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Table of Contents
October-December 2014
Volume 30 | Issue 4
Page Nos. -
Online since Wednesday, November 19, 2014
Accessed 70,997 times.
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EDITORIAL LETTER
Egyptian curriculum and assessment protocol for postgraduate study in otorhinolaryngology, head and neck surgery advanced training
p. 279
Zoheir El Hoshy, Ihab K Sefein, Mohamed M El Sheikh, Abdulrahman Younes
DOI
:10.4103/1012-5574.144958
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ORIGINAL ARTICLES
Endoscopic criteria of offending vessel in neurovascular compression syndrome
p. 305
Sherif Elaini, Jaques Magnan, Arnaud Deveze
DOI
:10.4103/1012-5574.144960
Objectives
The aim of this work was to detect the anatomical relationship criteria of the offending vessel with respect to the cranial nerve in neurovascular compression syndrome using the endoscopic-assisted minimally invasive retrosigmoid approach for microvascular decompression (MVD); these criteria help the surgeon to define the actual conflicting vessel during surgery for better results.
Materials and method
Between 1994 and 2009, we have performed 782 cases of MVD surgeries using endoscopic-assisted minimally invasive retrosigmoid approach (453 MVD surgeries for hemifacial spasm, 269 for trigeminal neuralgia, 56 for tinnitus and vertigo, and four decompressions for glossopharyngeal neuralgia). During these surgeries we recorded the anatomical relationships between the offending vessel and the affected cranial nerve to detect the endoscopic criteria of the offending vessel.
Results
There are certain criteria for the anatomical relationship between the offending vessel and affected cranial nerve; these criteria include common features such as a perpendicular contact between the vascular loop and the cranial nerve along two different perpendicular planes at its root exit zone, distortion of the nerve course, and distortion or compression of adjacent neural structures mainly brain stem. Other criteria include the vascular loop causing impression of the nerve or encircling the nerve causing reduction of its diameter.
Conclusion
Certain criteria for the anatomical relationship between the offending vessel and the affected cranial nerve should be fulfilled to diagnose the actual conflicting vessel during MVD surgery in vascular compression syndrome using endoscopic-assisted minimally invasive retrosigmoid approach.
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Chitosan patch scaffold for repair of chronic safe tympanic membrane perforation
p. 311
Ahmed Shehata, Samira Mohamed
DOI
:10.4103/1012-5574.144961
Objective
This study was designed to evaluate the performances of chitosan patch myringoplasty in patients with small and medium sized chronic safe tympanic membrane (T.M) perforations.
Patients and methods
After preparation of the chitosan patch scaffold (CPS), 60 consecutive dry small and medium sized(from <3 mm up to 5 mm) central tympanic membrane perforations were included in this study.
Results
Healing of T.M perforations was achieved in 14 out of 19 in small perforations (73.68%) and 25 out of 41 in medium sized perforations (60.97%) also significant improvement of hearing and tinnitus were achieved post-operatively.
Conclusion
Myringoplasty by water insoluble chitosan patch scaffold with 3% chitosan and 3% glycerol is easy, safe and quick method. It can be done in outpatient clinic without risk of general anesthesia and with noticeable reduction in the time of operation.
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Evaluation of facial nerve course, posterior tympanotomy width and visibility of round window in patients with cochlear implantation by performing oblique sagittal cut computed tomographic scan temporal bone
p. 317
Mohamed S Hasaballah, Tarek A Hamdy
DOI
:10.4103/1012-5574.144963
Background
Posterior tympanotomy is a well-known otologic procedure that allows surgeons access to the middle ear cavity. During posterior tympanotomy the surgeon can approach the round window niche and promontory, where a cochleostomy is carried out for cochlear implant electrode array insertion. The mastoid segment of the facial nerve and the chorda tympani nerve could be injured in cases of narrow facial recess or inadequate posterior tympanotomy. With the image reconstruction in an oblique sagittal plane and curve reconstructions, the whole tympanic and mastoid segments of the facial nerve can be visualized in just one image. It is necessary to preoperatively estimate both the facial nerve status and the anatomical relationships between the facial recess and the round window, this may reduce the risk of facial nerve injury and influence the decision on which side to implant, which approach to use and whether to enter the cochlea via cochleostomy or round window membrane route.
Objectives
The aim of our study is to evaluate the facial nerve (course and anomalies), visibility of the round window membrane and the width of posterior tympanotomy before cochlear implantation by using oblique sagittal cuts CT scan temporal bone.
Methods
A prospective study; done on 18 consecutive patients with severe to profound sensorineural hearing loss who are candidates for cochlear implantation in Ain Shams University Hospitals during years 2011 & 2012. We focused on oblique sagittal cut CT scan & its role to evaluate the course of facial nerve, posterior tympanotomy width and visibility of the round window.
Results
We tried to make a statistical correlation between CT scan and intraoperative findings. Statistically significant positive correlation between posterior tympanotomy width and 2nd genu angle, distance from facial bony canal to round window and distance from facial nerve to round window. The mean distance from facial bony canal to round window was longer in operatively viewed round window than non-viewed window (4.7 and 4.4 mm respectively) (
P
< 0.05). The mean distance from facial nerve to round window was longer in operatively viewed round window membrane than non-viewed window (5.9 and 5.5 mm respectively) (
P
< 0.05). The mean width of posterior tympanotomy was wider in operatively viewed round window niche than non-viewed window niche (3.1 and 3.0 mm respectively) (
P
< 0.01).
Conclusion
Oblique sagittal cuts CT scan temporal bone is very helpful preoperative radiological tool for evaluation of the facial nerve course and anatomical factors that may determine the field of view or the accessibility of the posterior tympanotomy for either cochleostomy or round window membrane approach. Other approaches can be used with more safety when the position of the facial nerve prevents an adequate posterior tympanotomy.
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Folic acid and vitamin-B
12
in idiopathic sensorineural hearing loss in children
p. 322
Mohamed S Taha, Mohamed Amir, Heba Mahmoud, Azza Omran, Hesham M Taha
DOI
:10.4103/1012-5574.144964
Aim
The aim of the study was to evaluate the role of vitamin-B
12
and folate blood concentrations in children suffering from moderate, severe, and severe-to-profound sensorineural hearing loss (SNHL).
Materials and methods
This study was conducted on 95 children: 30 children with severe-to-profound SNHL who were scheduled for cochlear implantation, 25 children who are hearing aid users for moderate and severe SNHL, and another 40 healthy volunteers considered as the control group. Full audiological examination was performed to all children, as well as computed tomographic scan and MRI to temporal bone were performed for the SNHL groups.
Results
Median vitamin-B
12
and folic acid levels were significantly higher in the control group 3 than in the SNHL groups 1 and 2 patients (
P <
0.001). There was no significant correlation between vitamin-B
12
and folic acid levels and the other parameters. There was no significant difference between groups 1 and 2 with respect to median vitamin-B
12
and folic acid level.
Conclusion
Study demonstrated that the serum levels of folate and vitamin-B
12
are decreased in patients with SNHL. Measurement of folic acid and vitamin-B
12
in patients suffering SNHL might be useful. These data may give us some clues about how hearing loss is developed in these patients.
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Topical tranexamic acid versus hot saline for field quality during endoscopic sinus surgery
p. 327
Ahmed Shehata, Mohammed Sabra Ibrahim, Mohammed Hamed Abd-El-Fattah
DOI
:10.4103/1012-5574.144965
Objectives
This study conducted to evaluate and compare between topical tranexamic acid (TA) and hot saline as an alternative to local vasoconstrictors on bleeding and surgery site quality during endoscopic sinus surgery (FESS).
Patients and methods
This study was performed on 75 patients with class I and II American society of anesthesiologists (A.S.A.), scheduled for elective FESS under general anesthesia. Patients divided into three groups, each (25 patients), group A: topical tranexamic acid (1000mg diluted in 20ml normal saline) was used during surgery for packing and irrigation, group B: hot saline up to 50°C was used and group C :(control group) normal saline was used.
Results
The use of local (TA) was associated with significant decrease in estimated blood loss 214.2 ml more than local hot saline which was 216.75 and both is much better than the normal saline which was 272.66. Also (TA) and hot saline showed decrease in the duration of surgery, improve the surgical field quality and blinded surgeon satisfaction as compared with the control group.
Conclusion
The use of local TA and local hot saline up to 50°C achieved reduction in blood loss, duration of surgery and improved surgical field quality during FESS.
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Impact of preoperatative tracheostomy on tracheostome recurrence and overall survival in patients undergoing laryngectomy
p. 332
Mohamed S Taha, Reda Sabra, Tarek A Hamdy, Magdy A Riad
DOI
:10.4103/1012-5574.144966
Background
The development of tracheostomerecurrence after total laryngectomy is a complication with a dismal prognosis .The average survival rate of tracheostome recurrence (TR) is 7.5%, ranging from 1.7% to 40%The TR consists of diffuse infiltration of tumor into the soft tissues of the neck and mediastinum; hence the control of this disease is difficult.
Objective
To analyze the impact of preoperative tracheostomy ontracheostome recurrence (TR), regional recurrence (RR), and overall survival (OS) in patients undergoing primary laryngectomy.
Material and methods
Thirty three consecutive patients, who underwent primary total laryngectomy for locally advancedlaryngeal squamous cell carcinoma, were enrolled in this study. Patients whounderwent primary chemo-radiotherapy, partial laryngectomyor those treated palliatively wereexcluded from the study.Patient factors analyzed included age,gender, primarytumor site, TNM classification, type of procedure, thyroid gland management, extent of neck dissection and preoperative tracheostomy (POT). The timeinterval between tracheostomy and definitive surgery was calculated.
Results
A total of 33 patients underwent total laryngectomy(TL) for squamous cell carcinoma of the larynx.Thirty patients (90.9%) were males, while 3 (9.1%) patients were females. Their mean age was 57.7 (±11.6) years, 26 (78.8%) of them were smokers, their follow up mean time was 23 (±6.6) months. Tracheostomy recurrence occurred in 3 (9.1%) patients and regional recurrence in another 3(9.1%) patients. The 2 years survivalfor the whole patients was 84.8% and overall survival was 81.1%. Nineteen patients had POTbetween 10 to 21days (median 15)prior to TL surgery. Fourteen patients had their tracheostomy at the time of surgery .There was no statistical significant difference between both groups as regard overall survival, stomal recurrence and regional recurrence.
Conclusion
Our results are in keeping with more recent studies, which suggest that POT is notnecessarily related to stomal recurrence or poor oncological outcome.
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Tonsillectomy under the age of 3 years: is it recommended or not?
p. 337
Khalid M Bofares
DOI
:10.4103/1012-5574.144967
Background and objectives
Tonsillectomy is the most common surgical procedure in specialty of otorhinolaryngology. Therefore, there are frequent premises regarding this procedure to be improved from different aspects, indications, time of surgery, techniques, safety measures, and postoperative care. One of the major issues regarding this procedure is the most suitable age for the surgery. This point is creating a lot of controversies particularly at extreme age groups - that is, less than 3 years and more than 60 years. Although the extreme old age groups are considered as risky for any surgical procedures specially for tonsillectomy due to lack of proper body tissues tolerance and response to post-tonsillectomy bleeding as well as upper airway edema and obstruction, those age groups are still at lesser incidence of morbidity and mortality as compared to the infantile age groups who take the wider spectrum of ENT surgeons' concentration, discussions, and studies regarding this issue. Therefore, this study was conducted prospectively to confirm whether tonsillectomy can be performed safely before 3 years of age with nonsignificant difference regarding postoperative morbidity and mortality as compared to the other age group of 3 years or above.
Patients and methods
A total of 648 children aged from 8 months to 8 years presented at ENT department, Al-Thowra central teaching hospital and Altarahom private center, Elbyda city, Libya during the period between September 2005 and October 2012 as cases of chronic adenotonsillitis with variable patterns of indications for tonsillectomy, namely snoring and apnea attacks, persistent otitis media with effusion, recurrent attacks of acute suppurative otitis media, failure to thrive, recurrent attacks of chest infection, and malocclusive dental deformity. In all, 241 patients were under age of 3 years who represented group A, whereas remaining 407 patients at age of 3 years and above constituted group B. As prospective analytic study, both groups were compared with respect to intraoperative time consumption and whether there is any significant difference between the two groups regarding the incidence of serious postoperative complications occurrence, namely post-tonsillectomy bleeding, aspiration, airway obstruction, dehydration, postadenotonsillectomy negative pressure pulmonary edema, and metabolic as well as nutritional deficiencies. In addition, both groups were compared for any significant difference regarding the period of postoperative hospitalization, which can be used as objective indicator to measure the postoperative morbidity rate.
Results
This presenting study confirmed that the tonsillectomy procedure is an easy procedure among children younger than 3 years of age as in older children; this can be indicated by the appearance of nonsignificant difference between both groups regarding the intraoperative time consumption. In contrast, this procedure approved to be a safe procedure among children with age below 3 years as in older children; this was illustrated by the presence of nonsignificant difference between group A and group B regarding the serious suspected post-tonsillectomy complications, namely post-tonsillectomy hemorrhage, aspiration, airway obstruction, negative pressure pulmonary edema, dehydration, and metabolic as well as nutritional deficiencies.
Conclusion
In general, tonsillectomy is a safe procedure that can be performed successfully among children at different age groups with low incidence of post-tonsillectomy complications as compared with adults.
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Insulin-like growth factor alpha changes after tonsillectomy for obstructive and nonobstructive causes
p. 343
Ismail Elnashar, Mohammad W El-Anwar, Ashraf Raafat, Eman Aesa, Seham Fathy
DOI
:10.4103/1012-5574.144969
Objective
To assess the effect of tonsillectomy, weather performed for obstructive or nonobstructive causes, on the serum levels of insulin-like growth factor alpha (IGF-1).
Patients and methods
This prospective study was carried out on 60 children who underwent tonsillectomy or adenotonsillectomy at Zagazig University Hospitals. The children were divided into two groups: the first group included 30 children who underwent tonsillectomy because of obstructive symptoms and the second group included 30 children who underwent tonsillectomy because of recurrent tonsillitis with no manifestations of upper-airway obstruction. Preoperative and 3 months' postoperative blood levels of IGF-1 were estimated and the data were statistically analyzed.
Results
Six children from the first group (24 children) and four children from the second group (26 children) did not follow-up after surgery and were excluded from the study. Both study groups were matched for age and sex. In the first (obstructive) group, there was a statistically significant increase in the mean level of IGF-1 from 119.08109 ± 27.81797 preoperatively to 222.395 ± 6.62559 postoperatively and the difference was significant (
P
< 0.0001). However, in the second (infection) group, the mean IGF-1 values increased from 155.0715 ± 89.83015 preoperatively to 191.4075 ± 57.38667 postoperatively, and the difference was not significant (
P
= 0.0883).
Conclusion
Insufficient weight and height gain in children who had obstructive adenotonsillar hypertrophy could be attributed to low IGF-1, and this can be corrected after surgery. This is not the case in patients with chronic tonsillitis without upper-airway obstruction, and other factors may explain the retarded growth in these patients.
Study design
A prospective study.
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Oropharyngeal packing for resistant post-tonsillectomy bleeding
p. 347
Magdy I Goda, Mohammad W. M El-Anwar, Ismail Elnashar, Eid Gumaa
DOI
:10.4103/1012-5574.144973
Background
Tonsillectomy remains a common surgical procedure with a substantial risk for complications, the greatest of which is postoperative hemorrhage.
Objective
The aim of this study was to assess the efficiency of oropharyngeal packing around the orotracheal tube to control resistant, potentially lethal, post-tonsillectomy bleeding.
Patients and methods
Six patients were presented to our institution with massive (potentially fatal) post-tonsillectomy hemorrhage from January 2002 to June 2011. After failure of initial measures to control bleeding, oropharyngeal packing around the orotracheal tube with or without a nasogastric tube was inserted to compress the bleeding areas.
Results
Oropharyngeal packing succeeded in controlling and stopping resistant post-tonsillectomy bleeding in all cases.
Conclusion
Resistant, potentially fatal, post-tonsillectomy bleeding could be controlled by oropharyngeal packing around orotracheal tubes, and this can be tried first before external carotid artery ligature.
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Tinnitus patients and the internet: impact on physician-patient relationship
p. 351
MW Mustafa, BS Badawy
DOI
:10.4103/1012-5574.144974
Introduction and rationale
The internet has become a trustable and increasingly available source for medical information. When patients explore the internet, their attitude toward their selected physician and his medical decisions becomes distorted and biased by the medical information they get from the web. This study was designed to address the effect of medical data available on the web on tinnitus patients and their expectations for treatment.
Design
A total of 106 patients who had tinnitus, for variable periods and due to different causes, participated in the current study. At the end of the counseling session, half of the patients (53) were randomly selected and were advised to try Google search engine, using these keywords in Arabic language (tinnitus treatment fx1 fx2 fx3). The other half of the patients were not advised to use the internet. Each patient who came back after 2 weeks answered a questionnaire in Arabic that was designed to outline the patients' choice among available treatment options.
Conclusion
Use of the internet among Egyptian tinnitus patients is a complimentary rather than a basic source of medical information. Its impact on the physician-patient relationship could be both positive and negative. However, it did not hamper the physicians' credibility and/or reliability.
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The study of central auditory processing in stuttering children
p. 357
Samir Asal, Rania M Abdou
DOI
:10.4103/1012-5574.144976
Background
There are evidences that indicate a relationship between auditory processing disorders and stuttering.
Aim
The aim of the study was to evaluate central auditory processing in stuttering children and to compare the findings with those of normal fluent children.
Patients and methods
Twenty stuttering school-age children of both sexes were included in the study. A control group included 20 age-matched and sex-matched nonstuttering children. Full informed consent from all participants was taken before initiating the study. All participants were subjected to the following central auditory processing tests: pitch pattern sequence test (PPST), dichotic digit test (DDT), speech in noise test (children version) (SPIN), auditory fusion test revised (AFT-R), and binaural masking level difference (MLD) test. All patients were subjected to stuttering severity instrument III to assess their stuttering and its severity.
Results
The stuttering group scored significantly poorer in the PPST, DDT, and SPIN, whereas they scored similar to the control group in MLD and AFT-R. There was no correlation between the severity of stuttering and the performance on the central auditory processing tests.
Conclusion
Stuttering children have an intact brain stem integrity shown by the normal MLD and an intact right hemisphere as signified by the normal right and left ear difference in the DDT and by the improvement in the PPST on humming. Left hemisphere deficit appears in more complicated tasks such as PPST, DDT, and SPIN, but not in simple tasks such as AFT-R. We can conclude that the deficit is within the left cerebral hemisphere.
Recommendation
The effect of the usage of central auditory processing disorder rehabilitation programs on those children should further be assessed.
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The side of cochlear implantation and speech intelligibility in pediatric and adult cochlear implantees
p. 362
Abdelhamid A Mohammed, Sally A Sarwat
DOI
:10.4103/1012-5574.144977
Background
A cochlear implant (CI) is an auditory prosthesis that stimulates the primary auditory nerve fibers electrically to elicit sound perception in individuals with severe-to-profound sensorineural hearing impairments. Speech intelligibility is a joint product of a speaker and a listener and can provide a close approximation of an individual's everyday communication status, and cochlear implants can facilitate the development of speech and language skills in prelingually deaf patients.
Aim
The aim of this work was to study whether there is an advantage of one ear in the improvement of speech intelligibility in pediatric and adult cochlear-implanted patients.
Study design
A cross-sectional study to assess the speech intelligibility of right and left cochlear-implanted patients.
Patients and methods
The study included 50 cochlear-implanted patients (24 male and 26 female): 25 of the patients were prelingual and 25 were postlingual. Twenty-six of the patients were implanted on the right ear and 24 were implanted on the left ear. Speech intelligibility assessment was conducted using the Arabic Speech Intelligibility test. This Arabic Speech Intelligibility test is meant to be an objective measure as the examiner does not have to evaluate how a word was said.
Results
The results revealed that there was no significant difference between the speech intelligibility percentage regarding the onset of deafness (prelingual or postlingual), the sex and the duration of therapy, but there was a significant difference between the speech intelligibility percentage in right-ear-implanted and left-ear-implanted patients, with marked advantage for the implanted right ear.
Conclusion and recommendation
Right-ear cochlear implantation has an advantage over left-ear implantation regarding the speech intelligibility. Hence, in case of bilateral profound deafness of the same degree with no anatomical complications in either of the ears, it is recommended to choose the right ear for cochlear implantation.
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CASE REPORTS
Dorsal nasal deformity: an unusual initial presentation of nasal schwannoma
p. 367
Ahmed S Elhamshary, Medhat H Mansour, Kamal Ebeid, Mostafa I Ammar
DOI
:10.4103/1012-5574.144980
Nasal schwannomas are very rare neoplasms. We present the case of a 54-year-old woman who had dorsal nasal deformity and partial right-sided nasal obstruction over 5 years. Computerized tomography scan of the nose and paranasal sinuses revealed a soft tissue mass in the anterior part of the right nasal cavity with expansion of the overlying nasal bony wall. Complete endoscopic excision of this mass was performed revealing benign schwannoma with no recurrence over 3 years of follow-up. According to the best of our knowledge, this case is the first reported case of a nasal schwannoma presenting with dorsal nasal deformity in the English literature. This case highlights the importance of thorough endoscopic nasal examination in every patient presenting with a dorsal nasal deformity as well as the consideration of nasal schwannoma in the differential diagnosis of a dorsal nasal deformity.
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Castleman's disease
p. 371
Ashraf A Kasem, Talal Al Thubaity
DOI
:10.4103/1012-5574.144981
Background and Aims
Castleman's disease is a rare disease of lymph node with two identified forms - the hyaline vascular type or angiofollicular type and plasma cell type. It usually presents as localized or systemic lymphadenopathy or even as extra nodal mass and may give rise to several differential diagnoses. Fine needle aspiration cytology (FNAC), as the initial investigation, may be misleading. Excision biopsy usually gives the diagnosis.
Materials and Methods
We report a case of an 8 year old male child who was Presented with a history of a slowly growing mass in his right side of neck for 3 yrs. He Was largely asymptomatic except for occasional discomfort around the mass. His past medical and family history was non-specific. On examination a non-tender, firm mass Was palpated . Initially Clinically suspected to be lymphoma, but was later histologically confirmed to have Castleman's disease.
Result
We had one case of Castleman's disease which presented as cervical lymphadenopathy of 3 * 2 cms in 8 year child. Patient was mostly asymptomatic with all relevant investigations within normal limits. The cytology findings mostly showed a predominance of small lymphocytes with capillary fragments. On excision biopsy, the case was diagnosed as Castleman's disease of the hyaline vascular type.
Conclusion
Castleman's disease should be kept as a differential of lymphadenopathy, especially in asymptomatic and young patients.
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BOOK REVIEW
Comprehensive and clinical anatomy of the middle ear
p. 374
Samia A Fawaz
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© The Egyptian Journal of Otolaryngology | Published by Wolters Kluwer -
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Online since 31 Jan, 2014