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   Table of Contents - Current issue
Coverpage
July-September 2018
Volume 24 | Issue 3
Page Nos. 135-208

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REVIEW ARTICLE  

Is there enough evidence to refute the antiviral therapy in vestibular neuritis: A best evidence review Highly accessed article p. 135
K Devaraja
DOI:10.4103/indianjotol.INDIANJOTOL_13_18  
Background: Recent research has provided extended support on the viral etiology of vestibular neuritis (VN); however, antiviral therapy is considered non-beneficial helpful in VN, contrary to its role in other similar viral-induced inflammatory conditions. The objective of this review is to segregate the available literature on antiviral therapy in VN and to evaluate and analyze the results of all those studies to know whether the antiviral therapy helps in VN patients or not. Materials and Methods: Electronic databases searched include PubMed, Scopus, Web of science, IndMED, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane library. Study Selection: Prospective randomized controlled trials (RCTs) comparing the outcomes of any form of antiviral therapy in VN, with that of placebo or any form of steroid or any other alternative therapy. Data Extraction and Data Synthesis: Among 581 screened articles, only one RCT was found on this topic, precluding the meaningful statistical analysis. However, this study did not consider the symptomatic improvement after antiviral therapy but only reported caloric response which is of less clinical relevance. No other controlled prospective study on antiviral therapy in VN has been published. Conclusions: The available evidence is not sufficient to disregard the beneficial effect of antiviral therapy in VN. Further randomized trials with better and clinically relevant study design are required to answer the question.
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ORIGINAL ARTICLES Top

The relative contribution of visual cues and acoustic enhancement strategies in improving speech perception of individuals with auditory neuropathy spectrum disorders p. 139
Jithin Raj Balan, Sandeep Maruthy
DOI:10.4103/indianjotol.INDIANJOTOL_30_18  
Background and Objectives: The present study aimed to assess the relative benefits of visual cue supplementation and acoustic enhancement in improving speech perception of individuals with Auditory Neuropathy Spectrum Disorders (ANSD). Methods: The study utilized repeated measure research design. Based on the purposive sampling 40 participants with ANSD were selected. They were assessed for their speech identification of monosyllables in auditory only (A), visual only (V), and auditory-visual (AV) modalities. In the A and AV modalities, the perception of the primary, temporally enhanced, and spectrally enhanced syllables were assessed in quiet as well as 0 dB signal to noise ratio (SNR) conditions. The identification scores were compared across modalities, stimuli, and conditions to derive the relative benefits of visual cues and acoustic enhancement on speech perception of individuals with ANSD. Results: The group data showed a significant effect of modality with the mean identification score being the maximum in AV modality. This was true both in quiet and 0 dB SNR. The mean identification scores in quiet were significantly higher compared to that in 0 dB SNR. However, acoustic enhancement of speech did not significantly enhance speech perception. When acoustic enhancement and visual cues were simultaneously provided, speech perception was determined only by visual cues. The evidence from individual data showed that most of the individuals benefit from AV modality. Conclusions: The findings indicate that both auditory and visual modality needs to be facilitated in ANSD to enhance speech perception. The acoustic enhancements in the current form have negligible influence. However, the inference shall be restricted to the perception of stop consonants.
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Evaluation of the hearing results after mastoidotympanoplasty operation with or without ossiculoplasty: A percentage change versus absolute change; a different methodology p. 148
Produl Hazarika, Seema Elina Punnoose, John Victor, Joyse Zachariah, Mrinmoy Hazarika
DOI:10.4103/indianjotol.INDIANJOTOL_128_17  
Purpose: Our article provides a comprehensive review of parameters of percentage change of the results regarding the documented hearing results (not based on any particular classification) in ear surgeries in chronic suppurative otitis media (CSOM) cases. Materials and Methods: Our series is a prospective cohort observational study in 230 cases of CSOM from 2009 to 2016 wherein we have evaluated the hearing improvement with a parameter of percentage change of hearing improvement between preoperative and postoperative period in various types of ear surgeries. Statistics and Results: A statistically significant difference was seen in 4 out of the 14 surgical groups, namely, in mastoidotympanoplasty, modified radical mastoidectomy (MRM), and MRM with tympanoplasty and in tympanoplasty. The rest of the 10 surgical groups had <10 cases, and therefore, the P significance could not be determined; however, these groups still showed hearing improvement. Conclusion: The superiority of the surgical techniques such as mastoidotympanoplasty, MRM, MRM with tympanoplasty and in tympanoplasty as demonstrated in our study aims to find an ideal surgical procedure in CSOM which gives the best chance to improve or preserve the hearing with complete eradication of the disease.
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The role of parental hearing status in theory of mind after cochlear implant surgery p. 157
Kourosh Amraei, Mohammadparsa Azizi, Amirali Khoshkhabar, H Soori
DOI:10.4103/indianjotol.INDIANJOTOL_128_16  
Introduction: Theory of mind (ToM), or the understanding of others' thoughts and feelings and their behavioral consequences, has been extensively studied in hearing typically developing preschool children over several decades, including research demonstrating the influence of ToM on preschool children's social lives. Hearing impairment is common type of sensory loss in children. Literature indicates that children with hearing impairment deficit in social, cognitive, and communicate skills. Aim: This study performed to compare ToM of cochlear-implanted first- and second-generation deaf children. Methodology: This research is causal comparative. All 15 deaf children with deaf parent selected from Baqiyatallah Cochlear Implant (CI) Center. Hence, 15 cochlear-implanted children paired with them by purposive sampling. Results: Findings showed that t-test (t = −4.52, P < 0.01) was statistically significant. According to t-test, the second-generation children was significantly higher than the first-generation children in ToM. Conclusion: We can assume that the second-generation children were joined with their family in sign language, lead to the use of primary experience before of implant. So, it is recommended to use the sign language before cochlear implantation.
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Subjective visual vertical in different peripheral vestibular disorders p. 162
Mostafa El Khosht Mahmoud, Maha Hassan Abou-Elew, Rasha Soliman, Aliaa Aly Moustafa El Brequi
DOI:10.4103/indianjotol.INDIANJOTOL_92_17  
Context: The subjective visual vertical (SVV) is considered to be a functional measure of otolith-mediated verticality perception. Aims: This study aims to detect the normative data of SVV and to analyze SVV changes in peripheral vestibular disorders. Settings and Design: This was a observational, cross-sectional study. Subjects and Methods: Forty-five adult patients with chronic peripheral vestibular disorders endolymphatic hydrops, vestibular neuritis, and benign paroxysmal positional vertigo and 20 normal individuals were included in this study. After full history taken, SVV deviations and caloric tests were completed. Statistical Analysis Used: Independent Student's t-test for independent sample when comparing 2 groups. ANOVAs test compared three or more means for statistical significance. Tukey's test compared the means of every treatment to the means of every other treatment. Chi-square test was performed. Normal cutoff value was calculated by mean +2 standard deviation (SD) as high limit and mean −2 SD as low limit. Results: The normative data of SVV ranged from −0.2° to 1.26° in clockwise direction and from −0.04° to 0.95° in the counterclockwise direction. SVV in counterclockwise direction were significantly deviated among the three groups of Peripheral vestibular disorder (PVD) patients when compared with controls. It revealed a significant deviation in counterclockwise tilt between left diseased ears in relation to controls. Conclusions: Normal adults displayed a narrow range of one-degree SVV deviation (1.06° and 0.91°) in clockwise and counterclockwise direction, respectively. The three vestibular disorders significantly deviate the SVV in counterclockwise direction compared to control with no gender difference. SVV test alone cannot differentiate between different PVD.
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Comparison of tragal perichondrium and temporal fascia grafts in tympanoplasties p. 168
Selma Hodzic-Redzic, Lana Kovac-Bilic, Srecko Branica
DOI:10.4103/indianjotol.INDIANJOTOL_119_16  
Objective: The objective of this study was to compare the anatomic and functional outcomes of the different graft materials used in tympanoplasty. Settings and Design: This was an observational, cross-sectional study. Patients and Methods: The study included 243 patients operated at Tertiary Care University Hospital, from January 2011 to December 2015. The study excluded patients who had previous ear surgery and patients with cholesteatoma and nose and paranasal sinuses diseases. Tympanoplasty was done under general anesthesia. The retroauricular approach was primarily used. All grafts were placed using the underlay technique. Audiological testing of all patients was done preoperatively and postoperatively. Statistical Analysis Used: All data were entered into Excel and analyzed using MedCalc Statistical Software version 15.8 (MedCalc Software bvba, Ostend, Belgium). Descriptive statistics was used. Audiological findings were compared using a paired t-test. The value of P < 0.05 was considered statistically significant. Results: The temporal fascia was used as the graft material in 160 patients, and tragal perichondrium was used in 83 patients. Improvement of audiological outcome in patients with temporal fascia amounted 62.5% and in patients with perichondrium amounted 60.24%. The graft success rate 3 months postoperatively was 92.5% in the fascia group whereas it was 95.18% in the perichondrium group. Conclusion: Improvement of audiological outcome was slightly better (62.5%) in the fascia group while graft acceptance in the postoperative period was slightly better (95.18%) in the perichondrium group.
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Does postural instability in type 2 diabetes relate to vestibular function? p. 172
Marniza Omar, Nor Haniza Abdul Wahat, Mohd Fawwaz Afif Zulkafli, Nur Fajarina Husain, Suhaina Sulaiman
DOI:10.4103/indianjotol.INDIANJOTOL_28_18  
Introduction: Diabetes mellitus (DM) can lead to complications including postural instability that may be related to impaired function of the vestibular system. Aims and Objectives: This study aims to measure vestibular and balance function in adults diagnosed with type 2 noninsulin-dependent diabetes mellitus (NIDDM) and to compare their findings with healthy age-matched control group. Materials and Methods: This is an experimental cross-sectional study, using purposive sampling method. Eight NIDDM patients (mean age = 36.8 ± 11.4 years) and eight age-matched healthy controls (mean age = 34.6 ± 11.0 years) were recruited. Vestibular end organs (i.e., saccule, utricle, and semicircular canals) were assessed using cervical and ocular vestibular-evoked myogenic potentials (cVEMPs and oVEMPs) and video head impulse test. Upright stance postural stability was assessed using force plate in four testing conditions, i.e., standing on firm or foam surface with eyes opened or closed. Dynamic stability was measured using Timed Up and Go (TUG) and functional gait assessment (FGA). Results: There was no statistically significant difference for all vestibular tests between groups. However, reduced p13-n23 interamplitudes (for cVEMPs) and n10 amplitudes (for oVEMPs) were observed in NIDDM patients. Upright stance postural stability was not significantly worse in patients. For dynamic postural stability, NIDDM patients demonstrated significantly poor performance in TUG and FGA than the healthy controls. Functionally, NIDDM patients walked significantly slower and less stable, and this is evident from poor performance in both TUG and FGA results. Conclusion: Our findings showed significant reduction in dynamic postural stability in NIDDM patients. However, we did not find any significant abnormal vestibular function in the patients as reported by previous studies. Further research studies are advocated.
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A prospective study of outcome of boomerang-shaped chondroperichondrial graft in Type i tympanoplasty p. 179
Yogendra Kumar Pareek, Digvijay Singh Rawat, Yogesh Aseri, Manish Kumar Tailor, Praveen Chandra Verma, Bhuvenesh K Singh
DOI:10.4103/indianjotol.INDIANJOTOL_31_18  
Context: Cartilage has proven to be an excellent graft material inside the middle ear. The use of cartilage for tympanic membrane grafting may provide additional benefits in some difficult situations. Aims: The study was planned to evaluate the graft uptake and hearing after placement of “boomerang-shaped chondroperichondrial graft” in Type I tympanoplasty. Settings and Design: The prospective study was conducted on 40 patients having chronic suppurative otitis media with no active disease at least for last 6 weeks in a tertiary care center of North India. Patients having cholesteatoma and ossicular erosion/or necrosis were excluded from the study.Subjects and Methods: Those patients underwent tympanoplasty Type I by postaural approach and underlay grafting using “boomerang-shaped chondroperichondrial graft” from tragal cartilage and were followed up for 3 months. Hearing evaluation was performed preoperatively and postoperatively after 3 months. Statistical Analysis Used: The mean, range, and standard deviation of air conduction and air-bone gap were calculated and compared with preoperative findings. Results: The mean age of study group was 26.23 ± 12.46 years. Ear discharge (100%) and hearing impairment (87.5%) were the chief presenting complaints. The mean duration of ear discharge was 6.67 ± 6.75 years. Type I tympanoplasty was performed in all cases using “boomerang-shaped chondroperichondrial graft” harvested from tragal cartilage. Graft was taken up at the 3rd month in all patients. The preoperative mean air conduction was 43.21 ± 7.17 dB, which at the 3rd month improved to 36.49 ± 6.60 (P = 0.00004). Preoperative mean air-bone gap was 25.45 ± 8.44 dB which was improved to 19.31 ± 8.18 dB postoperatively at the 3rd month (P = 0.0014). Conclusions: Boomerang-shaped chondroperichondrial graft has excellent “take rate” in Type I tympanoplasty.
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A cross-sectional study on hearing loss using world health organization protocol in Delhi p. 184
Suneela Garg, Vipra Mangla, Charu Kohli, M Meghachandra Singh, Shelly Chadha, Neha Dahiya
DOI:10.4103/indianjotol.INDIANJOTOL_57_18  
Background: The World Health Organization (WHO) as per its recent estimates has predicted increasing prevalence of hearing loss globally. Data on magnitude of hearing loss in Delhi, India, are scarce, and the present study aims to highlight the extent of hearing loss problem in population using the standardized WHO protocol. Materials and Methods: A community-based cross-sectional study using the WHO protocol on “Survey for prevalence and causes of hearing loss” was conducted in selected rural and urban areas of Delhi from January to December 2017 among study participants aged 3 months and above. The sample size of 664 was taken from rural and urban areas of Delhi. Data collection instruments included the WHO structured questionnaire, hearing test, and ear examination using handheld otoacoustic emission (OAE) in children <5 years of age and pure-tone audiometry in persons >5 years. Ethical clearance was taken from the Institutional Ethical Committee. Written informed consent/assent was taken from study participants. Data were analyzed using SPSS (version 25). Qualitative data were expressed in percentage and quantitative data were shown as mean + standard deviation (SD). Results: The prevalence of hearing loss was 26.9%–15.6% in rural area (Barwala) and 84.4% in urban areas (0.62% in Balmiki Basti, 15.6% in Delhi Gate, 64.4% in Gokulpuri, and 3.8% in Vikram Nagar). Mean + SD age of study participants was 32.17 + 20.85 years. Mild hearing loss was seen in 66.7%, 54.5%, and 43.5% in 6–9, 10–19, and 20–39 years' age group of participants, respectively. Severe hearing loss was seen in 46.7% and 68.3% of study participants in 40–59 and >60 years' age group, respectively. Severe hearing loss was seen in 55.3% males and 42.8% females, respectively. In children <5 years, OAE was passed in 69.4% male and 30.6% female children. About 14.3% children with OAE referred were males and 85.7% were females. Conclusion: The prevalence of hearing loss using the WHO protocol was 26.9% in Delhi, and severity increased with increasing age and more among males than females.
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Comparative study of clinical and audiological outcome between anterior tucking and circumferential flap methods of type I tympanoplasty in large central perforation p. 190
N Dhanapala, S Mohammed Hussain, L Sudarshan Reddy, Ramya Bandadka
DOI:10.4103/indianjotol.INDIANJOTOL_60_18  
Background: Tympanoplasty is a common operation performed by otolaryngologists worldwide. During the last 100 years various modifications in this surgical technique have come up because of continued efforts made by otologists all over the world to achieve the best surgical outcome. Objective: The aim of this study is to compare the surgical and audiological outcomes of anterior tucking and circumferential flap methods of type 1 tympanoplasty. Materials and Methods: This prospective randomized study included 100 patients who presented in the ENT outpatient Department of Bangalore Medical College and Research Institute with chronic otitis medialarge central perforation in an inactive stage. Patients were randomly allocated to two groups of 50 cases each. Group A contained 50 patients who underwent Type I tympanoplasty by circumferential flap method, and Group B contained 50 patients who underwent Type I tympanoplasty by anterior tucking method. Patients were followed up at the 3rd month postoperatively by otomicroscopy and pure tone audiometry (PTA), graft uptake and hearing gain were assessed. Results: There was a statistically significant mean hearing gain postoperatively compared to preoperative PTA in both techniques, among the two techniques, there was no statistically significant difference regarding hearing gain and graft uptake. Conclusion: Anterior tucking and circumferential flap methods of type 1 tympanoplasty are good regarding graft placement, graft uptake, and audiological outcome for chronic otitis media with large central perforation, especially with little or no anterior remnant of pars tensa.
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Mastoid cavity obliteration using bone pate and ribbon-like temporalis muscle flap: Our experience p. 194
Chetan Bansal, VP Singh, Arvind Varma
DOI:10.4103/indianjotol.INDIANJOTOL_36_18  
Objective: The aim of this study was to elucidate a mix of bone pate with ribbon-like temporalis muscle flap for mastoid cavity obliteration after mastoid surgery to avoid mastoid cavity problems. Materials and Methods: In 54 patients of unsafe chronic suppurative otitis media, canal wall down mastoidectomy was done, size of the cavity assessed and ribbon-like temporalis muscle flap with bone pate used for mastoid cavity obliteration. Follow-up was done at 3 weeks, 3 months and then at 6 months. Results: Dry cavity with success rate of 83% is achieved with temporalis muscle flap technique of mastoid cavity obliteration. Conclusion: A mix of bone pate to obliterate the small spaces in the mastoid cavity along with a ribbon-like temporalis muscle flap is effective method of mastoid cavity obliteration as it gives a dry ear, is not bulky and most importantly maintains the canal.
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Vestibular dysfunction and glycemic control in diabetes mellitus: Is there a correlation? p. 199
Chetana S Naik, Raviraj Tilloo
DOI:10.4103/indianjotol.INDIANJOTOL_70_18  
Objectives: The aim of this study is to evaluate and find the proportion of patients with Type-II diabetes mellitus (DM) with sensorineural hearing loss (SNHL) and vestibular dysfunction (VD) and association with glycemic control. Materials and Methods: An observational cross-sectional study was carried out in 100 patients (age group: 30–60 years) diagnosed with Type-II DM coming to the outpatient department of our Rural Tertiary Care Teaching Hospital, fulfilling the inclusion criteria. Prior approval of the Institutional Ethics Committee and written informed consent was obtained. All patients were subjected to investigations to assess their diabetes control, hearing, and vestibular function. The findings were subjected to statistical analysis. Results: Out of 100 patients, 62 were male and 38 were female between the age group of 30 and 60 years. The mean hemoglobin A1c (HbA1c) level was 9.16 ± 2.4. The patients were divided into three groups depending on HbA1c level, to denote control, good (≤7%), moderate (>7, ≤12%), and poor (>12%). There were a total of 69 patients with SNHL and 70 patients with VD. SNHL was present in 57.6% of good control group, 66.1% of moderate control group, and 100% of poor control group. Analysis with Chi-square test for correlation between glycemic control and SNHL was statistically significant. Out of the 70 patients with VD, 51.4% had right vestibulopathy, 41.4% had left vestibulopathy, and 7.2% had a bilateral vestibulopathy. Twenty-two patients had benign paroxysmal positional vertigo. VD was present in 42.3% of good control group, 74.5% of moderate control group, and 100% of poor control group. Chi-square test was statistically significant. Conclusion: There is a significant association between Type II DM, and SNHL and VD, especially with worsening of glycemic control. Screening for these debilities should be a part of the routine workup of a diabetic patient. VD is a potential cause for imbalance and vertigo in DM.
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CASE REPORTS Top

Preauricular iatrogenic epidermoid cyst through middle-ear surgery p. 204
Hatice Celik, Ozlem Akkoca, Mustafa Ibas
DOI:10.4103/indianjotol.INDIANJOTOL_40_18  
Iatrogenic implantation of squamous epithelium during middle-ear surgery may cause epidermoid cyst (EC) development. These cysts may arise in different localizations of the head and neck following otological surgery. In this rare case, a giant EC with a size of 56 mm × 30 mm, which appeared in the preauricular area growing in the past 1 year in a 40-year-old male patient who underwent type 1 tympanomastoidectomy due to chronic otitis media without cholesteatoma 8 years ago, was discussed with the literature in terms of clinical findings and differential diagnosis.
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Bilateral bullous myringitis in a teenager p. 207
Nurul Syeha Abdull Rasid, Shiun Chuen Chew, Mohd Khairi Md Daud
DOI:10.4103/indianjotol.INDIANJOTOL_52_18  
Bullous myringitis is commonly encountered in otorhinolaryngology clinic. The most common presenting symptoms are otalgia, reduced hearing, and tinnitus. It can affect patients of any age in spite of the fact that children are frequently affected. In our recent encounter in our clinic, a teenager presented with bilateral otalgia with reduced hearing. Otoscopic findings revealed bilateral bullous myringitis that is indeed rare. He responded well with antibiotic treatment and recovered completely.
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