Introduction: Professional identity formation requires students’ ability to reflect, which can be supported by constructive feedback from teachers. Feedback practice faces many challenges, including those related to sociocultural aspects. Feedback can be optimised by implementing a model suitable to the attributes of students, teachers, and the clinical environment. This study aimed to develop a suitable feedback model and test its effectiveness in promoting reflection. Methods: The model was designed based on the theoretical framework and identified feedback-related attributes in FMUI. Expert reviews and cognitive interviews were conducted before the model was tested. The model’s effectiveness was tested using a quasi-experimental design involving 74 students in the Paediatric Module. Students were asked to reflect on their mini-CEX experience after receiving feedback from teachers, and the depth of reflection was compared between students in the intervention and control group. The depth of reflection was measured using Kember scoring, and bivariate analysis was conducted using SPSS 20.0. Results: The model consists of 5 steps including: Rapport building, Acknowledge students’ strengths, Identify aspect(s) that need improvement, Share teachers’ experiences, and Establish a plan to improve. Deep reflection was more frequently found in the intervention group. Mann-Whitney test showed that the difference between groups was statistically significant (Z=2.964, p=0.003), indicating that reflection in the intervention group was deeper than the control group. Conclusion: The feedback model formulated based on feedback-related attributes in FMUI was named the RAISE model. Upon testing, students receiving the model could reflect more deeply compared to those receiving the standard model.

INTRODUCTION:This prospective cohort study aims to investigate the hearing dynamics and the changes in the central auditory pathways in infants with congenital cytomegalovirus (cCMV) infection. MATERIALS AND METHODS:cCMV-infected neonates aged ≤3 weeks old were recruited and underwent clinical and laboratory tests to detect viremia and symptomatic infection, hearing examinations at three and six months of age, and radiological imaging of brain auditory pathways using diffusion tensor imaging. RESULTS:From 26 eligible infants (52 ears), we detected symptomatic infection in nine (34.6%), viremia in 14 (14/25; 56.0%) and sensorineural hearing loss (SNHL) in 14 infants (53.8%). We observed 40 ears (76.9%) with unstable hearing thresholds, 17 (42.5%) of which fluctuated. Hearing fluctuation and progressivity were more common in symptomatic infection (66.7% vs. 14.7%, p<0.001; and 38.9% vs. 2.9%, p=0.002; respectively). A substantial proportion of ears had reduced fractional anisotropy (FA) in the medial geniculate body (59.1%), superior olivary nucleus (45.5%), trapezoid body (40.9%), auditory radiation (36.4%) and inferior colliculus (31.8%). Symptomatic infection was associated with an increased FA in the medial geniculate body (mean difference, MD: 0.12; 95% Confidence Intervals, 95%CI: 0.03, 0.22) and viremia in the inferior colliculus (MD: 0.09; 95%CI: 0.02, 0.16). An FA in the inferior colliculus of ≥0.404 had a sensitivity and specificity of 68.8% and 83.3% in predicting viremia (area under the curve 0.823; 95%CI: 0.633, 1.000, p=0.022). CONCLUSION:SNHL along with its fluctuation and progression are common in cCMV-infected infants. cCMV infection may induce structural changes in the central auditory pathway.

Approximately 79.8% of nursing students in Indonesia experience moderate stress while studying in a clinical environment. Resilience refers to the ability to rise from negative experiences when faced with difficult situations. This study aims to determine the optimisation of the ability to write reflective journals with constructivism theory approaches to increase the resilience of nursing students. This study, with a quasi-experimental one-group pre-test and post-test design, was conducted on 57 students. The results revealed a significant increase in the ability to write reflective journals and resilience level (p = 0.000), as well as a significant relationship between the ability to write reflective journals and an increase in the resilience of nursing students studying in a clinical environment (p = 0.000, r = 0.829). The constructivism theory views knowledge as something built in a person’s mind based on their interpretation of their experiences. This theory was applied in this study by optimising the experiences of respondents who had taken various experiences in the previous clinical environment to serve as material for self-reflection. Workshops using the constructivist theory approach improve nursing students’ resilience and ability to write reflective journals.

Background: Otitis media with effusion (OME) is the presence of middle ear fluid without acute ear infection signs or symptoms. OME is one of the causes of hearing loss. Chronic asymptomatic OME could be managed by careful waiting for 3 months because it is a self-limiting disease. During surveillance, autoinflation is a beneficial intervention with minimal side effects and high adherence. Objective: To evaluate the effectiveness of autoinflation to improve hearing in otitis media with effusion and hearing loss. Methods: Literature searching was conducted through PubMed, Cochrane, ScienceDirect, Scopus, and EBSCOHost with inclusion and exclusion criteria. The articles were selected and underwent critical appraisal using rapid critical appraisal of systematic review and level of evidence by the Oxford Centre for Evidence-based Medicine in 2011. Result: One systematic review and meta-analysis, or RCT, met the criteria. This article revealed a pooled estimate of RR 1.74; 95% CI [1.22-2.50] with a Z-score of 3.02 (p=0.0025). This result showed substantial significant (p=0.01) heterogeneity (I2=69%). Conclusion: OME patients with hearing loss who performed autoinflation >1 month had a 1.74 times greater chance of achieving hearing improvement than controls. Autoinflation with the Politzer method gives significant results in improving hearing loss. Large-scale RCT research is recommended to evaluate the effectiveness of autoinflation with the Politzer method or other available methods in OME patients with hearing loss.

PURPOSE:The practice of feedback is influenced by the characteristics of students, teachers, and the clinical environment. Most studies on feedback have been conducted in Western settings with different sociocultural backgrounds to Indonesia. This study explores feedback in Indonesian clinical clerkship using a sociocultural lens and aims to provide an exemplar of adaptive practice relevant to non-Western settings.METHODS:This qualitative study was conducted using an interpretive phenomenology approach. Data were collected through focus groups with students and teachers and interviews with program coordinators. Data were transcribed verbatim and grouped according to data sources, coded, and analyzed thematically.RESULTS:Themes identified from the focus group discussions and interviews were categorized as student, teacher, and environmental factors. Student factors include dependence on feedback, tendencies to use a group approach, difficulties recognizing social rules, a perceived lack of resilience, and tendencies to doubt praise. Factors related to teachers include a high level of expertise, being extremely busy, having a strong commitment, and being unsure of students' acceptance of feedback. Clinical environment factors influence interactions between teachers and learners and include high power distance and collectivistic values. A safe environment is needed to ensure effective feedback interactions.CONCLUSION:High power distance, collectivism, and generational characteristics of students likely impact feedback practice in clinical settings. Designing a safe environment is essential for effective feedback practice.

Background: The varying degrees of hearing recovery in idiopathic sudden sensory neural hearing loss (ISSHL) patients indicate the need of model to predict no hearing recovery. We aimed to aid in the counseling of ISSHL patients about their recovery chances by developing a simple clinical scoring system to predict no hearing recovery using clinical information available at first visit. Methods: A retrospective cohort study, using medical records was conducted from January 2017-May 2019 in Cipto Mangunkusumo General Hospital and Proklamasi Ear, Nose, Throat, Head and Neck (ENT-HN) Surgery Specialized Hospital in Jakarta, Indonesia. The outcome measure is no hearing recovery and we built the prediction score developed based on multiple logistic regression analyses and tested for discriminative ability. There were 183 adults unilateral ISSHL patients included in the study. Results: The proportion of no hearing recovery was 56%. The independent predictors were older age 30-60 years and >60 years old (Odds Ratio 4.0; 95% CI 1.4-11.8; p=0.012 and OR 5.3; 95% CI 1.5-18.4; p=0.008, respectively) as compared with 18-<30 years old, later onset (onset 15-60 days and >60 days had OR 5.4; 95% CI 1.7-16.9; p=0.004 and OR 12.6; 95% CI 2.9-54.6; p=0.001, respectively, as compared with onset < 3 days), and presence of vertigo (OR 2.3; 95% CI 1.1-4.6; p=0.026). Prediction scores ranged from 3 to 12, with three categories for age, four for onset, and two for the presence of vertigo. The predictions showed adequate calibration and good discriminative ability (AUC 0.77). Conclusion:Using information of age, onset and presence of vertigo at first visit, ISSHL patient with increased risk of no hearing recovery can be identified with moderate accuracy. This prediction model could help clinician in predicting patients’ prognosis.

The risk of face seal leak while using N-95 respirators is experienced by health workers and thus failing fit test are quite common. Finding solutions to overcome face seal leaks is crucial; one of which is by sealing the N-95 respirator. The seal used in this research was Tegaderm® a transparent film dressing or a plastic tape which is known to have the advantages of strong adhesion, high level of pore density and standardized medical grade. This study tries to determine the effectiveness of plastic tape adhesive on the N-95 type 1860 respirator in overcoming face seal leak qualitative fit test using Bitrex immediately after being worn and after 4 h of using it. The study used a quantitative approach with an incidence study design conducted pre and post experimental without comparison to see the effectiveness of plastic tape sealing. The subjects for the research were 81 health workers in the CMH environment who were at risk of being exposed to COVID-19. The study found a significant difference in the Bitrex fit test immediately after sealing the N-95 type 1860 respirator with plastic tape; 100% passed the fit test immediately after sealing, and 64.2% passed the fit test after 4 h of working. The effectiveness of sealing using plastic tape is considered to be quite good to overcome face seal leak on the N-95 type 1860 respirator. Health care workers need to be more vigilance to ensure better face seal.

Objective: We aimed to evaluate the effect of radiofrequency turbinate reduction as an initial treatment on clinical improvement, inflammatory mediators, and remodeling process. Methods: Between July 2018- February 2020, 32 patients with moderate-severe persistent AR were randomly divided into 2 groups. Intervention group received radiofrequency turbinate reduction followed by intranasal steroid and Antihistamine H-1 (AH-1), control group received intranasal steroid and AH-1. Both groups were evaluated for clinical improvement (using visual analogue scale based on total nasal symptoms score, peak nasal inspiratory flow, and turbinate size using imageJ) after 4 and 8 weeks of treatment. Inflammatory mediators (ELISA from nasal secretions was performed to measure ECP, IL-5, and HSP-70) and remodeling markers (nasal biopsy followed by immunohistochemistry examination was performed to evaluate MMP-9, TIMP-1, and PAI-1) were evaluated in week 4. Results: Three patients dropped out of the study, resulting in 16 patients in intervention group and 13 patients in control group. At week 4, clinical response improved significantly in the intervention group compared to control group (Chi-Square test, p<0.05). Compared to control, intervention group experienced a reduction of IL-5 and no significant change in ECP level (Mann Whitney test, p>0.05). Reduction in the ratio of MMP-9/TIMP-1 were significantly higher in intervention group (unpaired t-test, p< 0,05). Meanwhile, increase in HSP-70 in the intervention group was slightly lower than in control group, but the difference with control group was not significant (Mann Whitney test, p>0.05). Conclusion: Early radiofrequency turbinate reduction followed by pharmacotherapy given to persistent moderate-severe AR patients give more improvement only in early clinical symptoms and reduce MMP-9/TIMP-1 ratio, thus it might be suggested as one of the adjuvant therapies for the management of moderate-severe persistent AR. However, further investigation with a larger sample size and longer follow-up period is needed. Level of evidence: 1B.

Background: Hearing loss is the most common disability in the world, with a prevalence of 5% of the world's population of 466 million people. Knowledge about noise exposure and hearing protection equipment is related to hearing loss. Health is associated with a person's healthy lifestyle behaviour. This study aimed to determine the level of community behaviour towards hearing loss. Methods: This study used a descriptive analytical approach with a cross-sectional study design. The population in this study was Indonesian people who were not healthcare workers aged 17 years and over. The sample inclusion criteria included individuals who were not healthcare workers (such as doctors, nurses and midwives etc.), aged 17 years and over, and willing to participate in the study. The sampling method in this study was consecutive sampling. Results: Based on the distribution of patients, there were more female participants (1484, 61.6%) than male participants. Diploma-3 (D3) was the most common education type, with as many as 1095 people (45.4%), while the least common education type was not in school (eight, 0.3%). Most participants were in the ‘employee’ profession, namely 509 people (21.1%), while the lowest number of participants was in the Police profession (20, 0.8%). There were significant relationships between the respondent's knowledge and action about hearing loss, and the respondent’s knowledge and attitudes regarding hearing loss (p=0.000). Conclusions: There were significant relationships between the respondent's knowledge and actions about hearing loss and the respondent's knowledge and attitude, while there was no significant relationship between the respondent's attitude and actions regarding hearing loss.

ABSTRACTBackground: The appropriate management of patients with congenital deafness is installing hearing aids, either external hearing aids or implanted in the ear (cochlear implant), aiming to reduce the medical and social burden, besides improving the quality of life of the sufferers. Objective: To ascertain the cost of hearing aids in patients with congenital deafness, in the form of external hearing aids or cochlear implants. Method: A descriptive study with cross-sectional design using questionnaires through interviews. The sample size was 535 mothers whose children had congenital deafness at 24 hospitals with facilities for establishing a diagnosis of congenital deafness in 17 provinces in Indonesia. Result: Most respondents were aged 30-39 years (55%), occupations were housewives (71.8%), and education level was high school (52.5%). The type of hearing aid used mostly was external (92.7%), with 45.9% paid by personal expense. The surgically planted hearing aids in 22 children was mostly cochlear implants (95.5%), which were financed by the Indonesian Healthcare and Social Security Agency (BPJS) plus personal costs (50%). Discussion: This study found that the most common type of hearing aid used by children with hearing impairments was external hearing aids (92.7%) through independent financing (45.9%). Only 7.3% of patients chose surgery in hearing habilitation, and 95.5% were cochlear implants. The small percentage of surgery were due to the high-priced of cochlear implants, and the government did not cover all financial expenses. Conclusion: Most external hearing aids were paid independently-out-of-pocket, while cochlear implant surgeries were funded by BPJS, plus extra costs independently. ABSTRAKLatar belakang: Penatalaksanaan terbaik untuk penderita tuli kongenital adalah pemasangan alat bantu dengar (ABD), baik berupa ABD eksternal maupun ABD yang ditanam dalam telinga (implan koklea), dengan tujuan untuk mengurangi beban medis dan sosial, serta meningkatkan kualitas hidup penderita. Tujuan: Untuk mengetahui seberapa besar biaya pemasangan ABD pada penderita tuli kongenital, baik berupa ABD eksternal maupun implan koklea. Metode: Penelitian deskriptif dengan rancangan cross sectional study menggunakan kuesioner melalui wawancara. Besar sampel 535 ibu yang anaknya menderita tuli kongenital pada 24 rumah sakit yang memiliki fasilitas penegakkan diagnosis tuli kongenital di 17 provinsi di Indonesia. Hasil: Sebagian besar responden berusia 30-39 tahun (55%), pekerjaan terbanyak adalah ibu rumah tangga (71.8%), dan tingkat pendidikan SMA (52.5%). Jenis ABD yang terbanyak adalah ABD eksternal (92,7%) dengan pembiayaan secara mandiri 45,9%. Pemasangan ABD dengan tindakan operasi dilakukan pada 22 anak, yang terbanyak adalah implan koklea (95,5%) yang dibiayai oleh Badan Penyelenggara Jaminan Sosial (BPJS) ditambah dengan biaya sendiri (50%). Diskusi: Penelitian ini mendapati bahwa ABD yang terbanyak digunakan oleh anak dengan gangguan pendengaran adalah ABD eksternal (92,7%) dengan biaya mandiri (45,9%). Habilitasi pendengaran dengan tindakan operasi hanya dilakukan pada 7,3% pasien, berupa implantasi koklea 95,5%. Kecilnya persentase habilitasi bedah dikarenakan tingginya harga implant koklea, dan bantuan dari BPJS tidak meliputi keseluruhan biaya. Kesimpulan: Sebagian besar pembiayaan alat bantu dengar eksternal secara mandiri, sedangkan operasi implan koklea menggunakan biaya BPJS ditambah biaya sendiri.

Background: The purpose of this study was to obtain data on the prevalence of specialist doctors and Otorhinolaryngology-Head and Neck Surgery (ORL-HNS) residents in Indonesia who suffered from Coronavirus disease 2019 (COVID-19) after receiving the second dose of COVID-19 vaccination using the Sinovac vaccine (CoronaVac) and the length of time infected with COVID-19 after the second Sinovac vaccination. Methods: We performed a descriptive observational study, using a cross-sectional design. Data collection took place between August 2021 and October 2021. The respondents in this study included specialist doctors and ORL-HNS residents who worked in various hospitals in Indonesia who had received the second dose of the Sinovac vaccination. Data collection was performed by means of Self-reporting Online Survey Platform (Google Form). Results: This study included 1,530 respondents, and 54.2% of respondents were women. Respondents consisted of 68.6% ORL-HNS doctors and the rest were residents with an average age of 41.46 years old. The distance between the first and second doses of Sinovac was mostly under one month, which was 71.3% of the respondents. A total of 76.3% of respondents did not have co-morbid diseases. Based on this study, 16.9% of respondents suffered from COVID-19 after the second dose of Sinovac vaccination. The length of time suffering from COVID-19 after the second Sinovac vaccination was 3-6 months (9.7%). Conclusions: Based on this study, 16.9% of respondents suffered from COVID-19 after receiving the second Sinovac vaccination and 9.7% suffered from COVID-19 after 3-6 months of Sinovac vaccination.

Objectives: To investigate factors associated with time of diagnosis and habilitation of congenital hearing loss in Indonesia.Method: A retrospective cohort study was conducted from January to December 2020 by collecting data on patients with congenital hearing loss using validated questionnaires.Result: Among 535 children with congenital hearing loss, 2.7% had a family history of congenital hearing loss, 11.2% and 37.4% had a maternal history of ototoxic drugs and herbal medicine use during pregnancy, respectively, and 17.8% had prenatal exposure to TORCH infection. Lower maternal education level was shown to be associated with older age at diagnosis (p = 0.045), while older maternal age (p < 0.001), non-housewife mothers (p = 0.029), and out-of-pocket payment scheme (p = 0.027) were associated with a higher rate of habilitation.Conclusion: The present study showed that the presence of family history, the use of certain medications during pregnancy, and prenatal TORCH infection are prevalent in children with congenital hearing loss in Indonesia. Several factors such as maternal education level, age, occupation, and habilitation payment scheme may be associated with time of diagnosis and habilitation of congenital hearing loss.

This study’s objectives were to investigate factors affecting the adverse events of the COVID-19 vaccine in Indonesia among health care workers and compare adverse events following SARS-CoV-2 vaccine using CoronaVac as the first and second dose and Moderna used as the booster third dose. A cross-sectional study was conducted using the Self-reporting Online Survey Platform (Google Form) from August to October 2021. Subjects included in the study were ENT specialists and residents all over Indonesia who had been vaccinated with both doses of CoronaVac COVID-19 vaccine and Moderna COVID-19 vaccine as a booster dose. Among a total of 1394 participants, 51.2% and 43.7% of subjects experienced adverse events following the first and second dose of the CoronaVac vaccine. Adverse events are significantly higher following the third dose of Moderna vaccine (95.3%) with p-value <0.001, odds ratio (OR) 26.63 (95% CI 19.87-35.7). Adverse events following the CoronaVac vaccine were significantly higher in females and individuals with comorbidities in the first dose (p=0.002 and p=0.04), and the second dose (p=0.008 and p=0.042). Adverse events following the Moderna vaccine were significantly higher in females (p=0.01) and lower in individuals ≥40 years of age (p=0.017). Comorbidity status did not affect adverse events following the Moderna vaccine. Keywords: adverse events, SARS-CoV-2, COVID-19, vaccine, otorhinolaryngology. Faktor yang Mempengaruhi Efek Samping Vaksin SARS-CoV-2 terhadap Dokter Spesialis dan Residen Telinga, Hidung, dan Tenggorok di Indonesia Abstrak Penelitian ini bertujuan untuk mengetahui faktor-faktor yang mempengaruhi efek samping vaksin COVID-19 di Indonesia pada petugas kesehatan dan membandingkan efek samping setelah vaksin SARS-CoV-2 menggunakan CoronaVac sebagai dosis pertama dan kedua dan Moderna sebagai booster dosis ketiga. Studi potong lintang dilakukan dengan menggunakan self-reporting survei online (Google Form) dari Agustus-Oktober 2021. Subjek yang termasuk dalam penelitian adalah dokter residen dan spesialis THT di Indonesia yang telah divaksinasi dengan kedua dosis vaksin CoronaVac COVID-19 dan vaksin Moderna COVID-19 sebagai dosis tambahan. Dari total 1394 peserta, 51,2% dan 43,7% subjek mengalami efek samping setelah dosis pertama dan kedua vaksin CoronaVac. Efek samping secara signifikan lebih tinggi setelah dosis ketiga vaksin Moderna (95,3%) dengan p-value <0,001, rasio odds (OR) 26,63 (95% CI 19,87-35,7). Efek samping setelah vaksin CoronaVac secara signifikan lebih tinggi pada wanita dan individu dengan penyakit penyerta pada dosis pertama (p=0,002 dan p=0,04), dan dosis kedua (p=0,008 dan p=0,042). Efek samping setelah vaksin Moderna secara signifikan lebih tinggi pada wanita (p=0,01), dan lebih rendah pada individu ≥ 40 tahun (p=0,017). Status komorbiditas tidak mempengaruhi efek samping setelah vaksin Moderna. Kata kunci: efek samping, SARS-CoV-2, COVID-19, vaksin, otorinolaringologi.

ABSTRACTBackground: World Health Organization (WHO) announced a newly discovered virus that first identified in Wuhan, China on December 2019, namely SARS-CoV-2 as the cause of corona virus disease (COVID-19) which had become global pandemic. Doctors as medical practitioners are categorized as vulnerable group to be infected by corona virus, and many otorhinolaryngologists had been infected and even died in performing medical services. Among the causative factors why otorhinolaryngologists could get infected by corona virus is their behavior. Purpose: To assess the behavioral level of otorhinolaryngologists in medical services during Covid-19 pandemic. Method: Descriptive study with a cross sectional design. Research samples were otorhinolaryngologists in Indonesia who met the inclusions criteria. The samples were selected by consecutive sampling method, and got obtained 1299 subjects. Behavioral level was assessed from 3 aspects: knowledge, attitude, and practice, which were comprised of 12 questions. Result: It was found that 461 respondents had a good behavioral level (35.5%), 677 respondents had moderate levels (52.1%) and 161 respondents had low level (12.4%). There was a statistically significant correlation between knowledge with behavioral level, attitude with behavioral level, and practice with behavioral level (p=0.001). Conclusion: The study of behavioral level of otorhinolaryngologists in medical service during Covid-19 pandemic obtained the highest number was moderate level 677 respondents (57.2%), and there was a statistically significant correlations between the variable of knowledge with behavioral level, the variable of attitude with behavioral level, and the variable of practice with behavioral level (p=0.001).

Purpose Sensorineural hearing loss (SNHL) is commonly caused by the death or dysfunction of cochlear cell types as a result of their lack of regenerative capacity. However, regenerative medicine, such as stem cell therapy, has become a promising tool to cure many diseases, including hearing loss. In this study, we determined whether DPSCs could differentiate into cochlear hair cell in vitro. Methods DPSCs derived from human third molar dental pulp were induced into NSCs using a medium containing basic fibroblast growth factor (bFGF) and epidermal growth factor (EGF) for 7 days, and then into cochlear hair cell using a medium containing EGF and IGF-1 for the next 14 days. We used the neuroepithelial protein marker nestin and cochlear hair cell marker myosin VIIa as the markers for cells differentiation. Cells expressing the positive markers under the microscope were confirmed to have differentiated into cochlear hair cell. Results DPSCs were successfully induced to differentiate into NSCs, with mean 24% nestin-positive cells. We found that DPSC-derived NSCs have a great capacity in differentiating into inner ear hair cell-like cells with an average of 81% cells presenting myosin VIIa. Thus, DPSCs have high potential to serve as a good resource for SNHL treatment. Conclusion We found the high potential of DPSCs to differentiate into NSC. The ability of DPSCs in differentiating into neural lineage cell made them a good candidate for regenerative therapy in neural diseases, such as SNHL

Aim Chronic Suppurative Otitis Media (CSOM) with or without cholesteatoma is a global major problem and it is becoming a burden especially in developing countries. Studies have found that ethanol extracts of Puguntano leaves obtained by the percolation and socletation methods have phytochemical contents that provide anti-inflammatory effect. The aim of this study was to investigate the effects of ethanol extract and Puguntano on the viability of cholesteatoma keratinocytes. Methods This in vitro experimental study included 8 groups of the cholesteatoma keratinocyte culture: not given puguntano leaf ethanol extract, three positive control groups given different concentrations of dexamethasone, and four groups that were given different concentrations of ethanol extract of leaf Puguntano. Results A statistically significant decrease in procalcitonin level (p<0.001) and an amount of bacterial colonies (p<0.001) in four groups were found. Conclusion This study showed that Puguntano leaf extract has the same effect as dexamethasone in terms of suppressing cell viability and has lower side effects compared to dexamethasone as other herbal medicines. Thus, the ethanol extract of Puguntano leaves can be used as an alternative for the prevention of cholesteatoma.