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   Table of Contents - Current issue
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April-June 2020
Volume 26 | Issue 2
Page Nos. 59-114

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REVIEW ARTICLES  

Chronic suppurative otitis media: A microbiological review of 20 years p. 59
Pratima Gupta, Saurabh Varshney, Shyam Kishor Kumar, Aroop Mohanty, Mithilesh Kumar Jha
DOI:10.4103/indianjotol.INDIANJOTOL_141_19  
Chronic infection of the middle ear cleft for at least 2 weeks or more is known as chronic suppurative otitis media (CSOM). It usually manifests as a complication of acute otitis media. It is more prevalent in developing countries due to various predisposing factors such as malnutrition, overcrowding, poor hygiene, inadequate health care, and recurrent upper respiratory tract infection. Due to advancement in medical facility, India still falls under high prevalence zone. In India, the average prevalence of CSOM is 5.2%. Pseudomonas aeruginosa and Staphylococcus aureus were the predominant isolates in most of the studies. Other common aerobic isolates were Klebsiella spp., Proteus spp., Escherichia coli, Bacteroides fragilis, Prevotella spp., Candida spp., and Aspergillus spp. However, there was no significant geographical variation of pathogens in India. In recent years, there is increased preponderance of multidrug-resistant organisms due to the irrational use of antibiotics, making treatment of CSOM more difficult. Colistin and polymyxin-B were the most effective antibiotics which showed sensitivity against P. aeruginosa by up to 100%. Carbapenems were showing good sensitivity against P. aeruginosa in most of the studies, but there was decreased tendency of sensitivity for piperacillin-tazobactam, amikacin, gentamicin, ceftazidime, and ciprofloxacin. Nine studies isolated methicillin-sensitive S. aureus significantly higher in number than methicillin-resistant S. aureus. For S. aureus, vancomycin and linezolid showed ≥90% sensitivity in most of the studies. Amikacin, gentamicin, erythromycin, and ciprofloxacin were other active drugs against S. aureus, which were showing resistant pattern significantly.
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Deafness in COVID-19 Highly accessed article p. 68
Mahendra Kumar Taneja
DOI:10.4103/indianjotol.INDIANJOTOL_83_20  
COVID-19 is a highly contagious disease caused by RNA virus which is known to cause sensorineural deafness. The evidences are also prompting the risk of deafness in the near future. Respiratory virus, Mumps, measles, and Herpez are known for delayed presentation of deafness with poor prognosis. In the past, nitric oxide has shown evidence-based results in the treatment of coronavirus and respiratory pathologies. Humming enhances (Bhramari Pranayama) the production of nitric oxide. Suitable diet and lifestyle changes along with Tratak (focused concentration) and Bhramari Pranayama along with regular follow-up may be a must step to prevent and rehabilitate the patients with sensorineural deafness.
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ORIGINAL ARTICLES Top

Study on use of platelet-rich plasma in myringoplasty p. 71
Fayis Mohammed Anwar, Vijendra S Shenoy, Panduranga M Kamath, Suja Sreedharan, D Deviprasad, Haneesh Amit Domah
DOI:10.4103/indianjotol.INDIANJOTOL_103_18  
Aim: This study aims to analyze the use of autologous platelet-rich plasma (PRP) to improve graft uptake and benefit on hearing after myringoplasty. Objectives: The objective is to compare pre- and post-operative graft uptake and audiological benefit following myringoplasty with and without PRP. Materials and Methods: A total of 70 patients diagnosed with chronic suppurative otitis media tubotympanic type were divided into groups of 35 each. Patients in group one who underwent myringoplasty with PRP while in second group underwent myringoplasty without PRP. Pre- and post-operative graft status and pure tone audiometry were performed for all the patients, and the outcomes were compared. Results: Of 35 patients in each group; four in the study group and eight in the control group had residual perforation. Graft uptake in case group was 88.57% and graft uptake in the control group was 77.1%. Result was better in cases that underwent myringoplasty with PRP. Of 35 patients in case group, audiological improvement (>10 dB) was seen in 31 patients (88.57%), whereas in the control group of 35 patients, 27 (77.1%) had audiological benefits. Conclusion: This study shows there is a definite benefit using PRP in myringoplasty. As the PRP can be easily prepared, PRP myringoplasty can be routinely performed.
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Biofilm-producing organisms and their antibiotic sensitivity in chronic otitis media – Mucosal disease p. 75
Rajeshwary Aroor, Naina Narasimhadevara, Pratibha Bhat, Vadisha Bhat, Marina Saldanha, MK Goutham
DOI:10.4103/indianjotol.INDIANJOTOL_4_20  
Objectives: The objective of the study is to know the presence of biofilm-producing organisms in the middle ear mucosa in chronic otitis media (COM) mucosal disease and their antibiotic sensitivity. Materials and Methods: This was a prospective comparative study conducted on 100 patients who underwent tympanoplasty. They were divided into two groups: Group 1 included mucosal active disease (50) and Group 2 included mucosal inactive (50). During surgery, a biopsy from the middle ear mucosa was taken and sent for culture and sensitivity and tested for their biofilm-forming capability using tissue culture plate method. Results: In Group 1, 17 cultures were biofilm-producing organisms and 14 were non/weak biofilm-producing organisms. In Group 2, 14 were biofilm producing and 8 were non/weak biofilm producing. Piperacillin-tazobactam was the most sensitive drug for Pseudomonas aeruginosa, Klebsiella pneumoniae, and Staphylococcus epidermidis irrespective of their biofilm-producing capability. Linezolid had showed 100% sensitivity for Staphylococcus aureus. Ciprofloxacin was the most resistant drug irrespective of organisms and their biofilm-forming capability.Conclusion: P. aeruginosa and S. aureus are the common organisms present in the mucosa of the middle ear in COM. Piperacillin-tazobactam is the most sensitive drug for middle ear infection. The most resistant drug is ciprofloxacin.
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Endoscopic transcanal stapedotomy: Our experiences at a tertiary care teaching hospital of Eastern India p. 80
Santosh Kumar Swain, Alok Das, Bulu Nahak, Jatindra Nath Mohanty
DOI:10.4103/indianjotol.INDIANJOTOL_64_19  
Introduction: Although operating microscope is used worldwide for stapes surgery, the use of endoscopes would provide much benefit such as good panoramic view of middle ear and easy accessibility of the oval window area, stapes, and facial nerve. Objective: We aimed to analyze our experiences of endoscopic transcanal stapedotomy performed at a tertiary care teaching hospital of Eastern India. Materials and Methods: This prospective study was done at the Department of Otorhinolaryngology between March 2017 and April 2019. The patients were diagnosed as having otosclerosis with fulfilling the selection criteria. All underwent endoscopic transcanal stapedotomy. Results: Out of 52 patients those underwent endoscopic transcanal stapedotomy, there were 28 females and 24 males. The mean age was 32.40 years. The mean operation time was 35.43 min. The mean preoperative air–bone gap (ABG) was 34.84 dB, whereas the mean postoperative ABG was 9.81 dB. Tympanomeatal flap tear was seen in one case. One case showed chorda tympani injury and two patients presented with vertigo after surgery. No other complications were seen after endoscopic stapedotomy. Conclusion: The important advantages of endoscopic stapedotomy are good-quality visualization with identification of vital parts of the middle ear cleft, minimal handling to the chorda tympani nerve with almost no curettage of the scutum. The development of endoscopic ear surgery techniques promises the change the way we approach for stapes surgery. The wide field view of endoscope helps the surgeon to visualize better the middle ear recess, especially oval window niche and stapes.
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A study of incidence of hearing loss in newborn, designing a protocol and methodology to detect the same in a tertiary health-care center p. 85
Anisa Nishad, KS Gangadhara Somayaji, HK Mithun, Nimalka Sequeira
DOI:10.4103/indianjotol.INDIANJOTOL_63_20  
Background: Hearing impairment can have a negative impact on an individual's social, educational, and emotional life. If not detected early, it can affect the speech and language development. This delay in diagnosis and intervention can be mitigated by mandatorily implementing newborn hearing screening protocols. Objective: The primary objective of this study was to find the incidence of hearing loss in normal and high-risk neonates and recommend a protocol for the detection of hearing loss in the neonate. Materials and Methods: The study was carried out in a tertiary care teaching hospital over a period of 12 months. A total of 1000 babies including 693 normal and 307 high-risk babies were enrolled into the study. All neonates underwent otoacoustic emission (OAE) within the first 3 days of birth. Those who failed in this test underwent repeated OAE after 6 weeks, followed by brain stem-evoked response audiometry (BERA) if the second OAE was negative. Results: Of 307 high-risk babies, 48 showed absent OAE on initial screening. On follow-up, 10 babies still showed absent OAE. BERA was positive for hearing loss in five and normal in the other five babies. Among 693 normal neonates, 71 had absent OAE during the first test. On subsequent OAE test, seven babies failed whose BERA showed hearing loss in five and normal hearing in two babies. Conclusion: A proper protocol and methodology is required for the early detection of hearing loss so that rehabilitation can be started at the earliest. In this study, the incidence of hearing loss is found to be more in high-risk neonates as compared to normal ones. As OAE is simple and quick, it is preferred for screening, but BERA is required for the definitive diagnosis.
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Electrically evoked stapedial reflex threshold assessment among malaysian cochlear implant users: Comparisons between different stimulus rates p. 89
Cheu Lih Aw, Sook Kim Tan, Rosninda Abdullah, Nik Adilah Nik Othman, Mohd Normani Zakaria
DOI:10.4103/indianjotol.INDIANJOTOL_122_19  
Background and Objective: Cochlear implant (CI) mapping can be carried out using subjective or objective assessments. Electrically evoked stapedial reflex threshold (ESRT) measurement is one of the valuable objective assessments to establish appropriate CI maps. As such, more research efforts are required to determine the most optimum recording protocols when recording ESRT. In the present study, the effect of stimulus rate on ESRT among CI users was determined. It was also of interest to know which stimulus rate would produce the optimum correlation with the behavioral most comfortable level (MCL) results. Materials and Methods: In this study that employed a repeated measures design, 12 Malaysian CI users were enrolled (mean age = 22.3 ± 13.3 years, ranging from 14 to 51 years). MCL and ESRT (measured in charge units, qu) were measured for three representative electrodes (electrode 2, electrode 6, and electrode 11) using 1000 pps and 2000 pps rates. Results: ESRT was 100% recordable for electrodes 2 and 6. For electrode 2, the mean ESRT values were 20.5 qu and 20.4 qu for 1000 pps and 2000 pps, respectively. While for electrode 6, the mean ESRT was 25.4 qu for 1000 pps and 25.7 for 2000 pps. Excellent correlations were found between ESRT and MCL for both stimulus rates (intraclass correlation ≥0.90). Conclusion: Both stimulus rates were found to produce comparably good ESRT results. Since ESRT and MCL values were highly correlated with each other, the objective ESRT testing can be used conveniently to predict the behavioral MCL, particularly among difficult-to-test patients.
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CASE REPORTS Top

Gaze-stability exercises incorporating physical activity on functional mobility and disability in unilateral peripheral vestibular hypofunction p. 93
Theruvilparmbil Jayachandran Jayasree, Suruliraj Karthikbabu
DOI:10.4103/indianjotol.INDIANJOTOL_106_19  
Dysfunction of one or both peripheral vestibular apparatus can manifest with gaze instability, balance, and mobility issues. This case report describes the role of vestibular rehabilitation along with a tailored physical activity regime on balance and disability in a 49-year-old female complaining of sense of losing the standing balance for the past 6 months' duration.
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Unilateral left lateral rectus palsy: A rare complication of acute otitis media p. 95
Thanzeem Unisa, MB Bharathi, BS Rakesh, Nitish Aggarwal
DOI:10.4103/indianjotol.INDIANJOTOL_126_19  
Petrous apicitis is an extension of infection from mastoid air cells into the petrous apex. The infection may also spread outside the petrous apex to affect the meninges causing meningitis, cranial nerve palsies, encephalitis, brain abscess, cavernous sinus thrombosis, and even death; however, these complications are rare. Only a few patients with petrous apicitis exhibit the complete triad described by Gradenigo comprising retro-orbital pain, sixth nerve palsy, and otorrhea. We present a rare case of petrositis with pachymeningitis with unilateral abducens nerve palsy following acute suppurative otitis media, which was successfully managed medically.
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Hematohidrosis: Reports and update of clinically mysterious phenomenon p. 99
Marwa Saad Badry, Mahmoud I Elbadry, Abdul-Rahman Abdul-Majeed Ragab, Mohammed Elrabie Ahmed
DOI:10.4103/indianjotol.INDIANJOTOL_135_19  
Hematohidrosis is a mysterious and rare disorder characterized by one or more attacks of spontaneous, bloody sweating from intact surfaces of skin and/or mucous membranes. In the current literature, we faced a case of a 16-year old female who presented with recurrent attacks of right-sided bloody otorrhea upon exposure to extreme stress and anxiety. The patient had no history of bleeding disorders, trauma, or drug intake. Ear examination was completely normal with intact skin and tympanic membrane. All bloody investigations of the patient were within the normal range. The outcome was favorable in this case with medical treatment (beta-blocker and anxiolytics) and psychological support. In this article, we highlight with a detailed description of clinical characteristics and treatment options of this disease, followed by a review of the possible pathophysiological mechanisms. Our case together with previous reports should raise awareness of hematohidrosis occurrence, especially among ENT patients.
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Bilateral otitis media and nasopharyngitis as the presentation of tuberculosis p. 103
Nithya Kanesan, Mohd Khairi Md Daud, Zahiruddin Zakaria
DOI:10.4103/indianjotol.INDIANJOTOL_17_20  
Tuberculosis (TB) is a common infectious disease worldwide. It most commonly affects the lungs, though any organ can be affected. Upper respiratory tract involvement is uncommon, and involvement of the nasopharynx with bilateral TB otitis media is even rarer. These conditions can be overlooked and often mistaken for other more common and less extensive diseases, and these can lead to delay of diagnosis. We report a case of a 29-year-old man who presented with bilateral reduced hearing and tinnitus, but he was found to have TB of the nasopharynx, otitis media, and lung.
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Classical bartter's syndrome (Type III) with deafness: A very rare case management p. 106
Farid A Alzhrani, Rawan M Hudeib, Tahera Islam
DOI:10.4103/indianjotol.INDIANJOTOL_97_19  
Bartter syndrome (BS) represents a group of autosomal recessive salt-losing nephropathy, characterized by hypokalemic metabolic alkalosis with normal or low blood pressure. Hearing defect is a feature of BS Type IV and is typically absent in BS I, II, or III. We report the case of a 2-year-old boy with severe to profound sensory neural deafness who diagnosed with BS Type III in the neonatal period. His deafness was noted at 9 months. He used hearing aids regularly for 1 year with very limited benefit, an aided visual reinforcement audiometry test resulted in a reading of only 55 dB. Cochlear implantation was performed at the age of 3 years with excellent postoperative audiometric results and improvement in speech performance. To the best of our knowledge, this is the second-documented case of BS Type III with bilateral sensory neural deafness and the first-reported case of cochlear implantation in such a patient.
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Stapes fixation to the promontory and fallopian canal in a case of chronic otitis media: Implications on development and etiology p. 109
Kartikesh Gupta, Amit Kumar, Rachit Sood, Saurabh Varshney
DOI:10.4103/indianjotol.INDIANJOTOL_35_20  
Embryology of stapes has long been a topic of controversy. There are theories stating a single source to the dual origin of stapes. Chronic otitis media is also known to cause various acquired bony ossicular fixations. We present a case of an 11-year-old female with right chronic otitis media, active squamosal with cerebellar abscess who underwent drainage of cerebellar abscess followed by tympanomastoidectomy as a two-staged procedure. Intraoperatively, there were stapes suprastructure fusion to the fallopian canal and one crural attachment to the promontory. There are no clear criteria to differentiate bony fixation of congenital origin from acquired causes. This case also highlights the need to add a new subclass in the classification of minor middle ear anomalies given by Cremer, and our findings also support the dual origin for stapes development.
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Tick-induced vestibular ototoxicity and facial nerve paralysis successfully treated with intratympanic steroid injections p. 112
Senthilraj Retinasekharan, Sanjeevan Nadarajah
DOI:10.4103/indianjotol.INDIANJOTOL_95_20  
Tick infestation causing facial nerve palsy has been reported especially in Southeast Asian (this) region of the world. However, there has not been a report of tick infestation causing vestibular ototoxicity. A detailed otology history and careful otoscopic examination is paramount when an abnormal presentation is seen. Timely and appropriate treatment will mitigate long-term sequelae of toxicity. We report a case of a patient presenting with dizziness, reduced hearing, and unilateral facial paralysis secondary to tick infestation. We outline the successful management of this condition.
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