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   Table of Contents - Current issue
Coverpage
April-June 2017
Volume 33 | Issue 2
Page Nos. 473-555

Online since Thursday, May 11, 2017

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ORIGINAL ARTICLES  

Round window accessibility in transcanal approach Highly accessed article p. 473
Mohammed Rashad Ghonim, Mohammed Mohammed Ebrahim Abo-Samra, Waleed Moneir, Ahmed Hemdan El-Deeb
DOI:10.4103/1012-5574.206020  
Aim Our aim of this study is to evaluate the transcanal approach to visualize the round window whose visualization is a very important and challenging topic as it is used as a portal for electrode insertion during cochlear implantation. Methods This study was carried out over fifty patients suffered from conductive or mixed hearing loss with intact tympanic membrane suggested to be otosclerotic patients irrespective to their age or sex. The exploratory tympanotomy procedures were performed. The tympanomeatal flap is considered to be completely elevated when the posterior edge of long process of malleus, the long process of incus, the stapes and the stapedial tendon were visible and the flap is reflected anteriorly without tension. At this step, visualization of round window is assessed microscopically and endoscopically by using an oto-endoscope of 2.7 mm diameter and 30 angle. Results By using the microscope, we found that 48 cases were fully visible (Type 1), 1 case was partially visible (Type 2) and 1 case was not visible (Type 3). By using the endoscope, we found that the round window details are fully visible in all the fifty cases. Conclusion We experienced that better exposure of round window could be achieved with less effort via transcanal approach. Using the endoscope gives panoramic view with clear details. So, transcanal approach can be used instead of classic posterior tympanotomy to visualize the round window.
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Transcanal totally endoscopic stapes surgery: step-by-step procedure Highly accessed article p. 477
Ahmed A Omran, Ahmed S Habib
DOI:10.4103/1012-5574.206014  
Objectives The purpose of the present work was to evaluate the role of otoendoscopy in performing stapedotomy in clinically otosclerotic patients. Patients and methods Twenty patients presenting with clinically diagnosed otosclerosis were randomly selected from the outpatient ENT clinic in a tertiary referral Institutional Hospital. All patients were subjected to transcanal totally endoscopic stapes surgery (TTESS) from early 2013 to the fall of 2014. Methods This prospective study demonstrated the detailed technique of TTESS using mainly 0° lens of 14 cm length rigid endoscope for elevating the tympanomeatal flap, handling the chorda tympani nerve, curettage of posterior bony canal wall, visualization of oval window niche structures, creation of stapedotomy, and accurate prosthesis insertion. Postoperative audiogram was performed after 2 months. Assessment of postoperative complications, especially change in taste sensation, was carried out. Results The chorda tympani nerve was preserved in all cases. Two cases had change in taste sensation that was improved within 6 months postoperatively. There was a significant improvement in hearing. The preoperative air-bone gap mean value was 40.30±6.38, and the postoperative mean value was 7.15±4.27 (P=0.001), with complete closure of air-bone gap in four cases. No facial paralysis or tympanic membrane perforation was encountered during the follow-up period. Conclusion Transcanal totally endoscopic stapes surgery is a feasible and safe technique for the surgical management of conductive hearing loss associated with otosclerosis, which is recommended in bilateral and revision cases.
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Surgical management of the facial nerve in various skull base pathologies through different lateral skull base approaches p. 484
Ahmed A Omran, Mohamed M Badr El-Dine, Ahmed A Eshmawy
DOI:10.4103/1012-5574.206015  
Objective The aim of the present study was to demonstrate facial nerve (FN) outcomes in various skull base pathologies managed through different lateral skull base approaches. Materials and methods This retrospective study was conducted on 20 patients admitted to the ENT outpatient clinic of a tertiary referral center. All patients presented with different skull base lesions with or without FN involvement. A full preoperative assessment was carried out, including the House–Brackmann (HB) FN grading scale. Surgical techniques used to manage the FN depended on the surgical approach and the extent of the pathological lesion in the form of FN identification and monitoring, decompression, intact fallopian bridge technique, rerouting, anastomosis, or scarification. FN functional integrity was assessed 1 month and 1 year postoperatively using the House–Brackmann scale to assess different surgical techniques used to manage the FN and their effects on postoperative FN function. Results Half of the patients had glomus jugulare tumor, which were mostly managed through infratemporal fossa type A approach. At 1 month postoperatively, no great improvement was found in FN function in most of the cases. After 1 year, the improvement was statistically significant. Conclusion One year postoperatively could give idea of the FN surgical outcome. Grade III was the best result achieved in cases of FN grafting and anastomosis. In the present study, FN intact techniques were the most useful to yield better results than were grafting and anastomosis when the circumstances and extension of the pathology allow the surgeon to use such techniques.
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Young nasopharyngeal carcinoma: a review of an 8-year experience in the East Coast Malaysia Hospital p. 490
Azliana Aziz, Ramiza Ramza Ramli, Irfan Mohamad, V Murali K Bhavaraju
DOI:10.4103/1012-5574.206021  
Introduction Nasopharyngeal carcinoma (NPC) is among the most common head and neck malignancies seen among adults in Malaysia. It is the third most common cancer in males after colorectal and lung cancers. Even though it has bimodal peak distribution, young NPC is a rare occurrence. It accounts for less than 1% of all paediatric cancers. Objective The objective of this study was to describe the 8-year experience with young NPC in the year 2003 until 2010 in a tertiary centre in East Coast Malaysia Hospital. Method Twenty-four young NPC cases confirmed by histopathology and undergoing treatment in a tertiary centre in East Coast Malaysia Hospital between 2003 and 2010 were retrospectively reviewed. We studied NPC incidence observed during that period, focusing on the age and sex distribution and the ethnic background of patients. We also analysed the most prevalent signs and symptoms and staging of the NPC patients at first presentation, which include neck swelling, ear symptoms, nasal symptoms and other miscellaneous symptoms. Results Presentation was predominant in the Malay population, with age peaking between 16 and 20 years. Most patients were male (70.8%). The main presenting symptoms were neck mass (70.9%), unilateral nasal obstruction (33.3%), epistaxis (29.2%) and other miscellaneous complaints (20.9%), including headache, diplopia and facial paraesthesia. In all, 25% of patients had cranial nerve involvements either isolated or a combination of cranial nerves 2, 3, 4, 5, or 6. Stage I, II, III and IV patients accounted for 0, 4.2, 12.5 and 83.3%, respectively. Majority (91.7%) had WHO type 3 NPC (undifferentiated carcinoma). Conclusion Results from our series are comparable to those reported by other centres. A majority of the patients were diagnosed late and at the advanced stage. The TMN staging was a relevant prognostic factor.
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Certainty of pretreatment apparent diffusion coefficient in the characterization of thyroid gland pathologies p. 495
Tarek Abd-Alhamid, Ahmed G Khafagy, Hesham Al Sersy, Anas Askora, Tahany M Rabie, Mohamed S Taha, Amal Ebrahim, Hoda M El Sayed
DOI:10.4103/1012-5574.206019  
Introduction One of the most recent techniques in imaging tumors is the diffusion-weighted MRI. It provides information regarding the metabolic, molecular, and pathophysiological aspects of tumors, especially thyroid gland cancer. Diffusion-weighted imaging (DWI) has also been proposed as a sensitive marker for monitoring treatment response in head and neck cancers. The biophysical mechanism of DWI is based on the translational motion of water molecules in tissues. The magnitude of this motion is characterized by its apparent diffusion coefficient (ADC) values. Objective The aim of the present study was to evaluate the certainty of ADC value in differentiating between benign and malignant thyroid lesions. Materials and methods Neck MRI with several sequences including DWI in the axial plane were carried out for 49 patients who presented with thyroid masses either benign or malignant. ADC maps were calculated by using the MRI machine software. Results A total of 49 patients (77.6%) were included in the present study. There were 11 men (22.4%) and 38 women patients (77.6%), with a mean age of 44.4 years. The lesions were benign in 31 cases (63.3%) and malignant in 18 cases (36.7%). The ADC values were significantly different (P < 0.001) between benign and malignant lesions. Conclusion ADC value is a promising noninvasive imaging tool that can be used for characterization and differentiation of thyroid nodules.
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Comparing outcome of formal and informal remediation programs in children with central auditory processing disorder p. 502
Samah M Oraky, Somaia Tawfik, Mohamed Salama, Enass S Mohamed
DOI:10.4103/ejo.ejo_3_17  
Aim The aim of this study was to compare the outcome of central auditory processing rehabilitation when using two different strategies: In the first strategy, computer-based remediation program (temporal processing and phonemic awareness training) was used. In the second strategy, informal remediation program (temporal processing and phonemic awareness training) was used. Patients and methods Fifty children with learning disability due to Central Auditory Processing Disorder (CAPD) were selected from primary schools in Assiut city. They were subjected to psychophysical test battery. It comprised dichotic digits, pitch pattern sequence, auditory fusion test and electrophysiological test (cortical P1). They were divided into two equal groups (A and B): group A received the formal auditory training (AT) and group B received the informal AT for a minimum duration of 2 months. Re-evaluation of those children was performed using the same test battery used in the diagnosis. Results There was a statistically significant difference in all psychophysical tests and electrophysiological P1. Subjective improvement was noticed also at the level of the questionnaire. Conclusion Both formal and informal remediation programs used in this study proved to be effective and promising AT strategies for ameliorating central auditory disorder.
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Auditory brainstem evoked responses and vestibular evoked myogenic potentials: potential biomarkers in Parkinson's disease p. 508
Dalia M Hassan, Ali Shalash
DOI:10.4103/1012-5574.206023  
Objective The aim of this study was to investigate brainstem functions in Parkinson's disease (PD) through studying auditory brainstem evoked responses (ABRs), and ocular and cervical vestibular evoked myogenic potentials (oVEMP and cVEMP) and to explore their relation with motor symptoms, if any. Study design Fifteen individuals diagnosed as having idiopathic PD and 15 age-matched controls were included. The PD patients were evaluated using the Unified Parkinson's Disease Rating Scale, the Hoehn and Yahr Scale, and the Schwab and England Scale. The subscores of major symptom were calculated, such as tremor, rigidity, bradykinesia, and axial signs. During medication ‘on’ states, PD patients and controls underwent pure-tone audiometry, speech audiometry, tympanometry, ABR, oVEMP, and cVEMP. The test findings in PD patients were grouped into ipsilateral and contralateral results in relation to the clinically more affected motor side and were compared with the age-matched controls. Results PD patients showed abnormal ABR wave morphology, prolonged absolute latencies of ABR wave V, and I–V interpeak latencies. Absent responses were the evident abnormality seen in oVEMP. Prolonged latencies with reduced amplitudes were seen in cVEMP responses. The main motor features of PD (rigidity and bradykinesia) were correlated to the ABR and cVEMP responses contralateral to the clinically more affected side. Conclusion Dysfunction at different levels of the brainstem was confirmed in patients with PD. The impairment of ABRs and VEMP responses is related to characteristic clinical asymmetry of PD and its cardinal motor features. ABRs and VEMPs could be used as potential electrophysiological biomarkers for PD.
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Epley repositioning maneuver versus Gans repositioning maneuver on postural instability in elderly patients with benign paroxysmal positional vertigo p. 518
Abir Omara, Dalia M Mosaad, Ahmed S Mohamed, Neveen A Abd El-Raoof
DOI:10.4103/1012-5574.206025  
Introduction Patients with benign paroxysmal positional vertigo (BPPV), especially the elderly, often experience a greater incidence of falls and postural instability. The Epley repositioning maneuver has been proven to be effective in improving the postural control, whereas Gans repositioning maneuver (GRM) is still lacking data. Objective The objective of this study was to compare between the effectiveness of GRM and Epley repositioning maneuver in improving postural stability in elderly patients with posterior canal BPPV. Patients and methods In this randomized controlled trial, patients were randomly assigned into two groups. Group A (study group) was assessed by side-lying test and treated by GRM, whereas group B (control group) was evaluated by Dix–Hallpike test and treated by the Epley repositioning maneuver. Postural stability was estimated by computerized dynamic posturography. Results Patients in both groups showed improvement within the groups in equilibrium scores subtest 4, 5, 6 (P<0.05), whereas there was no significant difference between groups (P>0.05) regarding equilibrium scores. Conclusion GRM is as effective as the Epley repositioning maneuver in improving postural stability in elderly patients with posterior canal BPPV.
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Assessment the effect of noise on the sacculocolic pathway using vestibular evoked myogenic potential p. 523
Reem Elbeltagy, Dalia Galhom
DOI:10.4103/1012-5574.206022  
Objective The aim of this study was to detect the effect of noise on the sacculocollic pathway using cervical vestibular evoked myogenic potential (c-VEMP) and to check the correlation between the hearing thresholds and the c-VEMP responses in noise-induced hearing loss (NIHL) patients. Patients and methods The study included 40 (80 ears) participants. Their ages ranged between 30 and 45 years. They were divided into two groups: 20 (40 ears) participants with NIHL presenting with bilateral notched audiogram at 4 kHz, and 20 (40 ears) participants as a control group. All participants in the study were subjected to basic audiological evaluation and VEMP tests. Results As the average pure-tone hearing threshold increased, the c-VEMP latencies prolonged and peak-to-peak amplitude reduced in NIHL patients. Of the 40 ears, c-VEMP was absent in 12 (30%) ears. The latencies prolonged and the peak-to-peak amplitude reduced in 16 (40%) ears. VEMP results were normal in 12 (30%) ears. Conclusion Noise can cause more damage to the vestibular system, especially the sacculocollic pathway.
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Assessment protocol for patients with acquired apraxia of speech p. 528
Yehia Amin Aboras, Ghada Abdelhady Ashmawy, Reham Mohamed Elmaghraby, Sabah Saeed Gommaa
DOI:10.4103/1012-5574.206018  
Background Apraxia of speech can be defined as an articulation disorder that results from impairment of the capacity to order the positioning of speech musculature and the sequencing of muscle movements for volitional production of phonemes and sequences of phonemes. Objective The aim of this study was to adapt the Apraxia Battery for Adults II (ABA II) test to suit the Egyptian culture in order to apply this test for assessing Egyptian apraxic patients for proper management of this ailment. Subjects and methods This study was conducted on two groups: the first group consisted of 56 adult patients with expressive aphasia and/or dysarthria, who were evaluated with ABA II to detect any apraxic elements. The second group consisted of 100 healthy adults who served as the control group and were evaluated by ABA II to yield cutoff scores. Test reliability was assessed by internal consistency reliability using reliability coefficient α (Cronbach’s α). Test validity was measured on the basis of content validity, concurrent validity, and group differentiation. Results Reliability of the ABA II test was proved to be high, on the basis of the high values of coefficient α obtained for all test items (0.746–0.937), denoting an intercorrelation between test items. Validity of the ABA II was proven by three methods: content validity, concurrent validity (correlation matrix between different items of the test was determined and there was a strong correlation between the test items), and group differentiation (comparison of the test results between apraxic patients, nonapraxic patients, and controls was done and statistically significant differences were found between the scores of all test items among these groups.) The test was proven to be sensitive and specific. Conclusion The results were highly significant and were capable of discriminating between normal subjects and apraxic patients.
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Neural representation of speech in pediatric cochlear implant recipients p. 535
Tayseer T Abdel Rahman, Ihab M Nada, Hesham A.A. Abdel Kader, Ahmed A Abdel Monem
DOI:10.4103/1012-5574.206026  
Objective Cochlear implantation (CI) is an established treatment for selected individuals with bilateral severe-to-profound sensorineural hearing loss who derive limited benefits from conventional hearing aids. This work was designed to assess speech processing at the brainstem and the cortical level in children fitted with CIs after a variable duration of implantation and speech therapy compared with language acquisition. Patients and methods Thirty-one children between 4 and 5 years of age fitted with unilateral CIs of variable duration ranging from 1 to 3 years were assessed at 1 year (n=10), 2 years (n=12), and 3 years (n=9) after device activation. They underwent aided sound–field audiological evaluation, speech-evoked auditory brainstem response, and speech-evoked mismatch negativity test. The results were compared among the study groups and then correlated with language assessment and speech perception tests. Results Both speech-evoked auditory brainstem response and mismatch negativity test responses were significantly different among the three groups. Moreover, language development showed a significant difference among the three groups. Conclusion Children fitted with CI showed cortical and brainstem activation from the first year and these activity changes continue with CI use and both are highly correlated with receptive and expressive language. Thus, both electrophysiologic tests could be early and critical objective indicators of optimal speech encoding after programming of the CI device.
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CASE REPORTS Top

Post-tonsillectomy surgical emphysema – a case report p. 546
H Kamel, F Fahmy
DOI:10.4103/1012-5574.206027  
Tonsillectomy is still the most common surgical procedure performed in most ENT departments worldwide. Although it is considered a safe procedure, its complications can be serious and potentially life threatening. The development of cervicofacial emphysema after tonsillectomy is a very rare complication, which in most cases resolves spontaneously, but on the other hand it can be life threatening especially if associated with pneumothorax or pneumomediastinum.
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Papillary carcinoma thyroid coexisting with squamous cell carcinoma: series of two cases p. 549
Hemanth Vamanshankar, Sivaraman Ganesan, Arun Alexander, Sunil Kumar Saxena
DOI:10.4103/ejo.ejo_32_16  
Papillary thyroid cancer metastasizing to cervical nodes coexisting with squamous cell carcinoma of the upper aerodigestive tract is a rare finding. To the best of our knowledge, nearly 43 such cases have been reported in the literature. We present two such cases that were managed in our hospital. The first was a case of carcinoma of the lower alveolus with papillary carcinoma thyroid; the other was a case of carcinoma of the hypopharynx with an associated papillary carcinoma. The rarity of its presentation along with the dilemma in the management in such a patient has been discussed here, with a review of the relevant literature.
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LETTER TO EDITOR Top

Otolaryngology and audiology: integrated and not separated subspecialties p. 554
Nagwa Hazzaa, Tamer A Youssef
DOI:10.4103/1012-5574.206024  
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