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   Table of Contents - Current issue
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July-September 2020
Volume 26 | Issue 3
Page Nos. 115-198

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LEAD ARTICLE  

Middle ear mucosal compartm Highly accessed article p. 115
Mahendra Kumar Taneja
DOI:10.4103/indianjotol.indianjotol_221_20  
Mucosal folds of middle ear are not a significant barrier in spread of infection cholesteatoma spread towards the least resistance and usually follow the folds. The mucosa of the middle ear is continuous with that of the pharynx via Eustachian tube. It covers the ossicles, muscles, nerves and forms the inner layer of tympanic membrane. Mucosal fold are of two types Composite Fold – these are of ligament with lining mucosa. Duplicate Fold – Fusion of two expanding sacs in absence of any interposing structure. Epitympanic Diaphragm it is an oblique dividing septum between the posterior superior attic and anteroinferior mesotympanium. It comprises of anterior malleolar ligament, lateral malleolar ligament, posterior malleolar ligament, lateral incudal fold, tensor tympani fold and posterior incudal ligament fold. Tympanic Isthimus is 2.5 mm elongated narrow space in epitympanic diaphragm present naturally and provides ventilation. Key message is tensor tympani fold and anterior Pouch of VonTroltsch is responsible for ventilation of anterior compartment. It is extremely important to understand and restore the functional anatomy, proper gas exchange and mucosal clearance from the middle ear compartment. The obstruction site is at tympanic isthimus. It is crucial to visualise and clearance of disease to restore ventilation. In surgical procedures of ear just removal of tensor tympani fold along with resection of Cog provides good results by providing ventilation of attic, mastoid air cells and a successful tympanoplasty.
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ORIGINAL ARTICLES Top

Speech recognition in noise in patients with type II diabetes Highly accessed article p. 122
Somayeh Falahzadeh, Sima Tajik, Faezeh Azadi, Farnoosh Farjadi
DOI:10.4103/indianjotol.INDIANJOTOL_101_19  
Context: The chronic diabetes is associated with damage to the sensory and cognitive regions brain. The central auditory system is susceptible to the damage caused by high glucose level. Aims: Since the healthy auditory system plays an important role in communication, this study examined speech recognition in noise performance of these people so as to better identify the harmful impacts of diabetes on the auditory processing. Settings and Design: This cross-sectional comparative study compares the speech recognition in noise performance of 30 diabetic patients and 30 normal individuals aged 30–55 years with quick speech in noise (Q-SIN) test. Subjects and Methods: All people had normal hearing and the speech recognition performance in silent, the Persian version of the Q-SIN test was used. Statistical Analysis Used: Results of signal-to-noise ratio loss (SNR loss) and recognition of words at different SNR levels were analyzed with Chi-square test and independent t-test in two groups. Results: There was a significant difference between diabetic patients and normal individuals in mean of SNR loss (P < 0.05). The comparison of word recognition scores in each SNR showed no significant difference in 25, 20 SNRs between the two groups (P > 0.05), but the performance of diabetic patients was weaker in 15, 10, 5, 0 SNR (P < 0.05). Conclusions: In the absence of hearing loss, the diabetic patients have a significant speech perception disorder, especially at lower levels of SNRs, compared to normal people of the same age. Impaired speech comprehension in the presence of a competitive message can result from the damage to central auditory processing as a result of diabetes.
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Auditory brainstem response to level-specific CE-CHIRP® threshold estimation in normal-hearing adults Highly accessed article p. 127
Ahmad Aidil Arafat Dzulkarnain, Suhaila Ahmad Shuckri, Noraidah Ismail
DOI:10.4103/indianjotol.INDIANJOTOL_103_19  
Background: The aim of the present study was to compare the hearing thresholds between pure tone audiometry (PTA) and auditory brainstem response (ABR) from level-specific (LS) CE-Chirp® and click stimuli in normal adult subjects. Materials and Methods: Twenty-four adults with normal audiometric thresholds participated in the study. The ABR was recorded from the study participants at 80 dBnHL until their respective auditory thresholds using both the LS CE-Chirp® and click stimuli. Study Design and Statistical Analysis: A quasi-experimental study design was used. Audiometric thresholds (low frequencies [LFs], mid frequencies [MFs], and high frequencies [HFs]) and the ABR thresholds from both stimuli were compared using the Friedman test with Wilcoxon signed-rank test as the post hoc analysis. Results: No statistically significant difference was identified between the PTA and the ABR to LS CE-Chirp® thresholds at LFs and only small differences (<6 dB) median thresholds differences were identified at the MFs and HF. The amplitudes of wave III and V were larger for ABR to LS CE-Chirp® as compared to the ABR from the click stimulus. Conclusion: This study concluded that the ABR to LS CE-Chirp® has closer thresholds than the audiogram as compared to the ABR from click in normal-hearing adult subjects. At the suprathreshold (80 dBnHL), the ABR amplitudes of wave III, and V were larger in LS CE-Chirp® than the click stimulus.
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Vestibular evaluation in patients with congenital profound hearing loss using ice cold water caloric test and rotational chair test p. 132
Arun Dehadaray, Viraj Gaikwad, Maitri Kaushik, Prasun Mishra, Sai Belsare
DOI:10.4103/indianjotol.INDIANJOTOL_11_19  
Introduction: With the introduction of newborn hearing screening, hearing problems are often detected at the neonatal stage and in early infancy, and holistic approach including not only auditory but also vestibular function is needed. This study hopes to establish some corelation between cochlear and vestibular system dysfunction in a patient born with congenital profound hearing loss (CPHL). Materials and Methods: In this observational and descriptive study conducted at a tertiary care hospital, we evaluated eighty patients with bilateral CPHL from 2016 to 2018. After taking a detailed history and thorough ear, nose, and throat examination, the patients underwent vestibular function evaluation by ice cold water caloric test (ICCT) and rotational chair test (RCT) in the outpatient department, and the duration of nystagmus was calculated based on which hypoactive or absent vestibular function was found out. Results: In the present study, out of eighty patients with CPHL, vestibular function of 62 (77.50%) was normal, 9 (11.25%) hypoactive, and 9 (11.25%) with absent vestibular function. Conclusion: In the outpatient department where sophisticated equipment and laboratory facilities are not available, ICCT can be used to determine the vestibular function and also RCT can be used. From the present study, it can be concluded that vestibular dysfunction is present in 22.50% of patients with CPHL with the use of ICCT and RCT. There is a strong possibility of genetic origin etiology for vestibular dysfunction. The present study also concludes that consanguinity may be major etiological factor for vestibular dysfunction.
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Influence of cardiovascular risk factors on cochlear dysfunction p. 135
Nemanja Radivojevic, Nenad Arsovic, Zoran Dudvarski, Vladimir Nesic, Ljiljana Cvorovic, Snezana Babac, Aleksandra Radivojevic
DOI:10.4103/indianjotol.INDIANJOTOL_127_19  
Background: Cochlear dysfunction can arise not only from various factors such as ear diseases but also from systemic disorders of the body. The occurrence of otologic symptoms such as hearing loss, dizziness, and tinnitus can be due to cardiovascular disorders. Therefore, current understandings in the field of the diagnosis and therapy of cardiovascular diseases (CVDs) should include, among others, evidence of otologic disorders. Objective: The aim of this study is to determine the association between risk factors for CVD and cochlear dysfunction. Methods: The cross-sectional study included 128 participants with major CVD risk factors who underwent auditory function examination (pure tone audiometry). Results: There were 52 women (40.6%) and 76 men (59.4%) in total. The mean age of the participants was 58 years (a range of 28–83 years). The mean age among participants with hearing loss was 60 (±10.88), whereas the mean age among participants that had normal hearing thresholds was 54 (±12.18). Sensorineural hearing loss (SNHL) was measured in 59% of participants, of most frequent mild degree hearing loss. The prevalence of SNHL was higher in participants with arterial hypertension (P < 0.001, OR = 5.881, 95% CI 2.694–12.837) and the most common among them was moderate degree hearing impairment (38%). There is also a statistically significant association of SNHL with dyslipidemia and elevated body mass index (P < 0.001, [OR]: 4.118, 95% [CI]: 1.873–9.053 and P< 0.001, [OR]: 1.517, 95% [CI]: 1.237–1.859 ) with moderate and profound hearing loss. Conclusion: Based on the data obtained, it seems that the presence of major cardiovascular risk factors was a significant predictor for cochlear dysfunction.
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Examination of ototoxicity induced by imatinib, being a tyrosine kinase inhibitor: An experimental study p. 141
Emine Elif Altuntas, Kasim Durmus, Adem Bora, Nergiz Hacer Turgut, Hatice Terzi, Ahmet Kutluhan
DOI:10.4103/indianjotol.INDIANJOTOL_129_20  
Objectives: Two rats were excluded from the study. Because otitis media developing one rat in Group C (7th dayof the experiment) and bleeding-related death one rat in Group I-50 (14th day of the experiment). While the side effects of imatinib are investigated in the literature, it is remarkable that the case reports suggesting an ototoxic side effect also take place among the publications. The aim of this study was to investigate whether or not imatinib has any ototoxic effect on rats via auditory brainstem response (ABR) responses. Materials and Methods: Rats were divided into three groups as Group C (0.25 mL/kg/day), Group I-30 (30 mg/kg/day), and Group I-50 (50 mg/kg/day). In the ABR record, hearing threshold, latency, amplitude, and interpeak latency values on test days were recorded and assessed. Results: In the assessment made in terms of mean V Wave latency within the group, a difference was determined at all stimulus intensities at 8 kHz in Group I-50 (P < 0.05). In the within-group assessment performed in terms of mean Wave III latency, there were differences in Groups I-30 and I-50 (P < 0.05). In the within-group assessment performed in terms of I–III interpeak latency mean values, there was a difference at 4 kHz and 70 dB in Group I-30 (P < 0.05). In the within-group assessment in terms of mean III–V interpeak latency values, the difference between the groups was significant on the 7th day at 6 kHz and 50 dB (P = 0.044) and on the 14th day at 8 kHz and 70 dB (P = 0.036). In the within-group assessment in terms of Wave I amplitude mean values, the change in the amplitude values at 4 kHz (P = 0.003) and 6 kHz (P = 0.018) in Group I-50 was significant. Conclusion: It was observed that imatinib application caused elongation in latency and interpeak latency values and changes in amplitude values. These differences were not enough to state that imatinib is having an ototoxic side effect.
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Vestibular epilepsy: Clinical presentation, diagnosis, and management p. 147
Ajay Philip, GR Haripriya, Manju Deena Mammen, Anjali Lepcha, Ann Mary Augustine
DOI:10.4103/indianjotol.INDIANJOTOL_154_20  
Background: Vestibular epilepsy as a cause of vertigo is rare. This clinical entity occurs primarily due to epileptic activity in parts of the cortex that represents the vestibular system. It is often distinctive with sudden, brief episodes of vertigo followed by rapid recovery without sequelae. In vestibular epilepsy, vertigo is not simply an aura, but constitutes a part of the seizure, and maybe its only manifestation. Aim: The aim of this study was to describe the clinical profile of patients diagnosed with vestibular epilepsy who presented to the neurotology clinic in our hospital in the past 7 years from January 1, 2014, to May 1, 2020, and to present their clinical features, diagnosis, and management. Materials and Methods: This was a retrospective observational clinical study based on the medical records of all patients diagnosed with vestibular epilepsy who presented during the period January 1, 2014–May 1, 2020, to our neurotology clinics. Each patient's history and neurotological examination were documented. All investigations carried out such as audiovestibular tests, electroencephalogram, cardiac tests, and imaging were noted. Results: Ten patients were diagnosed with vestibular epilepsy in our clinic during this time period, with a prevalence of vestibular epilepsy being 0.001%. The main subjective aura in our patients was vestibular disturbance in the form of rotatory type of vertigo which lasted for a few seconds. These symptoms were followed by abnormal movements of limb and loss of consciousness (LOC) in six patients. The patients who experienced a LOC had cardiology workup. Electronystagmogram was abnormal in three patients, while magnetic resonance imaging showed an abnormality in three patients. All patients were started on anticonvulsant drugs and showed a good response to treatment. Conclusion: Vestibular epilepsy is a rare but treatable cause of transient dizziness. The diagnosis of vestibular epilepsy is often missed or delayed and should be considered when brief episodic spontaneous vertigo occurs with LOC and unresponsive to standard vestibular treatment. Treatment with anticonvulsants seems to give relief of symptoms.
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Efficacy of medical grade manuka honey in acute otitis externa: A pilot study p. 151
Amit Kumar, Shweta Mittal, Amit Kumar Tyagi, Hano Romesh, Saurabh Varshney, Manu Malhotra
DOI:10.4103/indianjotol.INDIANJOTOL_28_20  
Introduction: Manuka honey has been used in chronic diabetic ulcers and traumatic wounds. We have used Manuka honey in cases of otitis externa because of its antibacterial and anti-inflammatory properties. Objectives: The objective was to study the efficacy of topical applications of Manuka honey in the patients of acute otitis externa. Materials and Methods: Patients with acute otitis externa without any prior ear complaint or intervention were selected for the study after informed and written consent. All patients selected for the study were packed with Manuka honey-impregnated umbilical tape and pain scores; canal wall edema was recorded on days 0, 1, 3, and 7. Results: A total of 20 patients were included in our study. Twenty patients followed us on day 1, 15 patients on day 3, and seven patients followed us till day 7. The mean pain score for day 0 was 5.35, and the mean pain score decreased to 2.95 on day 1, and the difference was statistically significant. Conclusion: Manuka honey appears to be an effective therapeutic agent in the management of otitis externa.
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Effect of middle ear surgery on taste in patients with chronic otitis media p. 155
Vijin Ravindran, Deviprasad Shetty, K S Gangadhara Somayaji
DOI:10.4103/indianjotol.INDIANJOTOL_58_20  
Objective: The objective was to identify the gustatory changes in patients with chronic otitis media due to chorda tympani nerve involvement and to identify the gustatory changes with minimal manipulation, stretching, and cutting of the nerve during surgery and its postoperative recovery. Methodology: A total of 100 patients were selected. Clinical assay, with tests based on “taste strips” with different concentrations of salt, sweet, bitter, and sour, was done preoperatively. The taste strips used were sodium chloride for salt, sucrose for sweet, quinine sulfate for bitter, and citric acid for sour. The same was tested postoperatively after 1 week, 1 month, and 6 months. Analysis: Of the total 100 patients, 22 patients had squamosal disease, and the remaining 78 patients had mucosal disease. Fourteen patients were found to have taste changes preoperatively, of whom nine recovered their taste 1 week following surgery. Remaining five patients recovered at 1 month following the surgery. It was also observed that, in all the 25 patients where the nerve was cut, postoperative changes were noted, which recovered completely at the end of 6 months, except in two patients. In patients where the nerve was stretched, patients showed more gustatory alterations when compared with patients where the nerve was minimally manipulated. Conclusion: We conclude from our study that cutting the nerve produced less gustatory alterations, when compared with patients where the nerve was stretched. We also concluded that chronic inflammation of the middle ear itself can cause gustatory alterations, and these changes recovered once the disease was cleared.
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Assessment of vestibulotoxicity of neem leaf (Azadirachta indica) in a rat animal model p. 159
Rosdan Salim, Mohd Khairi Md Daud, Maithrea Suresh Narayanan, Aziah Ab Rani
DOI:10.4103/indianjotol.INDIANJOTOL_6_20  
Introduction: Otomycosis is a challenging and frustrating entity for both patients and otolaryngologists for it frequently requires long-term treatment and follow-up, yet the recurrence rate remains high. The management is directed toward intense aural toileting with administration of topical antifungals. There has been increased resistance to classical antifungal agents, typically involving the azoles and polyenes. This has led into the research of medicinal plants as an alternative treatment for treating fungal infections. Objective: This study aims to investigate the possible vestibulotoxic effects of neem leaf (Azadirachta indica), a commonly used home remedy on the inner ear in a rat animal model. Methodology: Twenty healthy, mature Wistar albino rats were divided into three groups: Groups A (eight animals), B (eight animals), and C (four animals). They underwent baseline vestibular parameter testing, following which an endoscopic-guided transtympanic instillation of aqueous and alcohol neem extract was performed into the right middle ear of the rats in Groups A and B, while normal saline was instilled into the right middle ear of rats in Group C. Vestibular parameter testing was repeated on the rats in both groups post instillation of transtympanic neem at 4-h, 24-h, 48-h, 72-h, 1-week, 2-week, and 3-week intervals. Results: There was no deterioration in all vestibular parameters recorded post instillation of neem extract within the middle ear. Conclusion: Neem extract is a safe alternative in the treatment of otomycosis in the presence of tympanic membrane perforation as it poses no vestibulotoxic side effects.
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Comparison of cognitive functions in elderly population with and without hearing loss p. 163
Amrutha Somnath, Archana Gundmi, PG Bhargavi, Shwetha Rai
DOI:10.4103/indianjotol.INDIANJOTOL_65_19  
Objective: The objective of this study was to investigate the association between hearing loss and cognitive functions in the elderly population. Methods: A cross-sectional study was carried out on 12 elderly individuals with hearing loss (elderly hearing impaired [EHI]) and 20 elderly individuals with normal hearing (elderly normal hearing [ENH]). The participants in the study were aged between 60 and 65 years. The audiological and cognitive tests were performed on both the groups. Results: The data compiled through descriptive statistics and multivariate analysis of variance revealed clinically significant differences between the EHI and ENH on different cognitive tests. This indicates that elderly population associated with hearing loss requires more time to process the tasks as compared to ENH individuals. Conclusion: There is a higher decline in cognitive functions in elderly individuals when associated with hearing loss compared to normal-hearing individuals. Since it is noticed as a comorbid condition, both cognition and hearing loss have to be assessed and treated in these individuals for better quality of life.
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A retrospective comparison of intratympanic dexamethasone with gentamicin in meniere's disease – A single-institutional study p. 168
Vinoth Manimaran, Sanjeev Mohanty, Somu Lakshmanan
DOI:10.4103/indianjotol.INDIANJOTOL_73_20  
Background: Intratympanic gentamycin or steroids are used to treat refractory Meniere's disease with variable results. The aim of this study is to analyse and compare the vertigo control and hearing outcomes of intratympanic (IT) Dexamethasone and Gentamycin in patients with definite Meniere's disease (MD). Subjects and Methods: A retrospective cohort study in a tertiary care hospital. Patient's age, sex, laterality of disease, vertigo control rates after 6 and 12 months of treatment, mean doses of IT injections given, pre- and post-therapy Pure tone audiogram (PTA) of Bone conduction levels and complications were recorded. Results: 31 patients who met the study criteria were included in the study. 18 received IT dexamethasone (Group 1) and 13 (Group 2) received IT gentamycin injections. The mean number of IT injections given irrespective of outcomes were 2.44 ± .705 and 2.08 ± 0.760 respectively (P= 0.176). Though the pre-treatment PTA was comparable in both the groups (41.76 ± 7.29 dB vs 45.66 ± 7.59 dB), Group A had better hearing preservation than group B (40.47 ± 7.79 vs 48.06 ± 8.56 dB) (P= 0.000). The vertigo control rates at the end of 6 and 12 months were 61.1% vs 84.6% & 81.25 vs 77.7% respectively (P= 0.363 & 0.093). Conclusion: Intratympanic Dexamethasone is an effective treatment option in patients with MD. Though the mean number of injections required were higher than Gentamycin, the difference was not statistically significant.
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Hearing loss among cement factory workers in Northwest Nigeria p. 173
Nasiru Aliyu, Kufre Robert Iseh, Abdullahi Mohammed, Stephen Semen Yikawe, Mfon Ime Inoh, Caleb Manya
DOI:10.4103/indianjotol.INDIANJOTOL_9_20  
Background: Exposure to noise has been observed to have deleterious effect on the health status of individuals working within the noisy environment. Continuous exposure to high and unwarranted sound remains a major cause of hearing disorder all over the world. Occupational noise-induced hearing loss (NIHL) constitutes a worldwide problem in industries and contributes about 16% of hearing loss among adults globally. Aims and Objectives: The aim and objective was to evaluate the impact of occupational noise exposure on the auditory performance of workers at a cement company. Methods: This was a cross-sectional descriptive study of consenting workers at a cement company (public liability company). A total of 341 respondents were recruited for the study with equal number of controls matched for age and sex. Ear examination was done and based on the exclusion criteria, 23 participants with diseased ears were excluded. There hundred and eighteen participants (616 for both study group and control group) each had an interviewer–administered, semi-structured questionnaire and underwent diagnostic pure-tone audiometry. A digital sound level meter (Type 2 well-calibrated TOMTOP-Model Number H4320) with a range of 30–130 dB was used to map out the sound in the respective departments. Results: One hundred and one (31.8%) noise-exposed workers had mild (23.3%), moderate (7.2%), and severe (1.3%) hearing loss in their right ears as against the 21 (6.6%) in the controls. This was found to be statistically significant (P = 0.000). Seventy-seven (24.2%) noise-exposed workers also had mild (17.9%), moderate (6.0%), to severe (0.3%) sensorineural hearing loss in the left ear with the controls having 6.3%; this was also found to be statistically significant (P = 0.000). The presence of notch at 4 kHz audiometric configuration was 14.5% and 17% in better and worse ears, respectively. Three hundred (94.3%) workers in the noise exposed group worked for <8 h in a day (40 h/week) irrespective of the intensity of noise they were exposed to. Conclusion: This study has revealed a high prevalence of sensorineural hearing loss in the factory. This pattern of sensorineural hearing loss, coupled with the significant presence of 4 kHz audiometric notch among the noise-exposed workers (16.9%) in the worse ear when compared with the controls (3.1%) in the worse ear, strengthened the assertion that the hearing loss of the workers was likely attributable to occupational NIHL.
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CASE REPORTS Top

Mastoid surgery during coronavirus disease 2019 pandemic: Focusing on mitigation measures p. 179
Kripa Dongol, Rabindra Bhakta Pradhananga, Pabina Rayamajhi, Urmila Gurung
DOI:10.4103/indianjotol.INDIANJOTOL_100_20  
Mastoid surgery is an aerosol-generating procedure and is considered as high-risk procedure during this pandemic of coronavirus disease. It should, however, be performed in certain life-threatening conditions. Otorhinolaryngologists should be well versed with the measures to protect ourselves from acquiring the coronavirus. We, therefore, report a case of mastoidectomy performed during this pandemic for an intracranial complication of chronic otitis media, focusing on the mitigation measures.
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The clinical value of bilateral bone conduction testing in hearing diagnosis p. 182
Maziah Romli, Wan Najibah Wan Mohamad, Mahamad Almyzan Awang, Cheu Lih Aw, Mohd Normani Zakaria
DOI:10.4103/indianjotol.INDIANJOTOL_106_20  
Pure tone audiometry (PTA) is the standard clinical test for diagnosing the severity and the type of hearing loss. For hearing diagnosis, air conduction (AC) and bone conduction (BC) thresholds are determined and analyzed. Typically, the unmasked BC testing is conducted in one ear as the interaural attenuation (IAA) for BC is considered to be 0 dB. In this case report, we demonstrate the usefulness of performing bilateral BC testing to achieve an accurate hearing diagnosis. As found, the IAA for BC could be as high as 15 dB, and the unmasked BC testing should be performed on both ears to avoid misdiagnosis (particularly on the type of hearing loss). Even though PTA is the standard clinical test for hearing diagnosis, it is still imperative to ascertain its results through comparisons with other clinical test findings.
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The diagnostic value of tympanometric width in identifying middle ear disorders p. 186
Mohd Normani Zakaria, Maziah Romli, Wan Najibah Wan Mohamad, Mahamad Almyzan Awang, Noor Alaudin Abdul Wahab
DOI:10.4103/indianjotol.INDIANJOTOL_120_19  
Tympanometry is a valuable test to measure the mobility of the tympanic membrane and middle ear function in an objective manner. Clinically, the middle ear status is determined based on the tympanogram types derived from typical tympanometric parameters, including static admittance, tympanometric peak pressure , and ear canal volume. Nevertheless, a further tympanometric parameter, tympanometric width (TW), is not commonly used for hearing diagnosis. In this paper, we report a case demonstrating the superiority of TW in detecting middle ear disorders. The TW parameter can be a useful indicator to verify the pure tone audiometry results and should be used regularly for identifying middle ear problems leading to conductive hearing loss.
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Adolescent temporal bone fibrous dysplasia p. 191
Johannas Mohd Yusof, Jeyasakthy Saniasiaya, Norhaslinda Ab Gani, Goh Bee See
DOI:10.4103/indianjotol.INDIANJOTOL_123_20  
Fibrous dysplasia (FD) is a rare, benign osseous tumor, whereby normal bone architecture is replaced by haphazard fibrous tissue. Temporal bone involvement is extremely rare and presents with vague symptoms. We present a case of temporal bone FD in an adolescent girl who presented with progressive unilateral hearing loss, which was successfully managed surgically with canal wall down mastoidectomy with no recurrence. FD although rare, has a tendency for cataclysmic complications if not discerned early.
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A rare case of recurrent massive petrous bone cholesteatoma: Subtotal petrosectomy without blind sac closure p. 194
Santhanakrishnan Kaliavaradan, Poornima Shankar Bhat, Nisha Muruganidhi, Sethu Palaniappam
DOI:10.4103/indianjotol.INDIANJOTOL_138_20  
Petrous bone cholesteatoma is a rare challenging disease that accounts for 4%–9% of all petrous bone lesions. Subtotal petrosectomy with mastoid obliteration without blind sac closure is presented here. A 25-year-old female patient presented with right ear discharge for 5 days, with a history of right ear surgery 19 years back. Right ear external auditory canal showed stenosis suggestive of blind sac closure in the past. High resolution computer tomography and magnetic resonance imaging of temporal bones were suggestive of massive cholesteatoma in right petrous bone with extension into the posterior cranial fossa. As the patient refused blind sac closure, the patient underwent right subtotal petrosectomy, with mastoid obliteration, with wide meatoplasty. The patient is on regular follow-up without any complications. Although blind sac closure is routinely done, mastoid obliteration with wide meatoplasty is an alternative method without increased incidence of complications. Early patient reporting and clinical suspicion of recurrence and prompt treatment is facilitated by wide meatoplasty.
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Aberrant course of facial nerve in the middle ear cavity p. 197
Seyed Basir Hashemi, Reza Jahangiri, Milad Hosseinialhashemi, Maryam Naghmachi
DOI:10.4103/indianjotol.INDIANJOTOL_40_20  
Facial nerve (FN) course anomaly is often found in patients with congenital aural atresia or other ear anomaly, but in this case report, we report an abnormal FN course with dehiscent facial canal found in a patient with congenital conductive hearing loss without any accompanying auricular deformity or cholesteatoma.
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