Topographic Anatomy of the Medial Labyrinthine Wall: Implications for the Transcanal Endoscopic Approach to the Internal Auditory Canal.

HYPOTHESIS: To characterize transcanal endoscopic landmarks of the medial labyrinthine wall and correlate these with anatomical features of the fundus of the internal auditory canal (IAC). BACKGROUND: The transcanal transpromontorial approach (TTA) enables minimally invasive access to the IAC. The establishment of a landmark-based dissection technique for the approach is crucial to avoid injury to the facial nerve. METHODS: Twenty temporal bones were dissected endoscopically through the TTA. Furthermore, high-resolution computed tomography (CT) scans from ten adult normal temporal bones were analyzed and three-dimensionally reconstructed. RESULTS: A stepwise dissection technique for the TTA was demonstrated depending on a newly described landmark used in the identification of the facial nerve. The proposed landmark, which was named the intervestibulocochlear crest (IVCC), is an integrated part of the otic capsule. It can be differentiated after the excision of the lateral labyrinthine wall as a laterally based bony pyramid between the cochlea and the vestibule. Its medially directed apex blends with the central part of the falcifrom crest and points to the distal part of the meatal facial nerve. The IVCC is best detected on axial CT images at the level of the tympanic facial nerve. The union between the IVCC and the falciform crest appears radiologically as a short stem or mini-martini glass. CONCLUSION: The proposed IVCC is a novel landmark with a consistent relationship to the IAC fundus and the facial nerve. It may be utilized in conjunction with the falciform crest to identify the facial nerve during minimally invasive transcanal surgeries.

Landmarks for Proper Round Window Electrode Insertion in Cochlear Implantation.

BACKGROUND: This study aimed to evaluate the role of landmarks for proper round window electrode insertion in cochlear implantation surgery. METHODS: This is a case series study. We included 150 patients undergoing cochlear implantation in a tertiary medical center during the period from January to December 2019. Patients with inner ear malformations or ossification or revision surgery were excluded. Three surgeons partici- pated in the study. During surgery, the round window electrode insertion was marked using 5 surgical landmarks: oval window, pyramid, fustis, round window membrane, and arborization of intracochlear blood vessels. Each surgeon reported on the identification of each landmark and its reliability for round window electrode insertion. RESULTS: Oval window and round window membrane were clearly seen by the 3 surgeons in all cases. Pyramid was seen in 94% of cases, fustis in 85%, and intracochlear wall in 90% of cases. The postoperative transorbital x-ray confirmed the intracochlear position of electrodes in all cases. CONCLUSION: Round window electrode insertion can be precisely performed using these 5 surgical landmarks in straight forwards cases as well as in difficult cases. These landmarks can also assist in teaching young surgeons, in a step-wise manner, how to properly do round window electrode insertion in cochlear implantation surgery.

Maternal COVID-19 and neonatal hearing loss: a multicentric survey.

PURPOSE: Gestational SARS-Cov-2 infection can impact maternal and neonatal health. The virus has also been reported of causing sensorineural hearing loss. The objective of this study was to determine the possible effect of maternal SARS-COV-2 infection on neonatal hearing as identified during universal hearing screening. METHODS: Retrospective cohort study in two tertiary referral centers including all neonates born from November 2020 through April 1st, 2021 and undergoing the universal hearing screening program. Maternal Covid-19 infection was recorded (timing and severity) and the results of hearing screening of their neonates compared to the incidence of neonatal hearing loss results of the national universal screening program during the same period. RESULTS: A total of 984 neonates were included (508 males and 476 females). Sixty-three neonates were excluded due to comorbidities which could cause hearing loss. The incidence of failed responses in the community at large was 2.3%. Twenty-seven failed both steps of screening (2.9%; p < 0.2). There were 34 Covid-19 positive mothers (17 in the first trimester, 8 in the second and 9 in the third). Twenty-nine neonates failed the first screening (p < 0.00001) but on further testing only one neonate failed (2.9%). CONCLUSION: In this study, neonates born to Covid-19 positive mothers do not seem to have an increased risk of hearing loss. However longer follow-up of these neonates is mandatory to detect any possible delayed effects of the virus.

Genetic Screening for 35delG Mutation in Egyptian Patients with Profound Sensorineural Hearing Loss Scheduled for Cochlear Implantation: A Population-Based Study.

OBJECTIVES: The aim of this work was to assess the type and site of the 35delG gene mutation in patients presenting with profound SNHL and scheduled for cochlear implantation. The secondary objectives were to determine their geographical distribution throughout Egypt, screening of the parents for the mutation, and to correlate the type of mutation with clinical severity and outcomes after surgery. METHODS: The study was carried out on 100 consecutive patients scheduled for cochlear implantation. Patients with syndromic hearing loss or noncongenital hearing loss (trauma, infections, and ototoxicity) were excluded. All patients were subjected to detailed history taking including geographic tagging for their origins in Egypt, imaging (CT and MRI cochlear implantation protocols), full audiological evaluation (PTA, ABR, and TEOAE), and genetic screening for GJB2 mutation using Invitrogen PCR mix and ApaI restriction enzyme (North America, CA, 10572-014). The parents of mutation-positive patients were also subjected to audiological and genetic analysis. All patients were subjected to postimplantation evaluation of hearing after 6 and 12 months. RESULTS: There were 64 males and 36 females from 98 families. Ages ranged between 1.9 and 7 years (mean 3.72 years). They originated from all over Egypt but the majority came from the Giza and Cairo areas. The 35delG mutations were found in exon 2 in 31% of the cases and all were heterozygous. In the parents, 18 mothers and 13 fathers were positive but only 8 had mild to moderate SNHL. Hearing evaluation by pure tone and speech discrimination scores at 6 and 12 months showed that the 35delG children had a statistically better result compared to the children without this mutation. CONCLUSION: The prevalence of the 35delG mutation in nonsyndromic children in this sample was 31% which is different from previous studies in the Egyptian population but close to the values found in other populations in the Mediterranean basin.

Radiologic Evaluation of the Round Window Niche Configuration: A One-Stop Approach.

BACKGROUND: Preoperative radiological prediction of the round window niche configuration. METHODS: Fifty patients were evaluated. A single-axial high-resolution computed tomography image at the level of the cochlear aqueduct was compared to the intraoperative surgical images. Radiological configuration was classified as open, hooded, or covered depending on the extent of bony overhang. Surgical images were processed using Image J software to determine the amount of drilling required before the round window membrane is exposed. These images were classified according to the St. Thomas classification into 3 grades. RESULTS: In all patients, the axial cut showing the cochlear aqueduct was obtained. There were 12 cases in the open category, 17 in the hooded category, and 21 in the covered one. Intraoperatively, the actual findings were type I 12, type II 18, and type III 20. The correspondence between the expected and actual classification was correct in 8, 12, and 18 cases, respectively. Comparing the intraoperative findings with the expected radiological configuration, there was a good concordance with a statistically non-significant difference ( χ2=0.2613; P=.87751). CONCLUSION: It is possible to predict the configuration of the round window niche on a single-axial computed tomography cut and plan the most suitable axis of approach and predict the amount of drilling expected to expose the round window membrane.

Omalizumab versus intranasal steroids in the post-operative management of patients with allergic fungal rhinosinusitis.

PURPOSE: Allergic fungal rhinosinusitis (AFRS) is a common disorder with a high prevalence and a very high incidence of recurrence. Management includes surgery and medical treatment in the form of local and/or systemic steroids. However, some cases are resistant to the action of steroids and further treatment is warranted. Being an immune-mediated disorder, targeting IgE seems a logical step. Immunotherapy drugs acting on the IgE (e.g. omalizumab) can modify the clinical course of the disease. This study aimed at evaluating the effect of omalizumab on the clinical course of patients undergoing surgery for AFRS. MATERIALS AND METHODS: This is a two-arm prospective, randomized, single blind clinical trial among patients with AFRS. Twenty patients were included and randomly divided into two groups: Group A; 10 patients received a single subcutaneous injection of omalizumab (Xolair ' Novartis) (150 mg) 2 weeks postoperatively. Group B: 10 patients received local steroids nasal sprays (budesonide or mometasone furoate, 100 µg twice daily for 6 months, starting 2 weeks postoperatively. All patients underwent history, examination, CT scan and IgE level estimation and were submitted to endoscopic sinus surgery. They were evaluated at 4 weeks interval for 6 months. RESULTS: In both groups there were highly significant differences between pre/post-operative SNOT-20 scores, TNSS scores, total IgE level and Philpott-Javer staging scores. Comparison between the two study groups at 24 weeks showed a highly significant difference (p = 0.001) between post-operative SNOT 20 and TNSS scores in favour of group A. There was no statistically significant difference between the two study groups as regarding postoperative total IgE or Philpott-Javer scores. There were two recurrences in both arms, but no significant side effects. DISCUSSION: We compared a single post operative injection of omalizumab with twice daily intranasal steroid spray for 6 months. Both treatments were effective, but the omalizumab group showed a more significant clinical and endoscopic response. There were no significant side effects in both arms. This novel approach used a single low dose injection of omalizumab increased the compliance of the patients with minimal complications. Longer follow-up of the patients is ongoing to determine the optimal time for re-injection. The only downside was the higher cost of omalizumab compared to that of local steroids.

Arterial Blood Supply of the Nose: An Angiographic Study.

OBJECTIVE: To define anatomical variations associated with arterial blood supply of the nose which has clinical implications on the management of different disorders, especially intractable posterior epistaxis. STUDY DESIGN: Case series. METHODS: Selective angiography of external and internal carotid arteries of 100 patients scheduled for routine angiography was done. RESULTS: Different anatomical variations were documented. The ophthalmic artery can arise from the middle meningeal artery in 1% while ethmoidal arteries can be absent in 5%. The maxillary artery courses as 2 loops in the pterygopalatine fossa in 64% of cases where the descending palatine artery originates before the first loop or on its top so that caution is needed in controlling epistaxis. The sphenopalatine artery has different patterns of branching and may have more than 2 branches in 18% of cases. In 19% of cases, there is cross-circulation between both sides through the nasal blood supply. CONCLUSION: Angiographic study of the nose is a very helpful tool for accurate knowledge of anatomical variations of the arteries with a tremendous effect on our surgical approaches and techniques for the management of different diseases in the nasal region, especially intractable posterior epistaxis.

Congenital Cholesteatoma: The Silent Pathology.

BACKGROUND: Congenital cholesteatomas (CC) arise from epithelial remnants around the petrous bone. They enlarge gradually causing progressive destruction and functional damage to the ear and surrounding structures. Because of their insidious course, most patients are misdiagnosed and present late with complications. METHODS: This is a retrospective study of 41 cases diagnosed as CC and followed up for 2 years. All patients underwent full audiological evaluation and a radiological study (CT, MRI). RESULTS: The male:female ratio was 2.3: 1, and the mean age was 30.89 years. The mean delay before presentation was 13 months. The commonest presentations in order of frequency were: discharge (60.9%), hearing loss (51.2%), facial paralysis (31.7%) and intracranial complications (31.7%). Forty patients were treated surgically by a variety of approaches depending on the extensions and functional status. The facial nerve was decompressed in 9 cases and cable grafted in 4. Two cases underwent VII-XII anastomosis later on. CONCLUSION: CC present with a myriad of clinical manifestations and should be suspected in all patients with unexplained otological signs and symptoms. They must be completely excised and the functional status of the ear rehabilitated either immediately or later. Follow-up must be indefinite as they have a high recurrence rate.

Environmental Risk Factors in Patients with Noninvasive Fungal Sinusitis.

Objective. The aim of our study was to try to determine the possible environmental risk factors for noninvasive fungal sinusitis in Egyptian patients. Methods. This is a prospective epidemiological case control study on the environmental risk factors of noninvasive fungal sinusitis. It included 60 patients and 100 age and sex matched controls. Results. There was a statistically significant relation between apartment floor, surface area, exposure to dust, exposure to cockroaches, poor air conditioning, and fungal sinusitis. Yet, no statistical significance was found between allergy related occupations, exposure to animals or plants, although their percentages were higher among cases, smoking, and urban or rural residence. Conclusion. We suggest that for patients with noninvasive fungal sinusitis a change in their living environment must be implied with better exposure to sunlight, larger well ventilated homes, proper cleaning of dust and cockroach extermination, and if possible the judicious use of air conditioners.

Evaluation of vitamin D levels in allergic fungal sinusitis, chronic rhinosinusitis, and chronic rhinosinusitis with polyposis.

BACKGROUND: Vitamin D3 (VD3 ) levels have been recently found to be responsible for a number of immunological, anti-inflammatory and anti-infectious roles. Some studies reported that some forms of allergic fungal rhinosinusitis (AFRS), occurs more commonly in patients who are more susceptible to VD3 deficiency. The aim of this work was to measure VD3 levels in patients with AFRS and chronic rhinosinusitis (CRS). METHODS: We report a prospective case control study conducted at Ain Shams University. It included 74 participants divided into 4 groups: group A, 25 patients with AFRS; group B, 15 patients with CRS with nasal polyps (CRSwNP); group C: 15 patients with CRS without nasal polyps (CRSsNP); and group D, 19 controls. RESULTS: There was a statistically significant (p < 0.001) difference of VD3 between groups A and B compared with groups C and D. There were no statistically significant differences between the 4 groups regard calcium levels. Finally, there was a statistically significant difference in phosphate levels when we compared groups A and B with groups C and D (p = 0.001). CONCLUSION: Serum level of VD3 in patient with CRSwNP and AFRS is significantly lower than that of patients with CRSsNP and control subjects. Although these results do not imply a specific etiological or therapeutic relationship, VD3 levels may constitute an inexpensive prophylactic and cost-effective option in the therapeutic armamentarium in the control of AFRS and CRSwNP, either by itself or as a synergistic agent with traditional agents.

Evaluation of vestibular function in patients with chronic suppurative otitis media.

OBJECTIVE: The objective of this study was to assess vestibular functions in patients with chronic suppurative otitis media (CSOM) with and without sensorineural hearing loss. STUDY DESIGN: This was a prospective case study performed at a tertiary referral university hospital. Sixty patients with CSOM were included, and patients with a history of head trauma, diabetes, hypertension, previous ear surgery, use of ototoxic drugs, neurological deficits and suspected fistulae were excluded. PATIENTS AND METHODS: The patients underwent basic audiological evaluation, and clinical and instrumental vestibular evaluation. The incidence and extent of vestibular dysfunction in patients with CSOM were analyzed. RESULTS: A total of 42 males and 16 females with a mean age of 29.5 years were included in this study. Forty ears had tubotympanic disease and 19 had cholesteatoma. There were 14 ears with sensorineural hearing loss. A positive history of vertigo was reported in 53.5% of the cases. Rotatory chair abnormalities were found in 70% of the cases, caloric hypofunction was found in 61.6%, and vestibular myogenic evoked potentials were abnormal in 25%. The only positive correlation with vestibular dysfunction was the duration of disease. CONCLUSIONS: The vestibular system is significantly affected in cases with CSOM. Both semicircular canals and the saccule are affected. All patients with long-standing CSOM should be evaluated for vestibular dysfunction irrespective of their hearing levels.

Nasal allergies in the Middle Eastern population: results from the "Allergies in Middle East Survey".

BACKGROUND: Chronic respiratory diseases such as asthma and allergic rhinitis (AR) are a major public health problem in developing countries including those in the Middle East. However, to date, there is a paucity of information related to physician-diagnosed AR in this region. The Allergies in Middle East Survey was undertaken to help clarify and broaden the understanding of physician-diagnosed AR across Egypt, Iran, Lebanon, Saudi Arabia, and the United Arab Emirates. The survey explores the frequency of physician-diagnosed AR, prevalence and types of associated symptoms, the impact on quality of life (QOL), current treatment practices, and therapy expectations. METHODS: In total, 7411 households in five countries (Egypt, Lebanon, Saudi Arabia, Iran and the United Arab Emirates) were screened to identify individuals that were ≥4 years old with a physician diagnosis of AR and either symptoms and/or treatment in the past 12 months. A total of 501 respondents from the five countries completed the survey. Standardized questionnaires were used to make comparisons across the regions; however, the data collection procedures were tailored for each country. The sample was probability based to ensure valid statistical inference to the population. RESULTS: Ten percent of the Middle East population surveyed had a physician diagnosis of AR, with 65% of respondents stating that their allergies were intermittent in nature. An otolaryngologist or allergist diagnosed the majority of the individuals surveyed. Runny nose, nasal and throat itching, postnasal drip, and nasal congestion or stuffed up nose were the most common and bothersome symptoms of AR. The majority of survey participants (58% of the overall survey population) with AR reported that the condition had an impact on their daily private and professional life. Seventy-two percent of adults reported that their AR symptoms limited their work/school activities and 35% reported that their AR interfered with and caused them to miss work or school within the past 12 months. One factor, in addition to the outward AR symptoms, that could have contributed to these function impairments may have been sleep disturbances. Although a secondary symptom to AR, sleep disturbances (difficulty getting to sleep, waking up during the night or lack of a good night's sleep) were shown in this survey to be extremely troubling in ∼15% of AR sufferers. In the past year >90% of patients reported taking a medication of any type for their AR, with nearly a 4:1 ratio of patients taking a prescription medication versus an over-the-counter (OTC) medication in the past 4 weeks. Over 75% of survey respondents reported taking an intranasal corticosteroid (INCS) in the last 4 weeks and the satisfaction rate of INCS medications was similar to that reported for OTC medications. The most common reasons cited for dissatisfaction with INCS medications were inadequate effectiveness, bothersome side effects (e.g., unpleasant taste and retrograde drainage into the pharynx), decreased effectiveness with chronic use, and failure to provide 24-hour relief. CONCLUSION: These data show that AR is common in the Middle East region as elsewhere in the world. Many patients with AR in Middle East region suffer from their symptoms (e.g., runny nose, nasal itching, nasal congestion, postnasal drip, and other symptoms) on all or most days during the times of the year that their allergies are worst. These symptoms have been shown to reduce QOL and performance at work/school to a significant degree. Additionally, the survey data underscore a considerable treatment gap with current therapies for AR and that many AR patients still have not found adequate effectiveness with currently available medications. Thus, through identification of disease impact on the Middle East population and highlighting treatment gaps, clinicians in the Middle East may better understand and treat AR, leading to improvements in overall patient satisfaction and QOL.

Nasal allergies in the Middle Eastern population: Results from the "Allergies in Middle East Survey".

BACKGROUND: Chronic respiratory diseases such as asthma and allergic rhinitis (AR) are a major public health problem in developing countries including those in the Middle East. However, to date, there is a paucity of information related to physician-diagnosed AR in this region. The Allergies in Middle East Survey was undertaken to help clarify and broaden the understanding of physician-diagnosed AR across Egypt, Iran, Lebanon, Saudi Arabia, and the United Arab Emirates. The survey explores the frequency of physician-diagnosed AR, prevalence and types of associated symptoms, the impact on quality of life (QOL), current treatment practices, and therapy expectations. METHODS: In total, 7411 households in five countries (Egypt, Lebanon, Saudi Arabia, Iran and the United Arab Emirates) were screened to identify individuals that were ≥4 years old with a physician diagnosis of AR and either symptoms and/or treatment in the past 12 months. A total of 501 respondents from the five countries completed the survey. Standardized questionnaires were used to make comparisons across the regions; however, the data collection procedures were tailored for each country. The sample was probability based to ensure valid statistical inference to the population. RESULTS: Ten percent of the Middle East population surveyed had a physician diagnosis of AR, with 65% of respondents stating that their allergies were intermittent in nature. An otolaryngologist or allergist diagnosed the majority of the individuals surveyed. Runny nose, nasal and throat itching, postnasal drip, and nasal congestion or stuffed up nose were the most common and bothersome symptoms of AR. The majority of survey participants (58% of the overall survey population) with AR reported that the condition had an impact on their daily private and professional life. Seventy-two percent of adults reported that their AR symptoms limited their work/school activities and 35% reported that their AR interfered with and caused them to miss work or school within the past 12 months. One factor, in addition to the outward AR symptoms, that could have contributed to these function impairments may have been sleep disturbances. Although a secondary symptom to AR, sleep disturbances (difficulty getting to sleep, waking up during the night or lack of a good night's sleep) were shown in this survey to be extremely troubling in ∼15% of AR sufferers. In the past year >90% of patients reported taking a medication of any type for their AR, with nearly a 4:1 ratio of patients taking a prescription medication versus an over-the-counter (OTC) medication in the past 4 weeks. Over 75% of survey respondents reported taking an intranasal corticosteroid (INCS) in the last 4 weeks and the satisfaction rate of INCS medications was similar to that reported for OTC medications. The most common reasons cited for dissatisfaction with INCS medications were inadequate effectiveness, bothersome side effects (e.g., unpleasant taste and retrograde drainage into the pharynx), decreased effectiveness with chronic use, and failure to provide 24-hour relief. CONCLUSION: These data show that AR is common in the Middle East region as elsewhere in the world. Many patients with AR in Middle East region suffer from their symptoms (e.g., runny nose, nasal itching, nasal congestion, postnasal drip, and other symptoms) on all or most days during the times of the year that their allergies are worst. These symptoms have been shown to reduce QOL and performance at work/school to a significant degree. Additionally, the survey data underscore a considerable treatment gap with current therapies for AR and that many AR patients still have not found adequate effectiveness with currently available medications. Thus, through identification of disease impact on the Middle East population and highlighting treatment gaps, clinicians in the Middle East may better understand and treat AR, leading to improvements in overall patient satisfaction and QOL.

Conservation surgery for early laryngeal carcinoma.

BACKGROUND: Squamous cell carcinoma is the commonest malignant tumour of the larynx. The traditional treatment options have included radiotherapy and total laryngectomy. Due to the pivotal role of the larynx in respiration, speech and deglutition, conservative approaches to the management of malignant lesions were suggested. These organ-preserving policies aim at preserving most of the laryngeal functions without compromising the oncological outcomes. Such approaches include organ-preserving radio/chemotherapy protocols, endoscopic laser surgery, photodynamic therapy and open conservative surgery. Each of these has their indications, advantages and disadvantages. The modern trend towards organ preservation protocols and endoscopic laser techniques seems to have supplanted open conservative surgery. However, these techniques still have an important role in the management of laryngeal malignancies. METHODS: This is retrospective study on 216 patients followed for a minimum of 2 years and a maximum of 16. All patients underwent partial surgery as first-line treatment: 135 underwent partial vertical laryngectomy, 76 underwent supraglottic hemilaryngectomy and 5 underwent supracricoid subtotal laryngectomy. RESULTS: Our overall disease-free survival was 92.1%, which compares favourably with most series. Total laryngectomy was performed in 11 patients (in 10 as salvage and in 1 for intractable aspiration) resulting in a laryngeal preservation rate of 94.4%. The decanulation rate was 95% (11 patients in the three types of surgery). There were no major morbidities or surgery-related mortalities. The most significant complication was aspiration (18.9% of patients), but it could be managed conservatively in all but one case. CONCLUSION: In this era of organ preservation policies, open conservative surgery offers a viable option with comparable functional and oncological results. It should be considered when logistic, economical or patient factors make other protocols impractical.

Complications of suppurative otitis media: still a problem in the 21st century.

The purpose of this study was to review the incidence of complicated suppurative otitis media in 10 years at a tertiary referral university hospital. During this period, 3,364 patients with suppurative otitis media (acute and chronic) were admitted to the department. The number of patients presenting with complications was 422 (12.54%). The ratio of extracranial to intracranial complications was nearly 1:1. The most frequent extracranial complication was mastoiditis while the most frequent intracranial one was lateral sinus thrombophlebitis. Multiple complications may present in the same patient. The onset of complications was insidious and 96% of the patients were already aware of their disease. There were 6 mortalities (1.42%), and additional morbidity was recorded in 16 patients (3.79%). Changes in the clinical picture should always alert the physician to the onset of a complication. Complications tended to occur in young patients from a lower socioeconomic class and without sex preponderance. Physicians should be aware of the continuing incidence of complications and the subtleness of their onset and investigate patients for the presence of more than one complication.

Spiral CT virtual bronchoscopy with multiplanar reformatting in the evaluation of post-intubation tracheal stenosis: comparison between endoscopic, radiological and surgical findings.

We evaluated the usefulness and accuracy of spiral CT in detection and assessment of post-intubation tracheal stenosis. Fourteen patients with post intubation stenosis underwent evaluation of their airway by spiral CT scan with multiplanar reformatting (MPR) and virtual endoscopy (VE) and conventional rigid bronchoscopy, and telescopy (RB). The following parameters were assessed: involvement of the subglottic larynx, site, number, and degree of the stenosis. The results were compared with the intra-operative findings. The detection rate for tracheal stenotic lesions was 94% by CT and 88% by rigid bronchoscopy. The sensitivity and specificity of both CT scan and bronchoscopy in the detection of subglottic stenosis was 100%. The preoperative assessment of the length of stenosis was accurate in 14 (87%) of the 16 stenotic segments detected by CT and in 11 (73%) of the 15 segments detected by bronchoscopy. The length of stenosis as assessed intra-operatively significantly correlated with the data obtained with CT scan (r = 0.98, p < 0.001) and RB (r = 0.94, p < 0.001). The grade of stenosis was correctly assessed by bronchoscopy in 13/15 lesions (86%). CT measurements correctly estimated 15/16 (93.75%) lesions and allowed accurate measurements of the stenotic segment as well as the proximal and distal airway segments. Spiral CT scan with MPR and VE may be considered as a substitute to direct endoscopic examination and the additional information on laryngeal function can be easily obtained during flexible nasolaryngoscopic examination of the awake patient. This policy can minimize patient morbidity and spare them an extra anaesthetic for evaluation.

The role of endoluminal self-expanding stents in the management of pediatric tracheal stenosis.

OBJECTIVE: Review of our experience in the management of pediatric tracheal stenosis using endoscopic techniques and self-expanding intraluminal stents. METHODS: Thirteen children (aged 1 week to 14 years) with various causes of tracheal stenosis were treated. A total of 15 stents were used, 13 self-expanding nitinol stents and 3 silicone self-expanding stents. Follow-up ranged from 6 month to 8 years. RESULTS: There were no stent related mortalities. Serious complications occurred in 4 patients [30.7%] but all were managed successfully. The most frequent problem was granulation tissue formation. Patient follow-up ranged from 6 months to 8 years. In the short-term (18-24 months) 12 stents remained patent and functional. On the longer term (5 years) 3 stents required removal, one required replacement and another resulted in stenosis. CONCLUSION: Endoluminal stenting can have an increasing role in the management of selected cases pediatric tracheal stenosis with acceptable morbidity and stable long-term results.

The keyhole retrosigmoid approach to the cerebello-pontine angle: indications, technical modifications, and results.

OBJECTIVES: Establish the versatility and usefulness of the keyhole retrosigmoid approach to the cerebello-pontine angle (CPA) in various pathologies. DESIGN: Prospective clinical study. SETTING: Tertiary referral university hospital. METHODS: One hundred twenty-one patients with various pathologies of the CPA underwent the relevant investigations and were operated upon by the retrosigmoid microendoscopic approach. The technical modifications and progression of our technique are described. RESULTS: This group consisted of 121 patients (103 men and 28 women). The pathologies included were 60 acoustic neuromas, 28 vestibular neurectomies, nine meningiomas, and four arachnoid cysts. For nonmass lesions, no additional facial nerve injury or deterioration of hearing occurred. Total excision of mass lesions was achieved in 94.5% of cases. Facial nerve integrity was preserved in 92.3% of cases with mass lesions and permanent facial paralysis occurred in 8.3%. There were no mortalities, and the most frequent complication was a delayed cerebrospinal fluid leak from the site of the wound (15%), which was managed conservatively in all cases. CONCLUSIONS: The keyhole retrosigmoid approach is a versatile one. It can be used to deal with different pathologies through a unified access, and with the increasing exclusive use of endoscopes, a truly minimally invasive surgery can be achieved.

The role of deferoxamine in the prevention of gentamicin ototoxicity: a histological and audiological study in guinea pigs.

CONCLUSION: The addition of deferoxamine to gentamicin seems to confer partial functional and histological protection to the cochlea. OBJECTIVE: Aminoglycosides are known ototoxic agents. The toxicity occurs via an activation process involving the formation of an iron-gentamicin complex with free radical production. Iron chelation will supposedly limit this toxic effect. This study aimed to determine the possible cochleoprotective role of deferoxamine on the ototoxic effect of gentamicin. MATERIALS AND METHODS: Sixty healthy active guinea pigs, weighing 400-600 g, with an average age of 6 months were used. They were divided into three groups. Group 1 received intramuscular gentamicin 8 mg/kg/day, group 2 received gentamicin 8 mg/kg/day and deferoxamine 150 mg/kg twice daily for 19 days and group 3 served as a control. All animals had a baseline measurement of distortion product oto-acoustic emissions. At the end of 33 days they were submitted to another measurement and then the animals were sacrificed and their cochleas were examined histologically by light and transmission electron microscopy. RESULTS: In group 1 the mean amplitude post-injection ranged from 5.83 dB at 1001 Hz to 22.33 dB at 6348 Hz. In the deferoxamine + gentamicin group the mean amplitude post-injection ranged from 5.10 dB at 1001 Hz, to 24.45 dB at 6348 Hz. This was statistically significant. At 4004, 5042 and 6348 Hz group 2 showed less histological damage than group 1.

Non-intubation traumatic laryngotracheal stenosis: management policies and results.

Traumatic laryngotracheal stenosis (LTS) is increasing in clinical practice. Causes include external trauma, post-intubation, and iatrogenic injuries. It is a complex problem and many patients undergo multiple procedures to achieve a stable and well-protected airway with adequate voice. We present our experience at Ain-Shams University Hospitals on 15 patients followed-up for 7 years. All patients had traumatic LTS excluding post-intubation injuries. Patients were aged 4-58 years. Nine were the victims of road traffic accidents; five were occupational trauma victims; and one tried to commit suicide by strangulation. The patients underwent a total of 53 procedures (mean 3.5 per patient). A total of seven laryngotracheal reconstruction, six partial cricotracheal resection, and four laser recanalization with stenting were performed. Six patients have mean follow-up of 26.5 months (3-60 months). Six patients had normal speech (GRBAS 0-5), three had a moderate degree of voice disturbance (GRBAS 5-10), and five had severe dysphonia (GRBAS > 10). As regards tolerance for daily activities, we used a modification of the McMaster University asthma quality of life questionnaire [Rea et al. Eur J Cardiothorac Surg 22(3):352, 2002] (using the activities and emotional scores total 112). Four patients could perform above the 90th percentile; all the remaining patients were above the 50th percentile. No patient was totally handicapped as a result of their airway problem and they could tend for their basic activities. The aim of this work is to demonstrate that non-intubation traumatic LTS is a complex problem that usually needs a longer time for reconstruction and a different way of approach. However, most of the patients can be finally rehabilitated with a stable, protected airway and adequate voice albeit at the price of a prolonged series of interventions and a long follow-up.