Otology

Epidemiology and predictive factors of fungal malignant otitis externa Rim Bechraoui, Mohamed Dhaha, Houda Chahed, Amal Ksentini, Rim Zainine, Mohamed Ben Amor, Najeh Beltaief, Ghazi Besbes Indian Journal of Otology 2019 25(1):1-5 Context and Aims: A recent upsurge of severe fungal forms of malignant otitis externa (MOE) has been recorded. Understanding the misleading clinical aspect of the disease allows earlier diagnosis, avoiding inadequate treatments that may complicate the adapted management. Our objective was to study the epidemiological and clinical aspects of the MOE in our department and to analyze some predictive factors of the fungal form of the disease. Materials and Methods: Medical data of 100 patients treated for MOE between 2004 and 2013 were retrospectively reviewed. Epidemiological findings were recorded. Clinical aspects and presentations were studied and noted. Analysis of some predictive factors of the fungal form of the disease was done. Results: Incidence of MOE was 10 new cases every year. The average age was 67.41 years, and the sex ratio was 0.92. All patients have diabetes. Otalgia was a constant symptom. Otorrhea was noted in 63% of cases. Hearing impairment and tinnitus were noted, respectively, in 23% and 18% of cases. Prior antibiotherapy was recorded in 33% of cases for a mean period of 21 days. Stenosis of the external auditory canal was observed in 92% of cases. Granulation tissue was present in 55% of patients. Twenty patients presented peripheral facial nerve palsy. Four others presented palsies of the VI, IX, and X nerves. Forty-one patients had mycological sampling. Twenty-six among them were diagnosed with fungal MOE. Identifying fungal agent took a mean delay of 40 days. Aspergillus and Candida were incriminated each one in half of the cases. Male gender and prior quinolone administration were predictive factors of fungal MOE with, respectively, P = 0.006 and P = 0.06. After multivariate analysis, only male gender was significantly correlated to fungal growth (P = 0.032). Conclusion: Management of fungal forms is challenging due to difficult and late diagnosis. An early mycological sampling is advisable with special attention to males and patients with prior quinolone administration.

Detection of single-nucleotide polymorphism Gap junction protein Beta-2 genes in deaf schoolchildren of javanese population in Surabaya, Indonesia Nyilo Purnami, Gwenny Ichsan Prabowo, Citrawati Dyah Kencono Wungu, Retno Handajani Indian Journal of Otology 2019 25(1):6-10 Background: Genetic factors account for about 50%–75% responsible for hearing loss. The existence of single-nucleotide polymorphism (SNP) as genetic factors that affect hereditary hearing loss. The widely studied SNP was the gap junction protein beta-2 (GJB2) gene encoding the gap junction beta-2 protein (connexin26) that found in cochlea and required to convert sound waves into electrical nerve impulse. This study was aimed to detect the SNP GJB2 gene of hereditary hearing loss patients from Javanese population in Surabaya, Indonesia. Methods: The design of this study was a cross-sectional, analytic observational. The participant was taken randomly among the students from a deaf School in Surabaya. The questionnaire was completed by the parents of the deaf children. Blood sampling was taken from venous peripheral blood. DNA was extracted and amplified on GJB2 gene area by polymerase chain reaction (PCR). The positive results of PCR were processed further for sequencing. The sequencing results were analyzed to detect the GJB2 gene SNP with reference sequence/rs-80338939. Results: A total of 22 children participated in this study; all were profound sensorineural hearing loss (SNHL). The hereditary hearing loss was obtained with fewer in five children (22.73%), who had a history of hearing loss in their family. It was compared to 17 children (77.27%) who had no family history of hearing loss. It was found that the nucleotide variation in nucleotide number 8473 of GJB2 gene as much as 3 (13.64%) out of 22 children in hereditary hearing loss patients in Deaf School Type B Surabaya. Conclusions: This study did not found any SNP GJB2 gene (rs-80338939) of hereditary hearing loss patients from the Javanese population in Surabaya, Indonesia. There was the nucleotide substitution G to A in nucleotide number 8473 of GJB2 gene, which indicated the change of amino acid code genetic code table (valine) to amino acid code genetic code table (isoleucine). It may as the cause of SNHL.

Surgical management of traumatic intratemporal facial nerve paralysis: Looks matter! Uma Patnaik, Garima Upreti, Ajith Nilakantan Indian Journal of Otology 2019 25(1):11-17 Objective: Patients with traumatic intratemporal facial paralysis often present late to the otologist, as assessment may be difficult due to altered neurological status, or the management of associated neurosurgical emergency takes precedence. Recommendations for surgical management of these patients are contentious, especially when the patient presents late to the otologist or when the history is dubious. The purpose of this study was to analyze the outcomes of surgery in these patients with regard to onset, clinical findings, timing of surgery, and recovery of facial nerve (FN) function; compare it with similar studies conducted in the past decade; and propose a management guideline for such cases. Study Design: Prospective cohort study. Methodology: Outcome analysis in patients who underwent surgical exploration for traumatic intratemporal FN paralysis at our tertiary care center from January 2008 to December 2015 was done. A detailed record of the history of onset and clinical findings with preoperative status of FN function and hearing status was made. Radiological findings and electrodiagnostic tests influenced the decision-making with respect to surgical exploration. Our observations regarding timing of surgery post trauma, intraoperative findings, and postoperative recovery of FN function were evaluated and outcomes were compared with similar studies in the last decade. Results: Eleven patients were included in the study. All patients had House–Brackmann Grade (HBG) V/VI paralysis prior to surgery. Time interval between injury and surgery ranged between 5 and 176 days (average 58 ± 55 days). Follow-up after surgery ranged from 9 to 72 months (average 31 ± 18 months). Two patients recovered to HBG I, 5 to HBG II, and 4 to HBG III. Conclusion: Surgical exploration for traumatic facial paralysis is often delayed due to late presentation to the otologist. Surgery should not be denied to patients presenting late, or with uncertain history, as it will still give significant recovery to the patient. We have also proposed a guideline for the management of such cases.

Visual defects in hearing-challenged schoolchildren from Ludhiana, Punjab Renu Thakur, Jaikishan JayaKumar, Sangeeta Pant Indian Journal of Otology 2019 25(1):18-21 Purpose: We compared Visual attention of normal hearing students and congenitally deaf students, Deaf students are visually depended; respective study help us to find out visual attention of Deaf as compared with age matched hearing students. Method: Total 118 deaf students aged from 6 to 25 years were screened from School for the Deaf Children, Kitchlu Nagar, Ludhiana Punjab 141001. 30 students were randomly selected from age group 8.5 to 11.11 years. All 30 deaf students where compared with age-matched hearing students from Peace Public School NH 95, Ferozepur - Ludhiana Road, Ludhiana, Punjab 141102. Informed consent was taken from all students pears, all the participants where having best corrected distance visual acuity 6/6 (snellen chart) and near visual acuity N6. Anterior and Posterior eye examination where evaluated in Sankara Eye Hospital Ludhiana, prior to the test; Visual attention was evaluated using two different test type, SDMT Symbol digit Modality test and Attention Blink by Visual attention Brain Baseline App. Result: Symbol Digit Modality Test; didn't show significant difference between. Deaf (N= 30) and Hearing students (N=30), Deaf students (Mean 0.97, S.D 2.57 and SEM 0.47), Hearing students (Mean 0.47, S.D 0.97, SEM 0.18) T-ratio 1 and P-Value 0.32 there was no difference between deaf and hearing impaired group. Visual attention- Brain Baseline App, the attention blink showed significant difference between Deaf and hearing impaired students. Deaf students (Mean 0.09, S.D 0.08 and SEM 0.02), Hearing students (Mean 0.22, S.D 0.18, SEM 0.03) T-ratio 3.41 and P-Value 0.001. Conclusion: Deaf group had made less error, deaf showed better attention as compare with hearing group. This finding indicates that deaf students are having better attention in the central visual attention. It can be one of the factors for peripheral distraction of deaf students.

Modified Stennert's infusion protocol for posttraumatic delayed facial nerve palsy Dipak Ranjan Nayak, Tulasi Kota Karanth, Shalini S Menon, Dheeraj Kondamudi Indian Journal of Otology 2019 25(1):22-25 Objective: The objective of the study is to validate the role of modified Stennert's infusion protocol in posttraumatic delayed facial nerve palsy. Materials and Methods: A retrospective chart review of 21 patients with delayed onset posttraumatic facial nerve palsy was carried out in a tertiary teaching hospital. All patients with delayed onset facial nerve palsy were treated with modified Stennert's protocol. It is a combination therapy which includes tapering doses of hydrocortisone, pentoxifylline, and low-molecular-weight dextran provided over 13 days. If the patient did not show signs of improvement with modified Stennert's protocol by the 10th day of therapy, they were advised to undergo transmastoid decompression of facial nerve. Analysis was performed based on House–Brackmann (HB) grading performed at the time of diagnosis and after 30 days of follow-up. Improvement was considered to have taken place if HB grading improved by minimum of two or reached normal value of one. Results: Twenty-one patients were started on modified Stennert's protocol of which 15 improved and 6 did not improve. They underwent transmastoid decompression of facial nerve and improved significantly afterward. Conclusion: A trial of modified Stennert's infusion protocols is a safe option in patients with posttraumatic delayed facial nerve palsy.

Evaluation of different graft materials (Temporalis Fascia, Tragal Perichondrium, and Vein Graft) in Type 1 tympanoplasty VP Singh, Nikunj Jain Indian Journal of Otology 2019 25(1):26-30 Aims and Objective: The present study was undertaken to compare the results of various autogenous tissues temporalis fascia, tragal perichondrium, and vein as graft materials for the Type 1 tympanoplasty. Materials and Methods: A total of 120 cases with large, subtotal, and total perforation were considered in the study. Of the 120 cases, temporalis fascia graft was used in 60 cases (Group-I), tragal perichondrium graft in 40 cases (Group-II), and vein graft in 20 cases (Group-III). The results were evaluated in the form of rate of graft success, hearing gain, and mean residual air-bone gap with respect to the graft materials. Results and Observation: A nonsignificant association was observed between the groups, that is, temporalis fascia (Group-I), tragal perichondrium (Group-II), and venous graft (Group-III), and the graft uptake (P = 0.96 > 0.05) and air-bone closure (χ2 = 2.908, P = 0.059 > 0.05). Conclusion: The graft take up rate and hearing improvement are similar for the different graft materials used. Size of the perforation does not significantly influence the success rate of tympanoplasty as per our study. Normal translucent appearance of neotympanum in the postoperative period was seen only with temporalis fascia and venous graft, while in tragal perichondrial, the neotympanum was whitish, thicker, and translucent to opaque.

Surgical excision of preauricular sinus Ashok Sharma, Vivek Taneja, Meenakshi Mehra, Pulkit Khandelwal, Madhurima Banerjee Indian Journal of Otology 2019 25(1):31-33 Background: Preauricular sinus is a congenital anomaly affecting both sexes. The sinus can be located near the tragus. The main difficulty arising in the treatment is the recurrence. Methods: A simple sinectomy technique along with dye infiltration and guidewire probing was used. Result: None intra-operative, post operative or complication related to local anaesthesia were seen, The surgical site healed well in all except for two patients who had wound infections which were managed by antibiotic therapy. Conclusion: A recurrence-free success rate could be achieved with the combination of dye infiltration, guidewire probing, and en bloc excision of the sinus tract and its branches.

Paraganglioma of external auditory canal: A rare entity Renu S Rajguru, Shruti Anil Sharma, Ritu K Mehta, Inderdeep Singh Indian Journal of Otology 2019 25(1):34-36 We present the description of a painful paraganglioma of the external auditory canal. Atypical presentation made the diagnosis difficult. We discuss the role of histopathology and immunohistochemistry in the diagnosis of the condition. A 43-year-old male presented with left-sided otalgia and hearing loss. Physical examination revealed a firm swelling arising from the posterosuperior portion of the left external auditory canal. Differential diagnosis of exostosis and squamous cell carcinoma of the external auditory canal was considered. The high-resolution computed tomography of the temporal bones was suggestive of neoplasia. The patient underwent excision biopsy. The hemorrhage during surgery led to suspicion of a vascular tumour. The histopathology and immunohistochemistry confirmed the diagnosis of paraganglioma. Early intervention with imaging and biopsy should be sought for unusual masses of the external ear.

Otogenic tetanus though immunisable but still existing Seema Ramlakhan Gupta, Sanket Deepak Vakharia Indian Journal of Otology 2019 25(1):37-39 Otogenic tetanus is an uncommon entity which may follow ear suppuration or ear injury. Straightforward diagnosis may not be possible if the otolaryngologist is not familiar with the entity. Delay in diagnosis may lead to serious consequences. The global incidence of tetanus is still estimated at about one million cases annually with a high case fatality ratio. These patients initially present with discharging ears; therefore, this case report is intended to increase awareness among otolaryngologists who would be the first to diagnose and initiate appropriate management. In spite of simple preventive measures available through immunization, tetanus remains a major cause of mortality in some developing countries such as India.

Hearing loss in infant with congenital cytomegalovirus infection Tri Juda Airlangga, Jenny Endang Bashiruddin Indian Journal of Otology 2019 25(1):40-42 Hearing loss is one of the sequels that often happened as a result of congenital cytomegalovirus (CMV) infection. Difficulties in diagnosing congenital CMV infection cause late detection of hearing loss which affects the patient's management and prognosis. We present three cases of hearing loss in infants with congenital CMV infection with other risk factors such as hyperbilirubinemia, low birth weight, premature birth, and ototoxic drug usage. The results of hearing assessment, imaging findings, and antiviral treatments are discussed. Hearing assessments in patient with congenital CMV infection should be checked routinely because hearing loss in this disease can be progressive and fluctuating.

Alexandros Sfakianakis
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