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   Table of Contents - Current issue
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October-December 2017
Volume 33 | Issue 4
Page Nos. 611-697

Online since Friday, October 27, 2017

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ORIGINAL ARTICLES  

Arabic translation and validation of SNOT-22 Highly accessed article p. 611
Samy Elwany, Ahmed Atef, Ahmed A Ibrahim, Ahmed S Ismail, Wael K Hussein, Ahmed S Youssef, Mohamed Elwany, Remon Bazak
DOI:10.4103/ejo.ejo_63_17  
Objective The objective of the study was to translate the Sino-Nasal Outcome Test 22 (SNOT-22) into Arabic and to check its reliability and validity in Arabic-speaking patients. Patients and methods The study included 178 patients with confirmed chronic rhinosinusitis (CRS) and 95 asymptomatic individuals as a control group. All participants completed the Arabic SNOT-22 (A-SNOT-22) questionnaire. The scores of the two groups were compared for validity analysis. Eighty-two patients completed the questionnaire twice, 1 week apart, for test-to-test reliability analysis. The A-SNOT-22 scores of 60 CRS patients were correlated with Lund–Mackay scores for criterion validity analysis. The preoperative and postoperative scores of 73 patients were compared for responsiveness analysis. Results All participants completed the questionnaire with no or minimal assistance. Internal consistency (α=0.90) and test-to-test reliability (intraclass correlation=0.78) were good. The differences between the scores of CRS patients and asymptomatic individuals were significant (P<0.005). There was a positive moderate correlation between A-SNOT-22 and Lund–Mackay scores. Preoperative A-SNOT-22 scores were significantly higher than postoperative scores. Conclusion A-SNOT-22 questionnaire is a reliable and valid outcome measure for CRS patients. The questionnaire is responsive to changes in the state of the disease and is recommended for clinical practice and outcome research.
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Safety and efficacy of pediatric functional endoscopic sinus surgery for the treatment of pediatric chronic rhinosinusitis Highly accessed article p. 616
Hossam Elsisi
DOI:10.4103/ejo.ejo_7_15  
Objective: The objective of this article is to evaluate the effectiveness and safety of pediatric endoscopic sinus surgery for the treatment of pediatric chronic rhinosinusitis (CRS). Patients and methods: This study was of a retrospective observational clinical type and was carried in the tertiary referral center. A total of 90 patients with CRS refractory to medical treatment and operated with endoscopic sinus surgery were included in this study. Computed tomography scan of the nose and paranasal sinuses was done for all patients. Sinonasal outcome test-20 German adapted version was used for preoperative and postoperative symptoms evaluation. Results Among these 90 children, there were 62 males and 28 females, with mean age of 12.5 (7–16) years. A total of 84 (93.3%) patients had CRS without nasal polyps, and CRS with nasal polyps was present in the remaining six (6.7%) patients. Nasal obstruction and purulent nasal discharge were the most reported symptoms. The follow-up period ranged from 6 months to 5 years, with a mean of 3.7 years. The overall success of the procedure was 68.8%. The most significant improvement was noticed by patients with nasal obstruction and purulent nasal discharge (90.3 and 88.8%). The least improvement occurred in patients with hyposmia (36.3%). Conclusion Functional endoscopic sinus surgery is a safe and effective procedure in children. Proper preoperative selection of patients is mandatory. Limited surgical intervention is needed in children with control of the disease and preservation of the nasal mucosa. Second-look operation may be needed in some cases. Follow-up is essential for success of the procedure.
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Current microbiological pattern and role of respiratory syncytial virus infection in children with acute otitis media in South Jeddah p. 623
Sherif K Mohamed, Heba G Hassan
DOI:10.4103/1012-5574.217387  
Introduction Otitis media is one of the most commonly encountered pediatric ENT diseases. Antibiotic resistance is increasing partly because of their overuse and largely because of changing microbiological strains leading to the disease. In this study, we aimed to determine the current microbiological pattern of the disease in children. Participants and methods Ear discharges of 200 children with acute otitis media between 6 and 14 years of age were microbiologically examined. Results Virus-only infection was positive in 13% of patients, 30% were only bacterial (48% of which is Proteus mirabilis), and 57% had combined viral and bacterial infections. Conclusion Changing trends in microbiological patterns warrant further researches to achieve better prevention and treatment.
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Formaldehyde-treated temporofascial graft versus cartilage graft in repairing failed tympanic membrane grafting p. 626
Mostafa O Ramadan, Ahmad A.A Abd-Algaleel, Rowaa A Ahmad
DOI:10.4103/ejo.ejo_29_17  
Aim The aim of this study was to compare the anatomical and functional outcomes of grafting the tympanic membrane (TM) − that is, previously failed grafting − by two graft materials: the first was formaldehyde-treated temporalis fascia graft (FTFG) and the second was tragal cartilage composite graft. Graft-take, hearing results, and complications were compared. Patients and methods The present study included 36 patients with chronic suppurative otitis media with recurrent TM perforation. Nineteen patients received tragal cartilage graft, and 17 patients received the FTFG. For each patient, history taking and complete general and ENT examinations were performed. Graft-take, preoperative and postoperative pure tone average, air–bone gap, and tympanometry scores were calculated and compared. Statistical analysis Data entry and data analysis were carried out using statistical package for social science version 19. Results and conclusion The present study showed that for repairing TM grafting, cartilage graft and FTFG were comparable in both graft-take and hearing results. The FTFG reflected the true configuration of tympanometry. It can be used in cases where the cartilage graft is previously consumed.
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The effect of direct application of dexamethasone on the round window membrane in patients with sudden sensorineural hearing loss p. 631
Fatthi A Abdel Baki, Ahmed A Omran, Samir I Asal, Khaled M Hassan
DOI:10.4103/ejo.ejo_49_17  
Objective The aim of this study was to test the effect of direct application of dexamethasone on the round window (RW) after its adequate exposure following a transcanal approach in patients with sudden sensorineural hearing loss (SSNHL). Study design This investigation was designed to be a prospective cohort study. Patients and methods This study included eighteen adult patients with SSNHL who attended our outpatient clinic at Alexandria Main University Hospital between 1 July 2015 and 1 July 2016. Under general anesthesia the small tympanomeatal flap was elevated to visualize the RW. If it was fully exposed, dexamethasone (4 mg/ml) was applied directly over a piece of gel foam; if not fully exposed the overhang was removed first and then dexamethasone was applied. After 2 weeks, a repeat audiogram was taken in all patients in order to evaluate the efficacy of the treatment on their hearing ability. Results Post-treatment assessment revealed 50% of patients with variable levels of improvement, whereas 50% did not respond to the given treatment. Of the patients showing improvement, 16.7% had normal hearing levels restored. Thus, direct application of dexamethasone on the RW membrane after its adequate exposure may reverse the hearing deficits in a few patients with SSNHL. Conclusion There is a definitive improvement in hearing in patients with SSNHL on direct application of dexamethasone on the RW membrane after its adequate exposure in patients.
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The effect of L-thyroxine hormone therapy on hearing loss in hypothyroid patients p. 637
Mohammed M Hussein, Samir I Asal, Tarek M Salem, Ahmed M Mohammed
DOI:10.4103/ejo.ejo_25_17  
Objective The aim of this work was to study whether or not the hearing loss encountered in some hypothyroid patients can be improved with L-thyroxine hormone therapy, as other symptoms of hypothyroidism. Study design The study design was a prospective cohort one. Patients and methods This study included 30 patients of either sex who were proved to be in a hypothyroid state with an additional symptom of hearing impairment. The study was carried out in Alexandria Main University Hospital and was conducted in a prospective manner. All selected patients were proved to be in a hypothyroid state in the Endocrinology Department. Moreover, their symptom of hearing impairment was confirmed by thorough audiological examination supplemented by pure-tone audiometry plus tympanometry that was carried out in the ENT Department and the associate Audiology Unit. L-thyroxine treatment for hypothyroidism was initiated in all cases for 6 months to maintain a state of euthyroidism. At the end of 6 months, a repeat audiogram and tympanometry were performed in all patients in order to evaluate the efficacy of the said treatment protocol on the hearing in these patients. Cases proved to have hearing impairment irrelevant to the hypothyroid condition were excluded. Informed consent was compulsory for recruitment in this study. Results Post-treatment assessment revealed that variable improvement was achieved in 48% of ears, whereas 52% did not respond to the given treatment, with the impairment remaining nearly the same as it was before. Of the improved ears, in 15% of ears hearing levels were restored to normal hearing levels. Thereby, adherence to replacement therapy may reverse the hearing deficits in a few number of hypothyroid patients. Conclusion There is a definitive improvement in hearing with the use of L-thyroxine treatment of hypothyroid patients with hearing impairment.
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Visual vestibular mismatch: is it a vestibular disorder? p. 645
Nadia Kamal, Hesham Taha, Rasha H El-Kabarity, Dina Housni
DOI:10.4103/ejo.ejo_69_17  
Background Visual vestibular mismatch (VVM) is a group of symptoms rather than a disease. All are exaggerated by introducing any visual conflict. For such reason, there is no adequate tools to investigate or to diagnose and limited research studies were done to explore such group of people. Aim To identify VVM disorder among dizzy patients and to study the vestibular function in them. Patients and methods This study was conducted on 30 patients suffering from VVM (out of 153 patients) who were selected by a questionnaire modified by the authors based on the original questionnaire. All patients were subjected to objective testing including: full neuro-otological history, office vestibular tests including dynamic visual test (DVA), modified clinical test of sensory integration of balance (MCTSIB), Fukuda stepping test, functional reach test, videonystagmography and vestibular evoked myogenic potentials (VEMPs). Results VVM symptomatology was found in 19 patients (subjectively by Mallison questionnaire) and reached 30 patients using a modified questionnaire. 23.33% patients had abnormal Fukuda test, 26.6% had abnormal functional reach test, while 97.6% of patients had abnormal MCTSIB test scores and 50% had abnormal DVA test scores. Abnormal cervical VEMP test results were present in 50% of cases, while only 10% suffered from videonystagmography abnormalities reflecting minor affection of semicircular canals as compared with the saccule. Conclusion This study showed that VVM is a fairly common complain among the dizzy population and it can be easily picked up using a simple questionnaire. Office tests as DVA and MCTSIB were highly sensitive tests for VVM patients but more research is needed to find the correlations between these tests and VVM. The study pointed out to the importance of cervical VEMP test to be routinely enrolled in testing of patients with suggestive symptoms of VVM. Further researches should be conducted for knowing the underlying cause and the exact role of saccule in VVM.
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Assessment of the audiovestibular system in patients with rheumatoid arthritis p. 650
Tarek M El Dessouky, Enas Abu El Khair, Rabab Ahmed Koura, Sara Ahmed El Sharkawy
DOI:10.4103/1012-5574.217388  
Objective This study was designed to assess hearing and vestibular function in patients with rheumatoid arthritis (RA) in comparison with a control group. In addition, we correlated these findings in disease activity and severity. Materials and methods Totally, 40 RA patients (35 women and five men) diagnosed according to the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria and 20 healthy controls (11 women and nine men), whose age ranged from 25 to 66 years with a mean age of 45.5±12.4 years, were included in the study. Each individuals was tested with pure tone audiometry. Mean values of air and bone conduction at each frequency and tympanometric values were calculated for the study groups. Videonystagmography (VNG) test including smooth pursuit, saccade, optokinetic tests, positioning tests, positional test, and water caloric tests was also carried out. Results The mean air conduction threshold values at high frequencies (4000 and 8000 Hz) in the RA group were lower than in the control group. The difference between mean air conduction threshold values of the control group and the RA group at high frequencies was statistically significant (P<0.05). There was no statistically significance between the two groups as regards speech reception threshold, speech discrimination (DIS), and tympanometric values (P>0.05). VNG testing revealed central abnormalities in 12 (30%) patients, peripheral abnormalities in nine (22.5%) patients, and mixed abnormalities in one (2.5%) patient. There was no association between VNG abnormalities in patients with RA and age, sex, duration of disease, accompanying vertigo complaint, and the laboratory findings (P>0.05). Conclusion There is an association between RA and audiovestibular system dysfunction regardless clinical and demographic situation of patients. We assume that the shearing and vestibular disturbances in RA are more prevalent than previously recognized. High-frequency hearing loss in RA patients could be an indicator of cochlear involvement.
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Complex auditory brainstem response in normal-hearing adults using binaural versus monaural speech stimuli p. 656
Abeir Osman Dabbous, Rabab Ahmed Koura, Mona Mohamed Hamdy
DOI:10.4103/ejo.ejo_74_16  
Background Binaural hearing refers to the ability of the auditory system to integrate sounds reaching both ears. The complex auditory brainstem response (cABR) to the /da/ synthetic syllable gives information about time-locked response that is either transient or sustained depending on the periodic or nonperiodic characteristics of the stimulus. Objective This is a preliminary research that was performed to study the binaural interaction component of cABR in normal-hearing adults. Patients and methods This study included 20 normal-hearing adults, whose age ranged from 15 to 60 years, with a mean age of 29.30±12.52 years. CABR was conducted for all patients. The stimulus used was the syllable [da] (40 ms), presented first monaurally (left and right) and then binaurally through TDH headphones, in alternating polarity at 80 dBnHL. binaural interaction component (BIC) was then computed by subtracting the binaural waveform from the sum of the two monaural responses. Results The mean right amplitudes were smaller than binaural amplitudes for waves V, A, C, D, E, and F. However, this difference was statistically significant at D, E, and F waves only. The mean left amplitudes were smaller than binaural amplitudes for waves V, A, C, D, and E only. In addition, this difference was statistically significant. The mean binaural amplitudes were smaller than the summed right+left amplitudes for waves V, A, C, D, E, F, and O. There was no statistically significant difference among the mean latencies of responses recorded from right, left, or binaural for all cABR waves. Conclusion BICs reflecting binaural process can be obtained for ABR using speech stimuli comparing the binaural and summed monaural recorded responses. We recommend assessing the BIC on a large scale to obtain normative data, for comparison with patients with known auditory processing capabilities (shown by behavioural tests) to see how well the data can be used as an index of binaural process.
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The relationship between visual–motor integration and handwriting skills in Arabic-speaking Egyptian children at the age of 4–6 years p. 663
Tamer Abou-El-Saad, Omayma Afsah, Hemmat Baz, Walaa Shaaban
DOI:10.4103/ejo.ejo_44_17  
Background Handwriting is a complex perceptual-motor skill that is dependent on the maturation and integration of a number of cognitive, perceptual, and motor skills. Aim To examine the relationship between visual–motor skills and handwriting skills (HS) in Arabic-speaking Egyptian children at the age of 4–6 years. Patients and methods Overall, 200 typically developing kindergarten and primary school Arabic-speaking children, in the age range of 4–6 years, were tested using a constructed battery for assessment of both visual–motor integration (VMI) and HS. Results and conclusion Performance on both VMI and HS tasks improved with age. Moreover, the older the child was, the lesser the duration for completion of the tasks. Copying lines was found to be the best predictor of copying letters, copying words, and copying numbers. Reliability and validity of the designed VMI and HS assessment battery proved to be excellent. VMI is an important prerequisite for Arabic HS.
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Correlation between stuttering severity and pragmatic development in Egyptian children who stutter p. 670
Sabah Mohammed Hassan, Yossra Abdel Naby Sallam, Mona Sameeh Khodeir, Ola Shaaban Mahmoud
DOI:10.4103/ejo.ejo_60_17  
Background Few studies have been carried out concerning the relation between stuttering behaviors and language pragmatics in children who stutter (CWS). The correlation between stuttering severity and pragmatic development in CWS is scarce in the literature so far. Aim This research aimed to study the relationship between stuttering severity and pragmatic language development in the Egyptian Arabic-speaking CWS. Patients and methods This study is an analytical cross-sectional study carried out at the Phoniatrics Clinics of El-Demerdash Hospital (Ain Shams University) and El-Zahraa Hospital (Al Azhar University). A total of 60 Egyptian CWS in the age range between 4 years 1 day and 9 years 11 months 31 days were selected conveniently based on inclusion and exclusion criteria. Selected children underwent the Ain Shams assessment protocol for fluency disorders, including assessment of stuttering severity by Bloodstein (BLS) classification and the Stuttering Severity Instrument for Children and Adults − Arabic version (ASSI). The standardized Egyptian Arabic Pragmatic Language Test has been used to assess the pragmatic language development. Pearson’s correlation coefficient has been used to correlate the total pragmatic language age and degree of stuttering severity by BLS classification and the ASSI. Results Upon application of the Egyptian Arabic Pragmatic Language Test, all the participating children had no pragmatic language delay. They had scores either at and/or above their fifth percentiles in all the test items except in the paralinguistic aspect. There was no statistically significant correlation between grades of BLS classification or ASSI and the total pragmatic language age. Conclusion CWS had no pragmatic language delay except in the paralinguistic aspects.
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Successful management of functional aphonia using a modified voice therapy technique: a case series p. 679
Aboloyoun I Ali, Marglani Osama, Elmorsy A Soha, El Kholy M Rasha, Farooq U Mian
DOI:10.4103/ejo.ejo_39_17  
Objective The aim of the present study was to report the experience of a tertiary-care center in Makkah, Saudi Arabia in managing cases of functional aphonia. Study settings and design A case series study was conducted at the Phoniatrics Outpatient Clinics of King Abdullah Medical City in Holy Makkah, Saudi Arabia. Materials and methods Cases with functional aphonia managed by modified voice therapy technique in the period from March 2011 to January 2016 at the Phoniatrics Outpatient Clinics were recruited. Management consisted of auditory perceptual assessment, acoustic analysis, laryngeal examination, and voice handicap index measurement. All these parameters were recorded for each case before and after management. Statistical analysis Data were analyzed using statistical package for the social sciences version 16, and data were subjected to descriptive as well as inferential analyses. Results A total of 15 patients with functional aphonia were managed. One female patient had an exceptionally long period of aphonia, and her case is presented separately. The success rate of the procedure used for management was 100%. Conclusion Using the nonphonatory function of vocal folds in a modified manner by experienced therapists leads to recovery of voice regardless of the period of aphonia.
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Language disorders in children with congenital hypothyroidism p. 685
Haitham M Mohamed, Efat Zaki, Adel Abdel Baki Abdall, Mohammed A Gomaa, Marwa M Abdel Wahab
DOI:10.4103/1012-5574.217383  
Introduction Congenital hypothyroidism (CH) represents one of the most common preventable causes of mental retardation. If fetal hypothyroidism develops, untoward effects may be shown in certain organ systems, including the central nervous system. CH may be associated with hearing and language impairment. It is possible that this impairment may worsen with delay of therapy. Problems in language, auditory processing, and reading may persist in hypothyroid children, particularly if their treatment with l-thyroxin is delayed into the third week of life. The aim of this study is to estimate the extent of language disorder and detect the factors influencing language acquisition in children with CH. Patients and methods This study included 60 children. The study group included 40 children who complained of CH. The age range of this group was 3–8 years. The children of the study group were divided according to the level of thyroid stimulating hormone (TSH) and T4 into two subgroups. The G1 subgroup included children with controlled CH and subgroup G2 included children with uncontrolled hypothyroidism. The results of the study group were compared with those of another group (control group), which included 20 children; both groups were matched for age and sex. The children of both groups were subjected to the protocol of language assessment. Results and conclusion The current study showed that the children with uncontrolled CH show delayed language, mental, social age, and intelligence quotient in comparison with children with controlled hypothyroidism and normal children. There is a need for the diagnosis and treatment of children with CH as soon as possible after birth, preferably no later than the second week of life. It is also important to screen hypothyroid children for hearing problems and to provide remediation in language and reading.
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CASE REPORTS Top

Lipoma of parotid: a case report p. 691
Ripon M Chowdhury, Dev Roy, Sanjib K Pattari
DOI:10.4103/ejo.ejo_10_17  
Lipomas are common benign soft tissue neoplasm, but they seldom occur in head and neck regions compared to other sites. Fine needle aspiration cytology (FNAC) accompanied with Computed tomography (CT) scan and Magnetic Resonance Imaging (MRI) determines its diagnosis preoperatively. In symptomatic cases, surgery remains the treatment of choice but requires an experienced surgeon because of possible damage to the facial nerve and its branches. The authors have discussed a rare case of lipoma, involving the deep and superficial lobe of parotid of a 42-year-old female patient with emphasis on its characteristics, preoperative diagnostic methods and its surgery. This case report shows MRI’s to be potent diagnostic tool for Lipoma of the parotid, by means of which a surgical procedure could be planned while maintaining function and aesthetics.
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Ameloblastic fibro-odontoma of the maxilla: a case report p. 694
Belal Alani, Muraja Aldoori, Amar Adham, Farag Ismail
DOI:10.4103/ejo.ejo_34_17  
The ameloblastic fibro-odontoma is a rare benign odontogenic lesion defined as a tumor with the general features of ameloblastic fibroma but that also contains enamel and dentin. In this article the authors describe a case of a young male patient with ameloblastic fibro-odontoma of the maxilla and the management of such condition.
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