially life-threatening condition. • Early clinical suspicion and imaging are important for a targeted management. • Endoscopic extraction of esophageal foreign body is a good and safe treatment alternative that should be considered first. • Surgical procedure, even more invasive, remains a necessary option for many patients.

The nasolabial cyst is a rare, non-odontogenic, soft tissue cyst that develops submucosally in the anterior nasal floor. This cyst accounts for 0.7% of all non-odontogenic cysts. Bilateral nasolabial cyst represents only 10% of the cases. This cyst originates from the remnants of embryonic nasolacrimal duct tissue. Generally, patients present with swelling and facial deformity and rarely local pain. The definite diagnosis should be based on clinical, radiological and above all histopathologic findings. The treatment is enucleation of the cystic tissue. Following is a case report of a bilateral nasolabial cyst in a 40-year-old woman who presented with a chronic nasal obstruction.

Fibrous dysplasia (FD) is a rare congenital non-malignant bone tumor that affects the skeletal system development and interferes with normal bone formation. It’s non-hereditary and its exact cause remains unknown. The condition is characterized by fibro-osseous connective tissue gradually replacing normal bone and marrow leading to the formation of bone that’s fragile and prone to fractures. It is not uncommon for the disease to affect craniofacial bones but the sinonasal cavity involvement remains extremely rare. We presented a case of an 80-years-old male patient who reported nasal obstruction and a long-term swelling in the upper jaw that dates back over 20 years resulting in facial deformities and unilateral proptosis from compression exerted on the eye by the tumor. The patient reported having taken drugs to treat symptoms especially nasal congestion. But his dyspnea persisted. Physical examination, computed tomography (CT) scan and MRI have been elaborated and discussed. And on last resort, surgery was recommended.

Highlights • Leiomyosarcoma of the larynx a very rare malignancy. • Leiomyosarcoma of the larynx may represent a serious diagnostic challenge. • No therapeutic protocol has been established yet. • Treatment modalities depends on size, location, extension of the tumor. • The prognosis is conditioned by the quality of surgical excision and the occurrence of recurrence and metastases., Introduction Leiomyosarcoma is a rare mesenchymal tumor that originates from smooth muscle cells. Head and neck LMSs represent only 3% of all leiomyosarcomas with less than 50 cases of laryngeal LMS reported in the literature till now. Case presentation We report a case of 50-year-old male presented at our ENT department for a chronic hoarseness. Clinical examination investigations found small submucosal lesion in the right vocal cord. Treatment consisted of CO2 Laser excision of the lesion. The evolution was marked by the appearance of a tumefaction in the left submandibular region and a severe dyspnea requiring an emergency tracheotomy. Paraclinical examination investigations found a supraglottis–glottis-subglottis tumor. A total laryngectomy with bilateral functional neck dissection was performed and the histopathological examination found a laryngeal leiomyosarcoma. Conclusion LMS of the larynx a very rare malignancy. The accurate diagnosis is histological. Surgery is the mainstay of treatment. Its prognosis is correlated to local recurrence and distant metastases.

Introduction—Although auditory brainstem response (ABR) testing is among the most frequently used investigations in pediatric audiology and it often requires sedation or general anesthesia. In recent years, melatonin has been successfully used as an alternative way of inducing sleep, particularly in children undergoing magnetic resonance imaging (MRI) or electroencephalography (EEG). Purpose—To assess the effectiveness of orally administered melatonin as an alternative to sedation or general anesthesia during ABR testing. Method—In total, 33 children with suspected hearing loss underwent ABR tests in melatonin-induced sleep. Each patient received an initial dose of 5 mg, which was re-administered in case of failure to obtain sleep. Click-induced ABR tests were performed on both ears. Results—ABR tests were successfully performed in 72.7% of the patients. The average total length of time needed to obtain sleep and complete the ABR testing was 45 min. There was no significant difference between the patients who completed the examination and those who did not in terms of age or psychomotor development. There was a statistically significant association between receiving a maintenance dose and successful completion of the test (p &lt, 0.001). There was also a significant connection between the degree of hearing loss and the success rate of the ABR tests (p &lt, 0.001). Conclusions—Melatonin-induced sleep is a good and safer alternative to anesthesia to perform ABR testing in young children. It is easily administered, tolerated by the patients, and accepted by parents.