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   Table of Contents - Current issue
January-March 2018
Volume 24 | Issue 1
Page Nos. 1-74

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Systematic review and meta-analysis of otitis media in Iran: Prevalence, etiology, antibiotic susceptibility, and complications Highly accessed article p. 1
Safar-Ali Amiri-Andy, Diana Sarokhani, Milad Azami, Hossein Vazini, Mostafa Rezaei-Tavirani, Ali Hasanpour Dehkordi
Otitis media (OM) is a relatively common infectious disease, and its chronic form may lead to complications such as hearing impairment. This study aims to determine the prevalence, etiology, antibiotic susceptibility, and complications of OM in Iran through meta-analysis. English language databases, including Science Direct, PubMed, Scopus, Web of Science, and Persian language databases, including SID, Magiran, Iranmedex, Medlib, as well as the Google Scholar search engine, were searched from 1994 to 2017, using the Mesh keywords: Otitis media, Middle ear, Causality, Etiology, and Iran. The heterogeneity assessment of the studies was done using Q-Cochran test and I2 index. Considering the high heterogeneity of the studies, the random effects model was used to estimate the point prevalence with 95% confidence interval. Data were analyzed using STATA version 11.1 software. Fifty-one articles with a sample size of 10,675 were reviewed in this study, the most common types of OM involvement were right otitis (51% [95% confidence interval (CI): 33–68]), left otitis (44% [95% CI: 36–52]), and bilateral otitis (33% [95% CI: 7–59]). The most common bacterial etiologies involved in OM were Pseudomonas aeruginosa (26% [CI 95%: 17–35]), Proteus (21% [95% CI: 0%–45%]), and Staphylococcus (20% [95% CI: 0–42]). The fungal etiology of OM was estimated to be 22% (95% CI: 4–40). The most common OM pathologies were ossicular changes (56%[95% CI, 27–85]), granulation (49% [95% CI: 18–80]), cholesteatoma (32% [95% CI: 13–51]), tympanosclerosis (17% [95% CI: 10–23]), and cholesterol granuloma (11% [95% CI: 0–26]). The results of this meta-analysis provide useful information on the epidemiology of OM in Iran to otorhinologists and health policymakers.
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Effect of smoke from medicinal herbs on the nosocomial infections in ENT outpatient department p. 9
TU Samanth, Sushil G Jha, Vikas Sinha, Shirishkumar Patel, Kairavi J Desai
Introduction: From time immemorial, human beings have used smoke of medicinal plants for curing disorders. Smoke produced from natural substances has been used extensively in many cultures, and famous ancient physicians have described and recommended such use. Aim and Objective: To reduce the nosocomial infections at the ENT outpatient department. Materials and Methods: Air sampling is done by set plate method. Air sampling of the medicinal smoke arising after burning a mixture of wood of mango or pipal tree andmedicinal herbs (obtained from shantikunj haridwar ) with rituals in an indoor environment. Results: Medicinal smoke caused over 95% reduction of aerial bacterial counts by 60 min. Conclusion: We have observed that 1 h treatment of medicinal smoke emanated by burning wood and a mixture of odoriferous and medicinal herbs (havan sámagri = material used in oblation to fire all over India) on aerial bacterial population caused over 95% reduction of bacterial counts by 60 min.
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Effect of postural restrictions on the outcome of benign paroxysmal positional vertigo, postcanalith repositioning maneuver Highly accessed article p. 13
D Anand Karthikeyan, PK Purushothaman, R Ramakrishnan, K Banumathi
Introduction: Postural Restrictions of Head are advised by some physicians after BPPV is treated by canalith repositioning maneuvers. Aim: To find out if these postural restrictions are beneficial. Methodology: A total of 682 patients were studied over a period of 2 years. They were separated into 2 groups where one observed postural restrictions and the other didn't. Both the groups were compared. Results: The group which observed postural restrictions had better symptom relief after the first repositioning maneuver itself and recurrences were less. An odds ratio of 1.7862 was obtained upon statistical analysis. Conclusion: BPPV patients who observed postural restrictions after canalith repositioning maneuver had a better outcome than those who didn't.
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Otoscopic, radiological, and audiological status of the contralateral ears in patients with unilateral chronic suppurative otitis media Highly accessed article p. 16
Mohammed Radef Dawood
Context and Aims: Since unilateral chronic suppurative otitis media (CSOM) does not look to be an isolated entity, but rather a series of constitutional events that affecting both ears, so this study aimed to evaluate the otoscopic, radiological, and audiological status of the contralateral ears (CLEs) in patients with unilateral CSOM. Patients and Methods: A prospective, observational study recruited 96 consecutive patients with unilateral CSOM with or without cholesteatoma, in whom their CLEs revealed an intact tympanic membrane (TM) were categorized as “Group 1” and “Group 2” respectively, they were evaluated with otomicroscopy, computed tomography (CT) scanning of temporal bones, pure tone audiometry and tympanometry. All above-mentioned observations were recorded and analyzed. Results: The incidence of otoscopic CLEs structural abnormalities was 47.91% in both groups; being 45.83% in “Group 1” mostly 25% of TM retraction, and 50% in “Group 2” mainly (20.84%) of thinning TM. Mastoid CT scan showed (35.41%) air cell abnormalities in both groups; being 37.5% in “Group 1” and 33.33% in “Group 2,” while tympanic cavity mucosal thickening was 33.33% “in Group 1” and 25% in “Group 2.” Conductive hearing loss was found (39.58%) in both groups; being 45.83% in “Group 1” and 33.33% in “Group 2,” while C-curve tympanometry curve was 63.63% and 36.36% in both groups, respectively. Conclusions: The incidence of otoscopic structural abnormalities of CLEs was mainly in the form of TM retraction in squamous type and thinning TM in mucosal type; also, the radiological and audiological abnormalities of the CLEs were shown more event in squamous than in mucosal type of CSOM.
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A novel modality of treatment for pseudocyst of auricle p. 20
Yogesh Dabholkar, Shreyas Chawathey, Haritosh Velankar
Introduction: Pseudocyst of auricle is benign painless idiopathic cystic swelling on anterior surface of auricular cartilage with no definitive treatment and with a tendency to recur. We describe a novel modality of treatment for this condition. Methods: 14 patients treated by aspiration followed by pressure dressing with a silicone-based impression material used for hearing aid fitting. These patients were followed up over a six month period. Results: 13 patients had a successful outcome with complete resolution of swelling and without any recurrence. Only 1 patient (7.14%) showed recurrence after 2 weeks of treatment due to ineffective compression which was subsequently managed successfully by the same procedure. Conclusion: Complete aspiration and compression dressing using a silicone-based material (used to make hearing aid moulds) in our experience is a safe, inexpensive, non-invasive and effective method for management of the pseudocyst of the auricle.
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Temporalis fascia graft versus composite graft in chronic suppurative otitis media with subtotal and total perforations p. 23
Manas Ranjan Rout, Deeganta Mohanty, Chintagunta Pakeer Das, P Vittal Prasad
Introduction: Temporalis fascia graft is the most commonly used graft material for reconstruction of the tympanic membrane in chronic suppurative otitis media. However, the success rate is low in case of subtotal and total perforations. We have used both cartilage and the temporalis fascia for the repair with greater success. Aims and Objectives: The aim and objective of the study was to compare the result of temporalis fascia graft and composite graft (temporalis fascia and cartilage) in the repair of subtotal and total perforation of tympanic membrane with respect to graft take-up rate and hearing improvement. Materials and Methods: A total of 300 patients were selected for the study. One hundred and fifty cases we used only temporalis fascia (tympanoplasty with temporalis fascia graft [TTG] group) and another 150 cases both temporalis fascia and cartilage (Composite graft, tympanoplasty with composite graft [TCG] group) were used. The result was assessed after 6 months of surgery. Results: Graft take-up rate in TTG group is 82.67% and in TCG group is 95.34%. More remnant and re-perforations were found in TTG group. It was found that, in TTG group out of 124 patients, hearings improved in 104 patients (83.87%), remain same in 15 patients (12.09%), and deteriorated in 5 patients (4.032%). In TCG group out of 143 patients, hearings improved in 116 patients (81.118%), remain same in 19 patients (15.322%), and deteriorated in 8 patients (6.451%). Discussion and Conclusion: Composite graft is a better graft in comparison to temporalis fascia graft for the repair of the subtotal and total perforation.
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Delivering an audiology outreach clinic in Gujarat: Clinical observations and challenges p. 28
Jeff Davies
Introduction: Audiology staff and students from De Montfort University delivered an audiology outreach clinic in Wankaner, Gujarat, with the aim of providing free audiological examination, hearing tests, and hearing aids to local residents with hearing loss. In addition, the project also presented a valuable opportunity to evaluate the spectrum of hearing-related symptoms in this rural region of India. Subjects and Methods: This was a prospective, observational clinical study. Participants aged 5+ were invited for a consultation at the Devdaya Diagnostic Centre. The consultation comprised of an audiological history, otoscopy, and a hearing test. Middle ear evaluation through tympanometry was also available. Digital receiver-in-ear hearing aids were fitted to participants deemed clinically suitable. Red flag otological symptoms were referred onward to an ENT consultant. Clinical consultations were translated into Gujarati by the local hospital staff. Results: Over 2 days, 170 participants (aged 6–94 years) were screened; 116 males and 54 females. A wide range of otological symptoms and conditions was observed including tinnitus in 70 participants (41%), perforated eardrums (22%), active ear discharge (15%), occluding wax (12%), otalgia (8%), and a history of noise exposure (5%). Average hearing threshold configuration showed a bilateral moderate-to-severe sensorineural hearing loss which was worse in males. Twelve participants had normal or mild hearing loss. Hearing aids were offered to 97 (57%) participants, 88 of which reported listener benefit and agreed to wear the aids on a daily basis. The remaining 44 participants were not considered suitable for hearing aids. Conclusions: A new partnership between De Montfort University and the Devdaya Diagnostic Centre has provided the local community of Wankaner with access to free audiological healthcare. While there were a number of environmental and technological challenges to overcome, this maiden visit proved to be successful, laying the foundation for future clinics.
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Treatment of cisplatin-induced ototoxicity by intra-tympanic corticosteroid injection p. 33
Wail Fayez Nasr, Mohammad Abdelhady, Mohammad El-Sayed Abd Elbary, Ebtessam Nada
Background: Cisplatin is a common chemotherapeutic drug often causes ototoxicity attributed to the formation of reactive oxygen and nitrogen species damaging critical inner ear structures. Steroids have been shown to reduce the formation of reactive oxygen species, and thus, may reduce ototoxicity. In this study, intratympanic corticosteroid injection is proved to help the recovery of cisplatin ototoxicity. Objectives: The objective of this study was to assess the efficacy of intratympanic corticosteroid injection in the treatment of cisplatin ototoxicity. Patients and Methods: This study was applied on 20 patients that have sensorineural hearing loss caused by cisplatin, which was used as a chemotherapeutic agent for the treatment of their malignancies. All cases were subjected to intratympanic corticosteroid injection. All patients were exposed to pure-tone audiometry before and after the procedure. Results: Significant increases in the average pure-tone thresholds (PTTs) at 8000 Hz were found in both the study and control groups after the cumulative dose: 43.15 ± 15.557 dBHL and 55.7 ± 13.2589 dBHL, a value of P = 0.0004 and <0.001, respectively. Significant increases in the average PTTs at 6000 Hz were found in both the study and control groups after the cumulative dose: 39.7 ± 11.885 dBHL and 52.6 ± 7.456 dBHL, a value of P = <0.001 and <0.001, respectively. Conclusion: Intratympanic corticosteroid injection appears to have the only minimal therapeutic effect to cisplatin-induced hearing loss, especially for 6000 and 8000 HZ.
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Comparative retrospective evaluation of outcomes of tympanoplasty according to graft support materials p. 38
Bilge Türk, Seçil Arslanoğlu, Mustafa Zafer Uğuz
Objective: The aim of this study is to evaluate and compare the surgical outcomes and hearing results in tympanoplasty surgeries according to graft support material. The results of patients with hyaluronate-carboxymethylcellulose membrane and spongostan and the results of patients with only spongostan were compared. Materials and Methods: This was a retrospective comparative study of 118 tympanoplasty operations of 118 patients who underwent tympanoplasty in the Department of Otorhinolaryngology at a tertiary medical center from September 2000 to December 2005. The subjects were classified into two groups; Group 1 (n = 38) in whom both sodium hyaluronate-carboxymethylcellulose membrane and spongostan had been applied and Group 2 (n = 80) in whom only spongostan had been applied as graft support material. The rate of graft success and pure tone audiometric results were evaluated and compared between the groups. Chi-square test and Mann–Whitney U-test were used for the analysis. Results: Pre- and post-operative audiometric results including air-bone gaps were not significantly different between the groups. In all groups, the postoperative air-bone gap was significantly improved compared to the preoperative air-bone gap. Graft success rate in Group 1 and Group 2 were 89% and 71%, respectively. The rate of tympanic membrane perforation closure was significantly higher in Group 1 (P < 0.05). Conclusion: Depending on these results, we suggest sodium hyaluronate-carboxymethylcellulose membrane as an additional option as graft support material in tympanoplasties. The positive effect on graft success rate is documented in the present study. Further investigations are needed to evaluate the benefits and clinical outcomes of hyaluronate carboxymethylcellulose membrane.
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Targeted screening for hearing impairment in neonates: A prospective observational study p. 42
Jehangir Allam Bhat, Rajesh Kurmi, Santosh Kumar, Roshan Ara, Amit Kumar Mittal
Background: The aim of this study is to estimate the incidence and determine the risk factors predictive of hearing impairment in newborn by targeted hearing screening. Methods: This was a prospective, observational study conducted over a period of 1 year. We screened high-risk neonates for hearing impairment admitted to the Neonatal Intensive Care Unit using evoked otoacoustic emissions (EOAEs) and brainstem auditory evoked response (BAER). Babies who tested refer on EOAE were subjected to BAER urgently. Babies having an abnormality on BAER where confirmed as hearing impaired for this study. Results: A total of 195 high-risk babies comprising males (95 = 48.7%) and females (100 = 51.3%) were screened. Fifteen neonates (7.69%) tested refer in the initial screening procedure, i.e., EOAE, who then underwent BAER and out of these 15 (7.69%) neonates, 12 (6.15%) had abnormal BAER, i.e., hearing impairment. The significant individual risk factors in neonates with hearing impairment were stigmata and/syndrome associated with hearing loss, craniofacial anomalies, and hyperbilirubinemia and Apgar score <4 at 1 min and <6 at 5 min. Hearing impairment increased from 0.917% for one risk factor, 6.66% for two risk factors, 10.52% with three risk factors, 28.57% with four risk factors, and 25% with five risk factors. Conclusions: In this study, the incidence of hearing impairment was 7.69%. Stigmata and/syndrome associated with hearing loss, craniofacial anomalies, and hyperbilirubinemia and Apgar score <4 at 1 min and <6 at 5 min are significant risk factors for hearing loss, hearing loss increased as risk factors increase.
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Audio-vestibular dysfunction in rheumatoid arthritis: An undervalued extra-articular feature p. 47
Reem Elbeltagy, Dalia Galhom, Marwa Hammad, Ghada A Dawa
Objective: The study objective was to assess vestibular system either peripherally or centrally in patients with rheumatoid arthritis (RA) using video-nystagmography (VNG) and cervical vestibular-evoked myogenic potentials (cVEMP) in an Egyptian group of RA patients and to study whether there is a correlation between hearing levels, VNG, and cVEMP test results. Materials and Methods: This study was a comparative cross-sectional study. A total of forty individuals (twenty apparently healthy controls [40 ears] and twenty RA patients previously diagnosed by a rheumatologist [40 ears]) were included in the study. RA patients were recruited from the Rheumatology and Internal Medicine Departments of Zagazig University Hospitals. All participants gave their written consent before participation in the study. All participants in the study were subjected to basic audiological evaluation and vestibular evaluation (cVEMP-VNG). Results: There was a highly significant difference in VEMP latencies between RA patients and controls (P < 0.001) and nonsignificant difference as regards amplitude (P > 0.05). There was no statistically significant difference in VEMP latencies and amplitude between males and females of the study group (P > 0.05). There was a nonsignificant difference between VEMP latencies and amplitudes among subgroups A and B. All RA patients showed absence of spontaneous gaze-evoked positional and positioning nystagmus, normal oculomotor test, and unilateral caloric weakness in 12 ears. Conclusion: The findings of the current study add more evidence to the cochlea–vestibular involvement in patients with RA. Audio-vestibular function assessment is highly recommended for all RA patients as a routine examination.
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The elusive eustachian tube and its role in chronic otitis media p. 53
Maitri Rahul Kaushik, Aishwarya Shukla, Arun Yashwant Dehadaray, Prasun Mishra, Jency Johnson
Aims: To evaluate ET function using impedance audiometry, to visualise its orifices in the nasopharynx and the protympanum of the middle ear, to correlate the findings seen. Setting and design: Prospective study conducted in a tertiary care hospital from September 2015 to August 2017. Materials and Methods: In all cases of COM posted for surgery, nasopharyngoscopy was done to visualise the pharyngeal end of the ET. Impedance audiometry was done for assessing physiological function. Intra operative visualisation of the ET opening in the protympanum was done. Findings were correlated. Statistical Analysis Used: Sensitivity, specificity, positive predictive value and negative predictive value was calculated. Results: On comparison of findings of the pharyngeal orifice of the ET and the ET opening at the protympanum of the middle ear, strong statistical co relation is seen. On comparing mucosal and squamosal COM intra operatively, almost double the cases of obstruction were seen in squamosal type. Conclusion: Nasopharyngoscopy and intra operative findings of patients suffering from COM are important indicators of ETD. Patients of COM with abnormal Eustachian tube opening in the nasopharynx are more likely to have an abnormal opening in the protympanum of the middle ear.
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Glomus tympanicum: Clinical presentation, management and outcomes p. 56
Priyanka Misale, Anjali Lepcha, Amit Kumar Tyagi
Objective: The objective of the study is to describe the clinical presentation, management, and outcomes of glomus tympanicum (GT) Grade 1–3 (based on Glasscock Jackson staging). Materials and Methods: This is a retrospective chart review of five patients who presented with GT (Grade 1–3) over a period of 4 years to a tertiary hospital. All of them had undergone tumor excision without preoperative embolization. Details of clinical features, diagnostic protocol, surgical approach based on grade of tumor, tumor control, treatment complications, and follow-up results were noted and analyzed. Results: All five patients presented with unilateral hearing loss and tinnitus. Imaging done was magnetic resonance imaging with gadolinium of the brain and high-resolution temporal bone computed tomography. Three patients had transmastoid facial recess approach and one had transcanal approach for tumor removal. One patient had canal wall down mastoidectomy. The average follow-up was 34.8 months. Symptomatic improvement in pulsatile tinnitus was observed in all patients. Hearing remained the same in 1 patient and improved in 4 patients. One patient presented with cholesteatoma 1 year postsurgery. None of the patients had recurrence/residual tumor. Conclusions: GT Grades 1–3 can be managed successfully without preoperative embolization. This gives satisfactory results with respect to hearing improvement and recurrence rates.
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Mucormycosis of middle ear in a diabetic patient p. 60
Farzin Khorvash, Seyed Hamid Reza Abtahi, Atousa Hakamifard, Maryam Derakhshan, Leila Zarghami
Mucormycosis is an infection caused by fungi belonging to class zygomycetes, with high mortality and morbidity rate. Acquisition of mucormycosis is inhalation of spores or cutaneous route. The common risk factors for invasive mucormycosis consist of diabetes mellitus, high-dose glucocorticoid therapy, and neutropenia. The most clinical manifestation of mucormycosis is rhinocerebral lesions. Other manifestations are pulmonary, cutaneous, disseminated, and gastrointestinal. Ear involvement is extremely rare. The authors describe a case of mucormycosis cholesteatoma with concomitant central nervous system lesion in a patient with diabetes mellitus that responded to therapy.
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Pinna granular cell tumor in a child p. 63
Guhan Kumarasamy, Philip Rajan, Mazura Mohamed Zahidi, Irfan Mohamad
Granular cell tumor (GCT) is a rare soft-tissue neoplasm that has a predilection to occur in the head and neck region, especially in the tongue. It tends to affect the females in their 3rd to 4th decade of age. Due to its insidious nature, tendency to recur, and possibility of the lesion to be malignant, it is prudent to always GCT as a differential diagnosis when encountering a painless nodule. GCT in a child is exceedingly uncommon. Although half the cases occur in the head and neck region, a GCT in the pinna has never been reported.
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Duplicated internal auditory canal and dolichoectasia causing bilateral profound deafness in an adult p. 66
Vishwaroop Bhattacharyya, Sandeep Kumar, Subhendu Parida, T Mandapal
Inner ear malformations contributing to bilateral profound hearing loss in adulthood are extremely rare. High-resolution computed tomography of the temporal bones and magnetic resonance imaging revealed unilateral duplicated internal auditory canal (IAC) and bilateral semicircular canal aplasia in such an adult. This is only the fourth reported case in literature known to us of duplicated IAC in adults and first in which there is a description of isolated bilateral lateral semicircular canal aplasia as the sole labyrinthine abnormality. Dolichoectasia of the vertebrobasilar artery was also present in the contralateral ear causing compression of the cochlear nerve and profound deafness in the other ear for which cochlear implantation was done.
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Congenital sensorineural hearing loss with anomalous vestibular nerve complex: A rare radiological finding p. 71
Asma Binti Abdullah, Faizah Binti Mohd Zaki, Luqman Bin Rosla
Radiological assessment is an essential tool for preoperative assessment of cochlear implant (CI) candidates with congenital sensorineural hearing loss (SNHL). It gives crucial information of the inner ear, vestibulocochlear nerve, and brain. Hypoplasia of the cochlear nerve bony canal is commonly associated with profound SNHL, whereby 88% of this abnormality was found in 95% of CI candidates. This finding may be associated with internal auditory canal hypoplasia or other cranial nerve abnormalities. We describe a rare case of a patient diagnosed with congenital SNHL exhibiting an interesting radiological finding of an anomalous vestibular nerve course alongside hypoplasia of the cochlear bony canal which could be postulated by the complex embryological development of the inner ear.
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Pseudomonas Aeruginosa in chronic suppurative otitis media p. 74
Beuy Joob, Viroj Wiwanitkit
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