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   2016| January-March  | Volume 32 | Issue 1  
    Online since February 5, 2016

 
 
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ORIGINAL ARTICLES
Intravenous L-alanyl-L-glutamine: an adjuvant in the management of immunocompromised patients with invasive fungal rhinosinusitis
Noha M Elsharnouby, Mohamed M Elsharnouby, Gamal Elewa, Mohamed A Elgendy
January-March 2016, 32(1):1-6
DOI:10.4103/1012-5574.175792  
Background Invasive fungal rhinosinusitis is a potentially fatal infection in immunocompromised patients. Glutamine, a conditionally essential amino acid, is an energy source for rapidly dividing cells, particularly those of the immune system. This randomized, double-blind, placebo-controlled, two-group parallel study was designed to investigate intravenous l-alanyl-l-glutamine as an immune adjuvant in the management of patients with invasive fungal rhinosinusitis. Patients and methods Fourteen patients with invasive fungal rhinosinusitis undergoing endoscopic debridement and with postoperative admission to the ICU were included in this study. Group D (n = 7) received the standard protocol therapy and l-alanyl-l-glutamine 0.5 mg/kg/day infusion postoperatively for 10 days; group C (n = 7) received only the standard protocol therapy with the same volume and rate of saline postoperatively for 10 days as well. The primary outcome measure was patient response, either cure or persistence, whereas secondary outcome included length of ICU stay, ICU survival, hospital survival, and complications. Results In group D there was significant improvement in response rate as all five patients who survived in group D had a complete cure (100%), whereas in group C among the three patients who survived only one (33%) patient was completely cured. There was significant decrease in length of ICU stay (P = 0.003) and incidence of complications (P = 0.03) in group D compared with group C. The incidence of intracranial extension, renal impairment, and septic shock as well as ICU and hospital survival, was decreased in group D compared with group C but did not reach statistical significance. Conclusion Intravenous l-alanyl-l-glutamine 0.5 mg/kg/day infusion postoperatively for 10 days in patients with invasive fungal rhinosinusitis undergoing endoscopic debridement resulted in a better response accompanied with a decrease in ICU length of stay and complication rate.
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Use of bipolar coagulation diathermy for the management of recurrent pediatric epistaxis
Osama G Abdel-Naby Awad, Montaser A Hafez, Mahmoud M Hasan
January-March 2016, 32(1):7-12
DOI:10.4103/1012-5574.175795  
Background There is a lack of consensus as regards the optimal approach to the problem of recurrent pediatric epistaxis. Objective The aim of this study was to evaluate the use of bipolar coagulation diathermy in the management of recurrent pediatric epistaxis. Patients and methods This prospective study was conducted on 75 pediatric patients (6-15 years) with recurrent epistaxis, who were evaluated and treated with bipolar diathermic cautery during a 6-month follow-up period. Results During the follow-up period, 65 (87%) patients had complete absence of epistaxis with significant improvement ( P ≤ 0.05), nine (12%) patients had less than 10 attacks of epistaxis, and one patient had more than 10 attacks and was controlled with another trial of bipolar diathermic cautery. Patients with normal coagulation profile had significantly better results compared with patients with coagulation defects. Patients had no complications after the procedure. Conclusion Bipolar coagulation diathermy is an effective and safe procedure in the management of recurrent pediatric epistaxis.
  1,721 121 -
Endoscopic-assisted septoplasty versus traditional septoplasty: assessment by the NOSE scale
S Guindi Sherif, S Mostafa Hany, O Fawzy Tamer
January-March 2016, 32(1):26-31
DOI:10.4103/1012-5574.175801  
Context Nasal obstruction is a very common complaint, which may be caused by various causes, one of the most important being septal deviation. Many techniques have been described to correct these septal deviations since the middle of 19th century. There have been several modifications since its inception. The application of endoscopic techniques to correct septal deformities was initially described by both Lanza and colleagues and by Stammberger in 1991. Aims Comparing the efficacy of endoscopic septoplasty with traditional septoplasty in the treatment of cases with septal deviations. Patients and methods Thirty cases complaining mainly of nasal obstruction due to significant septal deviations were selected. They were randomly divided into two groups: group A patients underwent endoscopic septoplasty and group B underwent traditional septoplasty. The Nasal Obstruction Symptom Evaluation (NOSE) scale was an important step in assessment. Results The two procedures are suitable to correct septal deformities, with a slight upper hand for the endoscope in particular cases. We highlight in this study the advantages and disadvantages of the use of the nasal endoscope to correct nasal septal deviation. Conclusion Although mainly used in sinus surgery, the endoscope has also found its way in nasal septal surgery as it facilitates accurate identification of the pathology due to better illumination, improved accessibility to remote areas and magnification. It allows precise resection of the pathological areas without the need of an extended dissection. Endoscopic septoplasty is associated with a significant reduction in the patient's morbidity in the postoperative period due to limited extent of flap dissection and limited manipulation and resection of the septal framework. However, the endoscope has its own limitations which include loss of binocular vision and the need for frequent cleaning. The NOSE scale also correlates well with the postoperative results of the study.
  1,541 259 -
The relationship between the electrical stapedial muscle reflex threshold and electrical and behavioral measures in cochlear implant patients
Samir Asal, Ossama A Sobhy, Mohammed Nooman
January-March 2016, 32(1):49-52
DOI:10.4103/1012-5574.175848  
Programming of multichannel cochlear implants (CIs) requires subjective responses to a series of sophisticated psychophysical percepts. It is often difficult for young prelinguistically deaf children to provide adequate responses for device fitting. This is especially true in setting levels of maximum comfortable loudness, whereby failure to indicate growth of loudness may result in elevation of stimulus levels to the threshold of pain. The acoustic or stapedial muscle reflex has been used previously to provide objective confirmation of acoustic stimulation, and there have been attempts to use the reflex in hearing-aid fitting. It has also been suggested that electrically elicited middle-ear muscle reflexes [electrically evoked stapedial reflex threshold (ESRT)] may have applicability in confirming and quantifying electrical stimulation through a CI. To assess the relationship between ESRT characteristics and levels of loudness perception with CIs, determine the reliability of the response, and investigate the potential use of ESRT in CI programming, 26 prelinguistically deafened CI users were evaluated. Reflexes have also been attempted on 312 electrodes, with responses present in 213 (68.3%). Comfort levels predicted by subjective judgments were highly correlated with the ESRT in individuals with CI. ESRT provides an objective, accurate, and rapid method of estimating maximum comfortable loudness levels, which may be useful in the initial programming of young implant recipients.
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The transnasal endoscopic management of spontaneous cerebrospinal fluid rhinorrhea from the lateral recess of the sphenoid sinus
Mahmoud N El Tarabishi, Hossam M Rabie, Tamer A Youssef, Mohamed M El-Sharnouby, Samia A Fawaz, Ihab M Nada, Mohamed S Hasab-Allah
January-March 2016, 32(1):13-20
DOI:10.4103/1012-5574.175797  
Background Spontaneous cerebrospinal fluid (CSF) rhinorrhea from the lateral recess of the sphenoid sinus is surgically challenging. Sternberg's canal has stirred great controversy as the potential source. The aim of this study was to present our experience with endonasal endoscopic repair, the possible etiopathology, and the outcomes. Study design This prospective study comprised 10 patients (seven female and three male) with spontaneous CSF rhinorrhea from the lateral recess of the sphenoid sinus, which was not related to trauma, previous surgery, tumors, irradiation, or meningitis. CSF rhinorrhea was confirmed with β2 transferrin test and high resolution CT scan (HRCT) and MRI cisternography. All patients were treated with the endonasal endoscopic conservative retrograde trans-sphenoidal approach. Results The mean BMI was 35.55 ± 2.84 kg/m 2 . Elevated intracranial pressure was present in all cases confirmed directly (with a mean intraoperative lumbar drain pressure of 27.5 ± 3.84 cm H 2 O), and indirectly [with the presence of primary empty sella (100%), arachnoid pits (30%), and attenuated skull base (40%)]. Osteodural defect was constantly present in the superior wall of the lateral recess, lateral to the foramen rotundum, none above the foramen rotundum or below the vidian canal orifice. The mean follow-up was 46.9 ± 8.26 months. Conclusion The endonasal endoscopic repair is a safe and effective method. The etiopathology is multifactorial. The management of elevated intracranial pressure is crucial. The potential source is not Sternberg's canal but persistent cartilaginous vascular channels at the ossification center of the alisphenoid, cartilaginous precursor of the greater wing of the sphenoid bone.
  1,466 162 -
Voice, swallowing, and quality of life after management of laryngeal cancer with different treatment modalities
Medhat MH Mansour, Mahmoud F Abdel-Aziz, Magdy E Saafan, Haytham RM Al-Afandi, Mohammed Darweesh
January-March 2016, 32(1):37-44
DOI:10.4103/1012-5574.175845  
Background Laryngeal cancer is the most common malignant tumor of the upper aerodigestive tract. Surgical treatment of advanced laryngeal cancer often requires a total laryngectomy (TL), resulting in a permanent tracheostomy and potential difficulties with a patient's speech and communication. Objectives The aim of this study was to assess post-treatment voice changes, swallowing, and quality of life (QoL) of patients with carcinoma of the larynx treated with different treatment modalities. Patients and methods A total of 100 patients with laryngeal cancer treated with different treatment modalities were included in the present study. The primary treatment modality included TL (n = 46), partial laryngectomy (PL) (n = 7), transoral cordectomy (n = 9), radiotherapy (Rx) (n = 29), or combined treatment during the last 10 years with radiation after TL (TL and Rx, n = 9). Patients were subjected to full history taking, complete ENT examination, and assessment of: global QoL, voice, and acoustic parameters using the computerized speech lab at the outpatient clinic of Tanta University Hospitals (TUH). Evaluation of swallowing was carried out using a modified Arabic version of the QoL questionnaire called the Sydney Swallow Questionnaire. Patients having problems with swallowing were further evaluated using fiberoptic endoscopic evaluation of swallowing, at the outpatient clinic of TUH. Respiratory function of the larynx was evaluated by applying a modification of St George's Respiratory Questionnaire. Results Results of voice analysis showed that the best voice was evident in patients who had undergone cordectomy, followed by those who had received radiotherapy. There was no significant difference in voice characteristics between patients using voice prosthesis, esophageal voice, or electrolarynx after TL and those using these aids after PL. Worst voice as well as swallowing was seen in patients who had undergone combined TL and postoperative radiotherapy. The best results of swallowing were seen in patients who had undergone cordectomy. Patients who had undergone TL or radiotherapy alone showed similar swallowing results, but better than those who had undergone PL, especially those who had undergone supracricoid laryngectomy. Assessment of respiratory function showed best results in patients who had undergone cordectomy, followed by those who had undergone TL and radiotherapy. Poorest results were seen in patients with combined surgery and Rx, and those who had been treated with PL. Conclusion Our study revealed that the best significant performance results were seen in patients who had undergone transoral cordectomy, followed by patients who had received radiotherapy only. This was followed by patients who had undergone TL and PL, with no significant difference between the two groups. The worst results were seen in patients who had undergone combined surgery and radiotherapy as the primary treatment modality.
  1,416 150 -
The role of fiberoptic endoscopic evaluation of swallowing in the assessment of pediatric dysphagia
Ahmed-Abdelhamid , Sally A Sarwat
January-March 2016, 32(1):67-74
DOI:10.4103/1012-5574.175863  
Background Swallowing is a basic, life-sustaining function that involves interplay between two distinct but related phenomena, airway protection and bolus transport. Pediatric dysphagia is one of the most important symptoms to be assessed and managed. The standard fiberoptic endoscopic evaluation of swallowing (FEES) protocol of Langmore (2001) was designed to assess dysphagia on all populations. Aim The aim of this work was to clarify the role of FEES in the diagnosis of pediatric dysphagia and the signs related to it. Study design This was a retrospective study that was conducted to assess pediatric dysphagia using FEES as a clinical diagnostic tool. Participants and methods The study included 64 children (38 male, 26 female). Of them, 32 patients were suffering from difficulty in swallowing of different degrees and 32 were controls (they were not suffering from any difficulty in swallowing). The mean age in months for symptomatic children was 41.47 ± 36.25 and the mean age in months for control cases was 42.08 ± 35.61. The examination was carried out using FEES applying the standard FEES protocol of Langmore (2001). Results Application of the standard FEES protocol of Langmore (2001) showed highly related signs of pediatric dysphagia, such as handling of secretions, pharyngeal function in part I and timing of the bolus flow/initiation of the swallow, structural movements during the swallow, and residue after the swallow and between swallows in part II. Conclusion and recommendation There are more common signs related to pediatric dysphagia than others and should be considered in any therapeutic program for overcoming dysphagia in children. Laryngomalacia is a structural disorder causing pediatric dysphagia in a considerable number of children. The standard FEES protocol should be applied on a larger number of pediatric populations with different disorders.
  1,215 162 1
Prevalence of mismatch negativity with tonal stimuli in normal-hearing individuals
Himanshu Kumar Sanju, Prawin Kumar
January-March 2016, 32(1):57-60
DOI:10.4103/1012-5574.175857  
Electrophysiological measures are one of the objective modes of assessment to check the integrity of the auditory function. The endogenous potentials like mismatch negativity (MMN) are responses which are due to internal events such as cognition or perception. In clinical practice and researches it was observed that MMN not present in all normal hearing individual. So, there is a need to study prevalence of MMN in normal population, which helps the researchers and clinicians in interpreting clinical findings. 50 participants recruited in the age range of 18-25 years. MMN was recorded with pair of stimuli. The pair was having /1000Hz/ and /1100Hz/ with /1000Hz/ as frequent stimulus and /1100Hz/ as the infrequent stimulus. Out of 50 normal hearing subjects, MMN was present only in 33 normal hearing subjects (66%). So clinician should be cautious during interpretation of clinical findings using MMN in abnormal population.
  1,149 94 1
Influence of BMI and head circumference on variables of auditory evoked potential in young healthy male human participants
Balaji W Ghugare, Sangeeta Jain, Dinesh J Parmar, Mukesh R Dinkar, Ravindra Ninama
January-March 2016, 32(1):53-56
DOI:10.4103/1012-5574.175854  
Context Age, hearing loss, sex, BMI, and head size are very important parameters that influence auditory evoked potential (AEP) variables. Although the correlation of BMI and head size with AEP parameters has been studied recently, there is no common consensus on it. A few studies show a positive correlation, whereas others report a weaker correlation. Further, normative values of the V/I ratio also show a wide range of normative values from different studies. Aims and objectives This study aimed to evaluate the association of AEP variables with BMI and head size in healthy young male participants and to collect normative data for the V/I amplitude ratio. Materials and methods This is a cross-sectional study in which 30 young healthy male participants with age range 19-25 years and BMI range 15-26 kg/m 2 underwent AEP testing. All were screened for inclusion and exclusion criteria established for the study. Informed consent was obtained and the data obtained were stored in an Excel sheet. A simple correlation regression coefficient was obtained between physical parameters and different AEP variables. Results We observed a strong positive correlation between head size and V wave latency (r = 0.5) and a weaker positive correlation between head size and AEP interpeak latencies (IPLs) I-V and III-V (r = 0.3). No correlation was observed between BMI and AEP variables. The V/I amplitude ratio was 0.98 ± 0.68 and 0.93 ± 0.7 for the left and the right ear, respectively. Conclusion We concluded that BMI had no influence, and head size showed an association with AEP outcome, especially V wave latency and the AEP-IPL difference. The V/I ratio needs to be examined further in studies with larger sample sizes as values were different from those of previous studies.
  1,129 99 -
Endoscopic evaluation of the patency of the aditus in tubotympanic type of chronic suppurative otitis media
Mohammed Bassiouny, Yasser G Shewel, Mohamed Yassin
January-March 2016, 32(1):45-48
DOI:10.4103/1012-5574.175846  
Objectives Endoscopic evaluation of the aditus in tubo-tympanic chronic suppurative otitis media (CSOM). Study design Prospective escriptive study. Methods This study carried out on 50 patients presenting with inactive tubo-tympanic CSOM with only mild or moderate conductive hearing loss, attending the Alexandria university hospital (tertiary referral center). Tympanoplasty was done for all patients. The patency and dimensions of the aditus were assessed by performing antral window through which 30Ί endoscope was introduced. Biopsy was taken from unhealthy mucosa to detect the presence of hidden cholesteatoma or granulation tissue. Results Ten out of 50 (20%) patients had blocked aditus. The dimensions of the aditus were measured. Biopsy taken from these cases revealed a granulation tissue in all cases. No hidden cholesteatoma was detected. Conclusion In inactive tubo-tympanic CSOM with mild or moderate conductive hearing, the aditus was not always patent. It was obstructed in 20% of our study.
  1,109 113 -
The speech outcome of definitive obturators constructed using two different impression techniques
M El-Maghraby Reham, M El-Didi Lobna, M Al-Shimy Ahmed, M Abdel Razek Mohamed
January-March 2016, 32(1):61-66
DOI:10.4103/1012-5574.175862  
Objectives The aim of this study was to evaluate the accuracy of two different impression techniques through the assessment of the performance of the two definitive obturators fabricated by each technique. Patients A total of six partially edentulous patients with unilateral maxillary surgical defects were selected from those admitted at the Prosthodontic Department, Faculty of Dentistry, Alexandria University. Methods For every patient, two hollow bulb obturators were constructed, each using a different impression technique. Three patients started with the open face tray impression technique and the other three started with the altered cast impression technique. Each patient was given one obturator at a time and was instructed to use it for 2 months. All patients were subjected to the following: (a) a preprosthetic evaluation, (b) an evaluation 2 months after the insertion of the first obturator, and (c) an evaluation 2 months after the insertion of the second obturator. During each session, speech and swallowing were evaluated. Results Regarding the three formant frequencies of the vowel /a/, there was a statistically significant improvement only in F1 between the altered cast and the preprosthetic phase and between the altered cast and the open face impression techniques, whereas concerning vowel /e/, there was a statistically significant improvement in F2 in favor of the altered cast impression technique. The degree of nasality in the vowels and the plosives were significantly improved in the altered cast technique. However, there was no significant improvement in the nasality between the two techniques with regard to oral and nasal sentences. There was an observed improvement in the competence and the shape of the velopharyngeal valve with the obturator than without the obturator. Conclusion The altered cast technique caused statistical improvement in the nasality of vowels and plosives as compared with the open face impression technique. Both treatment modalities caused general improvement in the patient's satisfaction and in swallowing with no statistically significant difference between them.
  917 118 1
CASE REPORTS
Unilateral submandibular gland agenesis associated with capillary hemangioma of the cartilaginous nasal septum
Janani Moorthy, Subramanian Ilanchezhian, Rajoo Ramachandran, Periasamy V Prithiviraj
January-March 2016, 32(1):79-81
DOI:10.4103/1012-5574.175865  
Congenital agenesis of the submandibular gland with compensatory hypertrophy of the contralateral gland is an extremely rare disorder and only few cases are reported in the literature. To our knowledge the reported cases of submandibular agenesis have been asymptomatic and associated with facial anomalies. In our study we present the imaging features of the right submandibular gland agenesis with associated capillary hemangioma of the cartilaginous nasal septum in a middle-aged man who presented with a right-sided nasal block.
  899 85 -
ORIGINAL ARTICLES
Pectoralis major flap reconstruction in the prevention of wound breakdown and fistula formation after salvage laryngectomy: a controlled study
Reda M Sabra, Mohamed S Taha, Tarek A Hamdy, Hossam Rabie, Magdy A Riad
January-March 2016, 32(1):32-36
DOI:10.4103/1012-5574.175803  
Background Patients undergoing salvage laryngeal surgery after high-dose radiotherapy or concurrent chemotherapy/radiation therapy regimen are more prone to develop pharyngocutaneous fistulas (PCFs). The fistula rates reported are as high as 70%. Aim of the study The aim of this study was to assess the effectiveness of pectoralis major muscle flap (PMF) in prevention of fistula formation and in enhancing wound healing in patients undergoing salvage laryngectomy. Patients and methods We compared results from patients of salvage laryngectomy repaired with pectoralis major flap with those of a similar group repaired by primary wound closure in 36 consecutive patients. Group A included 16 patients who underwent PMF following salvage total laryngectomy (12 male and four female patients; median age 56 years; interquartile range, 49.8-61.8). The other group included 20 patients who underwent primary closure of the wound without PMF (group B) (15 male and five female patients; median age 43 years; interquartile range, 36-54). Minimum follow-up in both groups was 3 months. Results The incidence of PCF in group A was 6.2% and that of wound gap was 6.2%, and there was no carotid blowout. The results in group B were as follows: 60% PCF rate and poor wound healing with gapping in 40% of patients and carotid blowout in 25% of patients (P < 0.001). The mean duration to fistula closure was 20 days in group A compared with 57.5 days in group B. Conclusion Pectoralis major flap will give the patients the advantages of less fistula formation, good wound healing, early oral feeding, short hospital stay and protection against catastrophic vascular blowouts.
  864 93 1
Detection of bacteria in the nasopharyngeal secretion and effusion associated with serous otitis media
Mahmoud El Fouly, Mohamed A Hegazy, Ahmed Shawky, Ahmed M Farahat
January-March 2016, 32(1):21-25
DOI:10.4103/1012-5574.175799  
Objective This study aimed at evaluating the accuracy of nasopharyngeal (NP) specimens in the identification of pathogens in the middle-ear fluid (MEF) in patients with otitis media with effusion. Materials and methods This was a prospective, hospital-based study with a cross-sectional design to evaluate the accuracy of NP isolates in identifying MEF pathogens and a case-control design to study NP secretion specimens taken from children undergoing an operation with no otologic indication, the middle-ear swab taken from patients undergoing stapedectomy, and middle-ear secretions taken from patients with secretory otitis media (SOM) of an older age group regarding the tympanogram result, radiograph, and endoscopy. Results The numbers and percentages of patients showed significant numbers of bacteria in both the MEF and the NP swap, and showed a statistically significant difference (P < 0.05). Conclusion Otitis media is the second most common disease of childhood and is responsible for a significant number of visits to the pediatrician. About 10% of the cases with middle-ear effusion after an episode of acute otitis media can persist for more than 3 months. Hearing loss associated with serous otitis media (SOM) can potentially have a detrimental effect on speech and language development.
  836 100 -
CASE REPORTS
Role of PET-CT scan in synchronous primary cancers of the upper aerodigestive tract: a case report
Ramanathan Chandrasekharan, Zoremsangi Ralte, Roshna R Paul, George A Mathew
January-March 2016, 32(1):75-78
DOI:10.4103/1012-5574.175864  
Oral field cancerization though not a new concept, has time and again, proven to be a challenge to the clinician, in terms of diagnosis and management. Prolonged exposure of the aerodigestive tract to carcinogens causes multifocal cancers. Intraepithelial migration of dysplastic or clonal cells becomes the seed for different primaries in the same field. The probability of synchronous malignancies should be borne in mind while evaluating a patient with head and neck cancer. With the advent of highly specific diagnostic tools like the PET scan, the chances of missing a second primary are eliminated/negligible. This is a case report on a patient who was found to have multiple primaries on clinical and radiological evaluation. Patient underwent multimodality treatment with chemoradiotherapy followed by surgery and is currently under follow-up. We aim to highlight the role of PET scanning in the evaluation of head and neck cancer to prevent missing a second primary.
  773 74 -