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   Table of Contents - Current issue
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October-December 2018
Volume 34 | Issue 4
Page Nos. 213-365

Online since Friday, November 2, 2018

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ORIGINAL ARTICLES  

Postauricular epidermoid and dermoid cysts in adults Highly accessed article p. 213
Abdullahi Mohammed, Kabir Abdullahi
DOI:10.4103/ejo.ejo_33_18  
Background Compared with other cutaneous cysts of the head and neck region, postauricular epidermoid and dermoid cysts are rare, asymptomatic benign swellings. Aim To describe the clinical profile of postauricular dermoid and epidermoid cysts in adults. Patients and methods A descriptive retrospective study was conducted on patients older than 16 years, diagnosed histologically with postauricular epidermoid and dermoid cysts who presented to the Ear, Nose and Throat Clinic of the Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria, from January 2005 to December 2017. Results A total of eight patients were reviewed: two (25%) males and six (75%) females. The age ranged from 22 to 55 years (mean age, 30.1±11.2 years). Most cases (seven, 87.5%) were epidermoid cysts. The mean duration of cystic swellings was 9.8±5.7 years. All the patients presented with asymptomatic postauricular extracranial cysts mostly at the left postauricular side (five, 62.5%). Complete surgical excision was carried out for all the lesions, and no recurrence was observed in the two (25%) patients who came for follow-up; the rest were lost to follow-up. Conclusion Postauricular cysts, mostly epidermoid cyst, are rare unilateral asymptomatic, extracranial swellings that are associated with a delay in seeking medical intervention.
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Correction of prominent ear by the two parallel incision technique with definition and folding of the antihelix by vertical mattress sutures Highly accessed article p. 217
Ashraf Khaled, Ramez Reda, Ahmed Kamel, Samir Shokr A Rhman
DOI:10.4103/ejo.ejo_48_18  
Background Multiple techniques have been advocated over the years for correction of the prominent ear. The basic techniques used to correct prominent ears with a missing antihelix depends on incision, scoring, bending and reposition of the auricular cartilages. This study was undertaken to correct prominent ears using cartilage incision and vertical mattress sutures to define antihelix. Patients and methods This study was carried out on 13 patients (25 ears) in the period between February 2014 and June 2017, twelve patients of them were presented with bilateral prominent ears and one patient was presented with unilateral prominent (bat) ear. This series comprised 8 males and 5 females. Their ages ranged between 7 to 33 years. In this technique 2 parallel incision in auricular cartilage, definition of antihelix with vertical mattress sutures and ellipse of skin was removed. Results Satisfactory results were obtained in all patients. Complications occurred in 2 patients only: one of them had mild protrusion of upper third of auricle and the other had keloid. Conclusion Our technique produces natural-looking of the operated ears with low complication rates.
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Effect of adding platelet-rich plasma to fat grafts in myringoplasty p. 224
Tamer Fawzy, Mohamed Hussein, Said Eid, Sherif Guindi
DOI:10.4103/ejo.ejo_53_18  
Background Platelet-rich plasma (PRP) is an autologous product derived from whole blood through the process of gradient density centrifugation. Autologous PRP, with growth factors up to 8 times that of normal serum, has been shown to be safe and effective in promoting natural processes of wound healing. Our study aims to examine the effect of combining the fat graft with PRP in myringoplasty procedures indicated for TMP secondary to chronic suppurative otitis media (CSOM) and whether it can significantly promotes Tympanic membrane (TM) healing. Methods This prospective study included forty patients, presenting with dry tympanic membrane secondary to tubo-tympanic CSOM. Half the patients underwent fat graft Myringoplasty with PRP application (group A), while others served as control and received the fat graft only, without PRP (group B). Results In group A, eighteen cases (90%) significantly showed an intact tympanic membrane, while Eleven cases (55%) were successful in group B. P=0.044. Conclusion Topical autologous PRP application during fat plug Myringoplasty is highly successful with no reported postoperative infections and minimal morbidity.
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Frontal sinus osteoplastic flap: is it relevant today? p. 229
Archana Shah, Moushumi Sengupta, Vedula P Saha, Somnath Saha
DOI:10.4103/1012-5574.244903  
In the present era where frontal sinus surgery is synonymous with functional endoscopic sinus surgery, we present a case series comprising six cases of varied frontal sinus pathology that were managed with an external approach using an osteoplastic flap technique. The study was carried out in the ENT Department of Calcutta National Medical College, a tertiary care center in Kolkata. A unilateral osteoplastic flap approach was adopted in three cases, of which two were reported as osteomas and one was that of inverted papilloma. Bicoronal osteoplastic flap was raised in another group, which included a case of communited fracture of the anterior wall of the frontal sinus with obvious cosmetic facial deformity, a case of fracture of the posterior wall of the frontal sinus with traumatic cerebrospinal fluid rhinorrhea with pneumoencephalus, and a case of plasmacytoma of the frontal sinus. The mean follow-up period ranged from 1 to 3 years. There was no recurrence of disease and no significant postoperative complications have been reported during the follow-up period so far.
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Anatomic variations of the nose and paranasal sinuses in saudi population: computed tomography scan analysis p. 234
Nada Alshaikh, Amirah Aldhurais
DOI:10.4103/1012-5574.244904  
Background Knowledge of the anatomy constitutes an integral part in the total management of patients with sinonasal diseases. The aim of this study was to obtain the prevalence of sinonasal anatomic variations in Saudi population and to understand their importance and impact on the disease process, as well as their influence on surgical management and outcome. Materials and methods This study is prospective review of retrospectively performed normal computed tomography (CT) scans of the nose and paranasal sinuses in adult Saudi population at Dammam Medical Complex. The scans were reviewed by two independent observers. Results Of all CT scans that were reviewed, 48.4% were of female patients and 51.6% were of male patients. The mean age of the study sample was 38.5±26.5 years. The most common anatomic variation after excluding agger nasi cell was pneumatized crista galli, which was seen in 73% of the scans. However, the least common variation seen in this series was hypoplasia of the maxillary sinus, which was encountered in 5% of the cases. We did not detect a single pneumatized inferior turbinate among the studied scans. Conclusion A wide range of regional differences in the prevalence of each anatomic variation exists. Understanding the preoperative CT scan is substantially important because it is the road map for the sinus surgeon. Detection of anatomic variations is vital for surgical planning and prevention of complications.
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Comparison of triamcinolone and mitomycin C nasal pack in functional endoscopic sinus surgery: a randomized, clinical trial p. 242
Natarajan Ramalingam, Pradipta K Parida, Sunil K Saxena, Gopalakrishnan Surianarayanan
DOI:10.4103/ejo.ejo_9_17  
Aims and Objectives Synechia formation in a postoperative nasal cavity is a major factor for suboptimal clinical outcome in functional endoscopic sinus surgery (FESS). Nasal packs medicated with steroids like triamcinolone and topical agents like mitomycin C have been shown to reduce the formation of synechiae in postoperative patients. This study attempts to compare the efficacy of mitomycin C and triamcinoloneimpregnated nasal pack in the prevention of crusting and synechiae formation in patients undergoing FESS. Methods Ninety-eight consenting patients with chronic rhinosinusitis were randomized into two groups of 49 each to receive either triamcinolone-impregnated or mitomycin C-impregnated nasal pack after FESS. Blinded, postoperative endoscopic examination was done at the first and third week and at first and third month and scoring was done according to the Lund Kennedy scoring system. The primary variable for assessing the outcome was synechiae formation in the postoperative period, while reduction of crusting, discharge, mucosal edema, polypoidal mucosal changes, and maintenance of ostial patency were secondary variables. Results Significant reduction in synechiae formation and crusting at 3 months duration was found in the group receiving triamcinolone nasal pack as compared with mitomycin C nasal pack. Mitomycin C was found to significantly reduce crusting in the first postoperative week. Positive trends in reduction of discharge, mucosal edema, polypoidal changes, and in maintenance of patency of ostia were observed in both the groups, but there was no significant difference between the two groups. Conclusion These results suggest that triamcinolone has a long-term effect in the reduction of synechia formation and crusting in post-FESS patients as compared with mitomycin C, though similar effects were seen in both groups in the immediate postoperative period.
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Assessing the correlations between subjective symptom scores and turbinoseptal relationships in pretreatment adults with chronic rhinosinusitis p. 248
Adekunle Adeyemo, Sanyaolu A Ameye, Yemisi B Amusa, Ajibola T Osukoya, Akumbu S Ohuche
DOI:10.4103/ejo.ejo_26_18  
Background This study was undertaken to assess the correlations between subjective symptom score in patients with chronic rhinosinusitis and endoscopic turbinoseptal relationship (TSR). Aim To assess the pattern of TSR and their correlations with symptom score in patients with chronic rhinosinusitis. Settings and design This was an observational study in a tertiary/teaching hospital setting Patients and methods Consecutive pretreatment adults with chronic rhinosinusitis completed the sinonasal outcome test 22 (SNOT22) and had nasal endoscopy. At endoscopy, the TSR was determined, as well as the presence of nasal polyps. Statistical analysis Mean SNOT22 score was calculated and TSR types were grouped and their distribution documented with types 3 and 4 taken as unfavorable types. χ2-Tests were used to determine the correlations between turbinoseptal types, presence of nasal polys, and SNOT22 scores with the level of significance set at P value up to 0.05. Results A total of 53 [23 (43.4%) men and 30 (56.6%) women] patients with a mean age of 42.5±18.6, completed the study. Median symptom duration was 36 weeks (13–112 weeks). Mean SNOT22 score was 29.7±2.8. Unfavorable TSR types were found in 42.5% of nostrils, more on the right (χ2=13.2; P≤0.01). There is no significant correlation between the presence of unfavorable TSR and worsening total SNOT22 scores [R (K-S=0.13 P=0.95) L (K-S=0.34, P=0.07)]. Conclusion Unfavorable TSR is common in patients with chronic rhinosinusitis. However, there is no correlation between the presence of abnormal TSR and symptom scores.
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Effect of biodegradable versus nondegradable nasal packings in the outcome of functional endoscopic sinus surgery: clinical and histopathological study p. 253
Ayman Al-Madani, Ahmed Youssef, Ayman Abduljalil, Hoda Khalifa, Mohamed Zahran
DOI:10.4103/ejo.ejo_14_18  
Background Nasal packing has been used to prevent bleeding and formation of adhesions between the middle turbinate and lateral nasal wall. There has been a debate whether biodegradable packing might improve the outcome, or could a nondegradable dressing offer a better course after endoscopic sinus surgery. Objective To compare the effect of biodegradable versus nondegradable nasal packings on the outcome of endoscopic sinus surgery on clinical, endoscopic, and histopathologic basis. Patients and methods Fifty patients with bilateral chronic rhinosinusitis of the same extent of sinus affection were enrolled in this study. None of them was a revision case. All patients had bilateral functional endoscopic sinus surgery by the same surgeon using the same technique of powered microdebrider utilization. At the end of the procedure, the operative cavity of each patient was randomly packed with Merocel as a nondegradable material on one side and a biodegradable material on the other side. We assessed the patients regarding immediate postoperative symptoms and endoscopic follow-up after 1- and 3-month postoperatively including biopsy taking for histopathological examination. Results Postoperative bleeding and patient discomfort were significantly higher in the nondegradable packing side, while biodegradable packing has caused significantly more edema. Merocel packed sides showed better epithelial restoration with marked epithelial hyperplastic changes and more goblet cells than the biodegradable sides. This difference was statistically significant 1-month postoperatively, but turned nonsignificant 3-month postoperatively. Conclusions Biodegradable nasal packing can offer patients a good quality of life during the early recovery period without beneficial or detrimental effects on postoperative mucosal healing. Nondegradable packs offer less post-functional endoscopic sinus surgery edema providing better aeration and rapid wound healing.
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Predicting factors of recurrent deviated nasal septum after primary septoplasty in Jeddah, Saudi Arabia p. 266
Abdullah A Alamri, Amjaad A Alsulami, Rawan A Almahyawi, Razan A Abushal, Abdulkreem R Fida
DOI:10.4103/ejo.ejo_51_18  
Background Deviated nasal septum is a common cause of symptoms for nasal obstruction. Patients with nasal septum deviation who undergo septoplasty have improvements in their disease-specific quality of life for nasal obstruction. Objective The aim of this study was to identify the contributing factors of recurrent nasal septum deviation following primary septoplasty. Materials and methods This retrospective cross-sectional study reviewed the records of all patients who underwent primary septoplasty between 2017 and 2018; then presented to Otolaryngology-Head and Neck Surgery Outpatient Clinic, King Abdulaziz University Hospital with recurrent deviated nasal septum. Results In the current study, 362 patients were included. Most patients were Saudis (73.2%); and had neither comorbidities (73.5%) nor chronic diseases (92%). At the time of primary septoplasty, most patients were aged from 18 to 59 years (78.2%). Most patients had left septal deviation; underwent closed approach; and did not suffer postoperative complications (94.5%). The most common types of deviated nasal septum at the time of primary septoplasty were types 3 (38.1%) and 2 (31.5%), while type 2 was the most common at second septoplasty. The time between first septoplasty and recurrence of deviated nasal septum ranged from 1 to 72 months; with a median time of 12 months. The results of multiple linear regression showed that Saudi male patients who had a concomitant nasal surgery had a significantly increased time interval between first septoplasty and recurrence (P<0.05). The presence of either comorbidities or chronic diseases resulted in a decrease of the interval. Conclusion In patients who suffered from recurrence after primary septoplasty, types 2 and 3, left deviated nasal septum, and closed approach septoplasty were significantly frequent. Factors that resulted in longer time interval between first septoplasty and recurrence were male gender, Saudi nationality, concomitant nasal surgery, and absence of either comorbidities or chronic diseases.
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Assessment of the nasal obstruction after endoscopic septoplasty compared with conventional technique by computed tomography and Nasal Surgical Questionnaire p. 272
Ayat A El Nasr, Mohamed A.M Belih
DOI:10.4103/ejo.ejo_38_18  
Background Nasal obstruction is a common annoying symptom of septal deviation, and endoscopic septoplasty gives better illumination and accurate vision, and hence can provide markedly good dealing with posterior deviations, isolated spurs, and high deviations. Computed tomography (CT) scan and Nasal Surgical Questionnaire (NSQ) are important for accurate postoperative follow-up. Objective The aim of this study was to express our experience in the assessment of the nasal obstruction after endoscopic septoplasty compared with conventional septoplasty in patients with nasal septum deviation by measuring the size of the inferior turbinate with CT scan and measuring patient satisfaction by NSQ score. Patients and methods This was prospective study of 100 patients, complaining mainly of nasal obstruction. They were divided into two groups: group A, who underwent endoscopic septoplasty, and group B, who underwent conventional septoplasty. All the patients underwent septoplasty alone without inferior turbinate surgery. Preoperative and postoperative CT scan and NSQ were the basic documentation for the results. Results Endoscopic septoplasty showed a better reduction in nasal obstruction than conventional septoplasty; however, the postoperative reduction on the size of the inferior turbinate and NSQ score were highly significant in both groups (P=0.001). Conclusion Both endoscopic and conventional septoplasty without turbinate surgery in patients with nasal septum deviation were effective in improving the nasal obstruction. However, endoscopic septoplasty had better results in improving nasal obstruction.
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Clinical implications of transpterygoid approach to mandibular nerve p. 278
Ahmed Youssef, Ricardo L Carrau, Shahzad Ahmed, Ahmed Tantawy, Ahmed Aly Ibrahim, Abdulaziz Al Azri, Mohamed Zahran
DOI:10.4103/ejo.ejo_30_18  
Background The endonasal transpterygoid approach has been very popular as a standard approach to the pterygopalatine and infratemporal fossa. However, its implications actually extend beyond these regions to include access to the middle cranial fossa and parapharyngeal space. Objective The aim was to illustrate the anatomical landmarks of the endoscopic transpterygoid approach especially the mandibular nerve and clinical implication of this approach through illustrated case presentation. Materials and methods A cadaveric study was performed on three cadaveric adult specimens. Endoscopic medial maxillectomy, Sturman Canefield approach, and completion of transpterygoid approach were done to visualize the different anatomical landmarks, especially the mandibular nerve. An example of clinical application of transpterygoid approach is an illustrated case to biopsy a perineural spread of squamous cell cancer along the mandibular nerve in the lateral wall of cavernous sinus. Conclusion Endoscopic transpterygoid approach is very useful to resect most of benign and some malignant tumors that involve the infratemporal fossa and middle cranial fossa. Good understanding of the V3 anatomy helps in the resection of tumors extending to the infratemporal fossa and poststyloid parapharyngeal space.
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Feasibility of reirradiation and treatment outcome in a previously irradiated territory in head-and-neck malignancies p. 283
Sweety Gupta, Amit Gupta, Prekshi Choudhary, Ashish Gupta, Manjari Shah, Shashank Srinivasan, Ruchir Tandon, Sudarsan De
DOI:10.4103/ejo.ejo_56_18  
Introduction Despite combined modality treatment, local persistent or recurrent disease is a primary cause of treatment failure in 30–50% of patients with advanced head-and-neck cancer (HNC). The role of reirradiation is feared because of increased risk of toxicity due to the previously irradiated target volume. In the present study, we have evaluated reirradiation by image-guided intensity-modulated radiotherapy in recurrent and second primary HNCs and its outcome. Materials and methods In all, 24 patients with recurrence or second primary tumors in HNC were included in the study conducted between January 2009 to August 2014. All patients were treated by the image-guided intensity-modulated radiotherapy technique. The most common site of recurrence/second primary was oral tongue. The time interval between initial radiotherapy and reirradiation ranged from 8 months to 17 years. Statistical analysis used The association between qualitative variables was tested using the χ2-test. Statistical significance was interpreted using an arbitrary cut-off of P=0.05. Kaplan–Meier Survival graph was plotted to depict the survival pattern of the study patients. Results The planning target volume volume of reirradiation ranged from 26.72 to 469.32 ml (median: 118.71 ml). Toxicity was more in patients receiving concurrent chemoradiation and in patients with less interval time between reirradiation. Out of the 24 patients, nine were no evidence of disease, eight patients expired (five disease progression, two comorbidities, and one due to hematemesis after the development of third primary), two recurred, one developed distant metastases, and four were lost to follow-up. Conclusion Surgical resection, with or without reirradiaton, provides the highest likelihood for successful salvage in locoregional (LR) recurrences in HNCs. Patients reirradiated after a long time from initial irradiation have better tolerance.
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The role of regional flaps in locally advanced cancer larynx with skin invasion p. 289
Mohamed Zahran, Ahmed Youssef
DOI:10.4103/ejo.ejo_40_18  
Introduction Laryngeal cancer with invasion of soft tissues of the neck including the skin is staged as T4a disease according to the TNM classification by the AJCC in 2010. The traditional treatment for this locally advanced disease is through total laryngectomy and en-bloc removal of the involved cervical skin followed by reconstruction by one of the regional flaps. In this study, we present our experience with the use of two regional flaps, namely, the pectoralis major myocutaneous flap and the deltopectoral flap, for reconstruction of T4a laryngeal cancer infiltrating the cervical skin. Patients and methods A total of 11 patients were included in the study during the period from January 2013 to October 2016. Ours was a retrospective analytic study that included analysis of the preoperative, operative, postoperative, and follow-up patient data. Results Both flaps proved to be versatile for reconstruction of the locally advanced cancer larynx and provided a simple alternative for the more complex free flap surgery.
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Montgomery tracheal t-tube stenting as a single first-line treatment in postintubation laryngotracheal stenosis p. 293
M. Ekram Osman, M.M. Roushdy, A.K. Abdel-Haleem, M.O. Ramadan
DOI:10.4103/ejo.ejo_46_18  
Objective The aim was to evaluate the use of Montgomery tracheal T-tube stenting as a single first-line treatment for postintubation laryngotracheal stenosis (LTS), addressing the outcomes, its main complications, and how to manage them. Materials and methods From March 2012 to April 2017, 25 patients with postintubation LTS had contraindication(s) for laryngotracheal surgery and were treated by Montgomery tracheal T-tube stenting as a single first-line treatment. The preoperative, operative, and postoperative follow-up data were collected retrospectively and analyzed. Results Successful outcome was reported in 16 (64%) patients, whereas seven (28%) patients had recurrent stridor after T-tube removal. It was reinserted in two of them, and the rest were subjected to other surgical procedures. Mortality was reported in two patients. Complications of different nature, severity, and durations were reported, and most of them were detected and managed successfully by applying close follow-up protocols. Conclusion Montgomery tracheal T-tube stenting is a very valuable modality in the treatment of LTS as a single first-line treatment when surgical option is contraindicated. It has a relatively low incidence of treatable complications; however, false sense of security must be avoided to ensure good outcome.
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Working memory training and language outcomes in children with cochlear implants p. 301
Azza Samy, Azza Abdel Aziz, Iman El Rouby, Reham Ahmed
DOI:10.4103/ejo.ejo_30_17  
Objective The aim of this study is to provide information on whether improvements in language skills might be achieved by improving working memory capacity in cochlear-implanted children. Patients and methods This study was carried out on 30 prelingual cochlear-implanted children at the Hearing and Speech Institute. They were divided into two groups: group I received communicative therapy plus a working memory training program. Group II received communicative therapy only. Post-therapy evaluation was carried out after 6 months using the Modified Preschool Language Scale-4 for assessing language and the working memory subtests measures of the Stanford–Binet Intelligence Scale ‘5th Arabic version‘ for the assessment of working memory. Results The results of this study showed an improvement in verbal working memory capacity, nonverbal working memory capacity, and the total working memory in the group of children with cochlear implants (CIs) who received 6 months of a working memory training program in addition to communicative therapy. The findings indicate that there is an improvement in the verbal and nonverbal working memory in the participants following the training on certain tasks in the computer-based working memory training program. This will lead to an improvement in the language skills as well. Conclusion Working memory training may improve some memory and language skills for children with CIs. As a result, interventions specifically designed to address the basic underlying verbal working memory deficits of children with CIs may be expected to have wide-ranging effects that generalize well beyond the trained working memory tasks and stimuli themselves and show transfer to nontrained language perception and memory tasks.
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High frequency audiometry in tinnitus patients with normal hearing in conventional audiometry p. 308
Doaa M Elmoazen, Hesham S Kozou, Alaa A Mohamed
DOI:10.4103/ejo.ejo_44_18  
Context Hearing loss is the most important risk factor of tinnitus, but this relation is not straightforward; some patients with severe tinnitus have normal hearing, whereas many patients with hearing loss do not have tinnitus. Aims The aim was to determine if high frequency audiometry (HFA) may reveal significant differences between normal hearing participants with and without tinnitus. Settings and design This is a case–control study. Participants and methods HFA was done on two groups of participants with normal hearing sensitivity. The first group was composed of 20 adults with tinnitus, whereas the control group was 15 age-matched and sex-matched participants, not suffering from tinnitus. Statistical analysis Data were analyzed using SPSS software package version 20.0. Significance of the results was judged at the 5% level. χ2 with Fisher’s exact as a correction, Kruskal–Wallis, Mann–Whitney, and Pearson’s coefficient tests were used. Results HFA showed no significant difference between the two studied groups. Conclusion Tinnitus in normal hearing participants does not necessarily indicate corresponding damage in the cochlea
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Assessment of cochlear implantation outcome in patients with enlarged vestibular aqueduct syndrome p. 316
Ossama A Sobhy, Mohamed B Attallah, Rania M Abdou, Amira M Al-Mahy
DOI:10.4103/ejo.ejo_43_18  
Context Theoverall outcome of cochlear implantation (CI) in patients with enlarged vestibular aqueduct (EVA) was comparable to other CI users. However, there were various concerns regarding surgical issues that may affect postoperative outcome. Moreover, exact timing for CI is still a matter of debate owing to the fluctuating nature of the disorder. Aim This study aimed to investigate speech and language outcome in patients with EVA who had undergone CI. Patients and methods This prospective study included 48 participants who underwent CI. The participants’ age ranged from 4 to 28 years. The participants were divided according to preoperative radiological studies of petrous temporal bone into isolated EVA, EVA-IPII (incomplete partition type II), and control groups. Patients’ records were revised for preoperative investigations as well as available intraoperative data. Aided hearing thresholds, auditory skills, and aided speech perception abilities were all assessed postoperatively in all participants. Results No major surgical complications were found in patients with EVA. Speech and language development in EVA group was comparable to that of control group. Conclusion CI outcomes in patients with EVA regarding surgical issues, auditory benefit, and speech perception abilities are generally good.
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Assessment of effects of hearing aid fitting on the perceptual characteristics of tinnitus p. 326
Moustafa El Kousht, Tarek M.El Dessouky, Rabab A Koura, Mohamed Fawaz, Shaemaa A Sabry
DOI:10.4103/ejo.ejo_97_17  
Background Evidence of systematic relationships between the perceptual characteristics of tinnitus, like its pitch or loudness, and those of the absolute hearing threshold curves, like the presence and degree of hearing loss at certain frequencies, would probably help to understand how tinnitus is related to the configuration of hearing loss. Objective The objective of this study was to determine the effects of hearing aid fitting on the perceptual characteristics of tinnitus. Participants and methods The participants of the study were 50 adults (20–60 years old) with subjective tinnitus and different degrees of hearing loss. Otorhinolaryngological examination, tonal audiometry, and acoustic immittance testing were done. Participants answered Tinnitus Handicap Inventory (THI) Questionnaire at the time of the first fitting with their hearing aid and performed at 0, 3, 6, and 12 months postfitting. Results THI showed a significant decrease throughout the 12 months from 74.80±15.98 at baseline to 61.84±14.02 3 months later, then 38.35±10.98 by the sixth month and 12.90±4.26 by the end of 12 months. At the baseline, no slight or mild cases were detected, whereas moderate THI represented 16%, severe 28%, and catastrophic 56%. These rates changed 3 months later as catastrophic cases decreased almost to one-third of its rate at the baseline. By the sixth month, no catastrophic cases were detected and severe stages recorded trivial rates, whereas most of cases were categorized as mild or moderate. By the end of the study, the great majority of cases were slight (81.6%) and the remaining portion was mild, with no moderate, severe, or catastrophic cases recorded. Conclusion Analysis of the results has shown that the use of hearing aids are one of the number of therapeutic options offered to tinnitus patients and promote the improvement in the perceptual characteristics of tinnitus.
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Comparison between pitch discrimination in normal children, children with hearing aids, and children with cochlear implant p. 332
Rania E Ahmed
DOI:10.4103/ejo.ejo_91_17  
Background Cochlear hearing loss causes variations in the way that sounds are represented in the auditory system and for cochlear implant (Cl) users, pitch information that is transmitted to the central nervous system is not ideal. The aim of this study was to compare between pitch discrimination and its associated language development in normal children, children with cochlear implant and children with hearing aids to know which prostheses is more useful to the patient. Materials and Methods The study measured pitch discrimination test, just noticeable difference test and language evaluation in 45 children divided into 3 groups. Results This study suggested that CI had less pitch discrimination ability but better language development than HA. Conclusions The benefit that CI users get through better accessibility to high frequencies outweighs the deficit in pitch discrimination.
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CASE REPORTS Top

Localized subglottic laryngeal amyloidosis: a case report p. 337
Hazem M Abdel Tawab, Ibrahim A Sulaiman
DOI:10.4103/ejo.ejo_74_17  
Amyloidosis is a heterogeneous group of diseases characterized by accumulation of amyloid protein in different organs of the body. Localized affection of the larynx by amyloid deposits is a rare event. This is a case of localized laryngeal amyloidosis in a 24-year-old female patient presented with hoarseness of voice. The amyloid mass was occupying the anterior part of the subglottic region and reaching up between both the vocal folds. Complete excision was achieved by cold instruments. Localized laryngeal amyloidosis despite being rare should be kept in mind as one of the causes of mass lesions in the larynx.
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Kimura’s disease of the tongue: a new case report p. 341
Muraja Aldoori, Belal Alani, Adham Ammar, Moustafa Alkhalil
DOI:10.4103/ejo.ejo_19_18  
Kimura’s disease (KD), a chronic inflammatory disease of uncertain etiology, manifests as a painless subcutaneous swelling mostly in the head and neck region that involves major salivary glands and regional lymph nodes. To date, the majority of cases of KD have been documented in Asian men aged 20–40 years. However, the number of reported cases of KD involving the oral and maxillofacial area is limited, and since the masses appear similar to cysts or benign tumors, the establishment of an accurate preoperative diagnosis is challenging. The accurate diagnosis of KD is considered to require surgical excision followed by histopathological examination. In this case report, we present a case of KD affecting the ventral surface of the tongue, a unique site of the disease that is not reported earlier according to our knowledge.
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Clinical and histopathological study of a rare sinonasal glomangiopericytoma: a case report p. 345
Taha M Abdelaal
DOI:10.4103/ejo.ejo_41_18  
A 42 year old female patient visited our clinic with reports of a 5 month history of progressive nasal obstruction, associated later with decreased smell sensitivity and left ear block. Routine rhinoscopic and endoscopic examinations revealed a greyish polypoid mass of the left nasal cavity. CT showed a hypervascular mass lesion obliterating the left nasal cavity which was compressing the medial wall of the ipsilateral maxillary sinus. MRI confirmed CT findings of a hypervascular lesion, with MRA identifying the left internal maxillary artery branch as the mainfeeding vessel. Endoscopic surgical excision was performed, with preoperative embolization done prior to excision, to reduce intra-operative blood loss and facilitate complete excision. Histopathology confirmed sinsonasal glomangipericytoma. The patient did not present with any of the known predisposing risk factors and the etiology of the tumor remains unknown. Although it is thought that the incidence of recurrence is low following complete excision, the reported recurrence of 9.5% to 50% necessitates life long follow up.
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Middle ear myxoma: a diagnostic dilemma and its management, a case report p. 351
Santanu Dutta, Prasanta K Gure, Sudipta Pal, Somnath Saha
DOI:10.4103/1012-5574.244901  
The aim of this study was to present a rare case report of myxoma of the mastoid cleft/temporal bone with intracranial extension and its management and follow-up. A 13-year-old girl presented with discharge from the right ear with gradually progressive hearing loss for the last 4–5 years and facial palsy of grade III on the right side for the last 4–5 months. She was diagnosed as having chronic otitis media, squamosal type, and underwent canal wall down mastoidectomy on the same ear 6 months back. On examination, an aural polyp occupying the whole of the mastoid cavity along with mucopurulent discharge and lower motor neuron facial palsy were seen on the right side. high resolution ct scan (HRCT) of the temporal bone showed a soft tissue mass occupying the whole of the mastoid cavity breaching bony confinements, extending up to the posterior fossa, extradurally, and engulfing the facial nerve. The patient underwent re-exploration of the right mastoid cavity under general anaesthesia and a soft jelly-like substance was removed from whole of the mastoid cavity, extending anteriorly up to the Eustachian tube, inferiorly up to the jugular bulb, posteriorly up to the retrosigmoid cells, superiorly up to the tegmen plate, extending medially intracranially up to the posterior fossa dura through Trautmann’s triangle and engulfing the facial nerve from the first genu to the stylomastoid foramen. Facial nerve decompression was performed along with disease clearance and wide conchomeatoplasty. The patient developed grade IV facial palsy postoperatively. The histopathology report of the dissected jelly-like soft tissue revealed myxoma. The patient is at present under regular follow-up and there is no recurrence after 6 months, although facial palsy is still persisting as grade IV. Myxoma of the temporal bone or the mastoid cleft is a rare entity. Complete surgical excision is the treatment of choice in this case, although recurrence is very common. The clinical presentation, management and outcome of this tumour are discussed in view of available literature.
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Migratory abscess of the middle ear resulting from an odontogenic infection: an unusual case report p. 355
Kubsad Veerabhadrappa Arun Kumar, Mukesh Soni, Deepa Dhruvakumar
DOI:10.4103/ejo.ejo_93_17  
Infections of odontogenic origin are the commonly encountered diseases in their routine practice by head and neck specialists. Their spread to adjacent fascial spaces may follow as sequelae of untreated odontogenic infections, along a predictable route. Unusually, these infections may follow an uncommon path for the spread and may appear at a distant site in contrast to the site of infection, resulting in the formation of a ‘migratory abscess’. This case report is entitled to present an unusual and rare case of migratory abscess of the right middle ear in a 20-year old male patient, occurring as sequelae of an odontogenic infection in the right lower second molar and to explain a possible route of transmission of infection in this challenging case presentation.
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Isolated laryngeal amyloidosis: a case report p. 359
Sarniza Zainol, Mawaddah Azman, Santhia Muthusamy
DOI:10.4103/ejo.ejo_12_18  
Background Amyloidosis is extracellular deposition of an amorphous amyloid substance in various tissues. It can occur in any bodily organ. Clinically, it is divided into systemic and solitary amyloidosis. Isolated laryngeal amyloidosis is very rare in prevalence. We report a case of isolated laryngeal amyloidosis in a healthy 54-year-old lady who presented chronic dysphonia for 2 years with no history of smoking or alcohol intake. The histological, immunohistochemical study and further examinations confirmed the diagnosis of isolated laryngeal amyloidosis without systemic involvement. The larynx is a rare site for isolated laryngeal amyloidosis. Hoarseness or dysphonia is the main presentation of this disease, followed by difficulty in breathing, stridor, and chronic cough. Laryngoscopy may falsely suggest a neoplastic disease. Histopathology is the gold standard diagnostic tool to diagnose this disease. Amyloid can be identified histologically as subepithelial extracellular deposits of acellular, homogeneous, and amorphous eosinophilic material displaying apple–green birefringence with polarized light when stained with Congo red. Surgery is the mainstay of treatment of symptomatic laryngeal amyloidosis. The survival of patients with laryngeal amyloidosis often exceeds 10 years and the prognosis is better than systemic amyloidosis.
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A rare case of laryngeal carcinoma in pregnancy p. 363
Hui Mon Teh, Mohd Sayuti Razali
DOI:10.4103/ejo.ejo_10_18  
Cancer in pregnancy is uncommon. The ethical problem of managing head and neck cancer in pregnancy has always been a common issue to ensure the mother and fetal well-being. Choices for the diagnostic and treatment modalities are crucial to ensure optimal outcome for the mother as well as to preserve fetal vitality. Best clinical decision for the pregnant patient should be made through a multidisciplinary approach. We are reporting a case of a 24-year-old female patient who presented with stridor owing to supraglottic squamous cell carcinoma at 13 weeks of gestation. She underwent tracheostomy as an emergency procedure and later had tumor excision using carbon dioxide laser at 15 weeks of gestation. She was subsequently decannulated off tracheostomy and later underwent normal vaginal delivery at term and had no recurrence within 2-year follow-up.
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