Anterior part middle turbinoplasty in endoscopic sinus surgery: a randomized controlled study.

OBJECTIVE: Resection of middle turbinate in the setting of endoscopic sinus surgery is a controversial procedure. Our aim is to assess the impact of the anterior part middle turbinoplasty on the outcome of endoscopic sinus surgery, incidence of synechia between the middle turbinate and the lateral nasal wall, intra- and post-operative accessibility to the paranasal sinuses. METHODS: Single blinded randomized controlled study of 120 patients with chronic rhinosinusitis without polyps, they were allocated into two groups, we performed anterior part middle turbinoplasty in the group one "60 patients", and we preserved the middle turbinate in the group two "60 patients". We assessed the patients pre-operatively by Sino-nasal outcome Test (SNOT-22), intra-operatively by Likert scale score for the sinuses accessibility. At least 6 months post-operatively, we assessed the patients by SNOT-22, and Likert scale score for sinus accessibility. RESULTS: During and after surgery, the Likert scale score in the group one showed statistically significant better sinuses accessibility than in the group two. We noticed synechia between the MT and the lateral nasal wall in 9.2% and 18.2% of the operated sides in group one and group two, respectively. SNOT-22 and its smell item improved significantly in both groups with no statistically significant differences between them. No major complications were reported. CONCLUSION: Anterior part middle turbinoplasty is a safe and effective technique during endoscopic sinus surgery to improve the intra- and post-operative sinus accessibility, and decrease the incidence of post-operative synechia, with no adverse effect on olfaction or bleeding.

Audio-vestibular Abnormalities in Patients With Vitiligo: A Prospective Case-control Study.

INTRODUCTION: Vitiligo is a disease that is characterized by a deficit of functional melanocytes all over the body including the inner ear. OBJECTIVES: To study the effect of the reduction of melanocytes on the audio-vestibular system in patients with vitiligo. SUBJECTS AND METHODOLOGY: Our study included 35 patients with vitiligo (study group) and 35 healthy volunteers (control group). Audiological and vestibular function assessments were performed in all the participants and the results were compared between the two groups. We assessed the auditory function utilizing pure-tone audiometry and the auditory brainstem response, while vestibular function was assessed by the Dizziness Handicap Inventory, the cervical vestibular-evoked myogenic potential (cVEMP), and videonystagmography. RESULTS: Twelve patients with vitiligo showed impairment of the hearing especially in high frequencies in comparison with the control group. Auditory brainstem response wave III and I-III inter-peak latencies were significantly prolonged in the study group relative to the control subjects. On cVEMP testing, waves P13 and N23 were significantly delayed in the study group and the caloric test results showed that five vitiligo patients had unilateral weakness and three patients had bilateral weakness. CONCLUSION: Vitiligo is a systemic disease that can influence the audio-vestibular system. Screening tests for early detection of audio-vestibular changes in patients with vitiligo are important, as they are more susceptible to oxidative damage of ototoxic medications, noise exposure, and age-related hearing loss.

Platelet-Rich Plasma Fat Graft versus Cartilage Perichondrium for Repair of Medium-Size Tympanic Membrane Perforations.

OBJECTIVES: To compare clinical and audiologic outcomes among patients who underwent myringoplasty with fat graft enriched with platelet-rich plasma and cartilage perichondrium graft. STUDY DESIGN: Prospective randomized controlled study. SETTING: Department of Otolaryngology-Head and Neck Surgery, Tanta University, Egypt. SUBJECTS AND METHODS: The study comprised 50 patients who had tympanic membrane perforation of medium size (25%-50% of its surface area) without evidence of active otitis media or ossicular abnormalities and who had surgery between December 2016 and December 2017. Patients randomly underwent myringoplasty with fat graft enriched with platelet-rich plasma (group 1) or cartilage perichondrium graft (group 2). RESULTS: Twenty-five patients were included in each group. Rates of successful closure at 3-month follow-up were 88% (group 1) and 92% (group 2). The mean overall improvement in pure tone average was 18.08 dB (95% CI, 16.9-19.25) for group 1 and 18.24 dB (95% CI, 16.94-19.53) for group 2. CONCLUSION: Fat graft enriched with platelet-rich plasma can be recommended as an alternative choice for first-line treatment of medium-size central perforations of the tympanic membrane, with healing and hearing results comparable to those of conventional cartilage perichondrium myringoplasty.

Foreign body aspiration, a continuously growing challenge: Tanta University experience in Egypt.

OBJECTIVE: To evaluate the different factors that affect the spectrum and frequency of foreign body (FB) aspiration as a growing problem in different ages, and express the experience of our department in managing the problem in the recent two decades. METHODS: The charts of 3600 patients who underwent bronchoscopic evaluation over a period of 20 years for a suspicion of FB inhalation were reviewed. The patients were divided according to the age into group A; up to 10 years, and group B; more than 10 years. Each group was investigated and compared with the other with respect to sex, history of FB aspiration, time elapsed between aspiration and hospital admission, clinical and radiographic findings, and FB location, type, retrieval, and complications. Seasonal, geographic, and socio-cultural factors and frequency of FB aspiration in relation to the study period were also recorded. RESULTS: In group A, boys were affected more than girls (1.3:1), while in group B, females were affected more than males (40.5:1). Among history positive patients in group A (72.8%) and B (96.8%), FB was detected in 88% and 97% respectively, while among history negative patients, FB was found higher in group A (49%) than group B (25%). The time elapsed before admission was longer in group A than group B. Cough was the most prominent symptom, while decreased breath sounds was the commonest sign in both groups. Pneumatic infiltration was the most frequent radiographic finding in group A (33.6%), while radio-opaque FB was higher in group B (94.1%). Peanut (67.3%) and seeds (21.2%) were the commonest FBs detected in group A, whereas, headscarf pins (91.3%) were predominant in group B. Foreign bodies were almost equally distributed in the laryngotracheobronchial tree in group A, while the left bronchial tree was much more affected in group B. Rigid bronchoscopy was used in groups A and B with a success rate of 99.8% and 99.7% respectively, while flexible bronchoscopy was only used in 0.2% in group B. Complications such as laryngotracheal edema (16.6%) and pneumothorax (2.3%) were encountered in group A more than group B (3.1%, 1.2%) and there was no mortality. Most of the aspirated FBs were recorded during summer months and commonly detected in patients of low socio-cultural status in both groups. CONCLUSION: Foreign body aspiration is a continuously growing problem in Lower Egypt affecting all ages with two peaks at 3 and 14 years old. The rate of FB aspiration was affected by age; sex; traditions and believes; and seasonal, geographic, and socio-cultural factors. A high index of suspicion, rapid hospital admission, and bronchoscopic evaluation by experienced specialists were crucial for successful retrieval of the FB with low rate of morbidity. Public awareness through mass media needs attention to decrease the growing rate of this problem.

Dysautonomia rhinitis: associated otolaryngologic manifestations and characterization based on autonomic function tests.

CONCLUSIONS: Dysautonomia is a multisystem disorder. Beside the nasal symptoms, some otolaryngological disorders may be explained on the basis of autonomic dysfunction. Testing of the autonomic nervous system (ANS) complements the clinical findings and provides objective measurements to substantiate the presence of ANS dysfunction. The term dysautonomia rhinitis may be used to specify this autonomic-related rhinitis. OBJECTIVES: Nonallergic, noninfectious perennial rhinitis is a heterogeneous disorder comprising several pathophysiological entities. This study was designed to objectively investigate the relation of idiopathic perennial rhinitis to ANS dysfunction. PATIENTS AND METHODS: This was a prospective controlled clinical study; 78 patients, carefully diagnosed as having idiopathic perennial rhinitis, were enrolled. Workshop protocol included diagnostic measures for exclusion of other causes of rhinitis and autonomic function assessment at a clinical cardiology laboratory. Results were compared with those of 20 age- and sex-matched normal control subjects. RESULTS: In addition to their nasal symptoms, all patients reported more than one regional and multisystem complaint. Each patient had at least one autonomic function test that displayed a hypervagal response and the overall response score was as follows: 46 (59%) had hypervagal response, 32 (41%) had mixed response and none had a normal or hyperadrenergic response.

Molecular profile of the antrochoanal polyp: up-regulation of basic fibroblast growth factor and transforming growth factor beta in maxillary sinus mucosa.

BACKGROUND: Various pathogenetic mechanisms have been proposed to explain the development of antrochoanal polyps (ACPs); however, the cause is still largely unknown. The aim of this study was to characterize the expression and the potential role of a battery of molecular markers in the development of ACPs. A prospective controlled study of a case series was performed. METHODS: Tissue samples of maxillary sinus mucosa were obtained from 14 patients with ACPs, 17 patients with chronic nonpolypoid maxillary sinusitis, and 4 patients with normal maxillary sinus mucosa; RNAs were extracted from the sinus mucosa, and semiquantitative reverse transcription-polymerase chain reaction was performed for basic fibroblast growth factor, transforming growth factor P, and mucin genes (MUC), MUC5AC, MUC5B, and MUC8, to investigate their expression. RESULTS: The expression of basic fibroblast growth factor and transforming growth factor beta was significantly higher in ACPs than in chronic rhinosinusitis and healthy mucosa. Meanwhile, the levels of expression of MUC genes were higher in ACPs and chronic rhinosinusitis compared with healthy mucosa. CONCLUSION: These findings suggest that ACPs may represent an inflammatory reaction caused by overproduction of tissue-derived growth factors in an inductive environment.

Cartilage tympanoplasty for management of tympanic membrane atelectasis: is ventilatory tube necessary?

OBJECTIVES: Cartilage/perichondrium composite graft with concomitant placement of a ventilation tube is a common practice among otologists to reverse atelectasis and to repneumatize the middle ear. We conducted this study to investigate the necessity of a ventilation tube primarily incorporated into the perichondrium/cartilage graft for reconstruction of the atelectatic tympanic membrane (TM). STUDY DESIGN: Prospective clinical trial. METHODS: Forty-six patients with TM atelectasis and intact ossicular chain were randomized to 2 groups. In Group I, 23 patients underwent reconstruction of the TM with perichondrium/cartilage graft and intraoperative T-tube insertion and in Group II, 23 patients underwent reconstruction of the TM with perichondrium/cartilage graft without ventilation tube insertion. Outcome measures were as follows: graft success, improvement of hearing, and postoperative complications. Analysis of the results was performed by Student's paired t test. The level of significance was set at 5%. RESULTS: Significant postoperative improvement of pure-tone air-conduction threshold averages and air-bone gap averages were reported in the 2 studied groups (p < 0.001). The postoperative air-bone gap averages showed no statistically significant difference between Groups I and II (p > 0.05). Conductive hearing loss requiring revision developed in 2 patients (8.69%) in Group I and in 3 patients (13%) in Group II. CONCLUSION: In the atelectatic ear, cartilage allowed reconstruction of the TM with good anatomical and functional results. Primary insertion of a ventilation tube into the graft is not necessary.

Up-regulation of MUC5AC and MUC5B mucin genes in nasopharyngeal respiratory mucosa and selective up-regulation of MUC5B in middle ear in pediatric otitis media with effusion.

OBJECTIVES: Mucins are the major component responsible for the gel-like properties of mucus secretion. Currently, little is known about the regulation of mucins in otitis media with effusion (OME). We investigated the expression of MUC5AC and MUC5B mucin gene messenger (m)RNAs in middle ear effusions as well as in tissue biopsies of the respiratory mucosa of the nasopharynx by means of reverse-transcription polymerase chain reaction (RT-PCR). STUDY DESIGN: A prospective, controlled, clinical trial. METHODS: The study group consisted of 25 children with a diagnosis of OME who were to undergo bilateral ventilation tube insertion with adenoidectomy. A sample of middle ear effusion (n = 50) as well as tissue biopsy from nasopharyngeal respiratory mucosa (n = 25) were obtained from each patient. For the nasopharyngeal mucosal biopsies, two control groups were made up from 30 children with healthy ears who underwent tonsillectomy +/- adenoidectomy operation; control A, 15 children with adenoid hypertrophy, and control B, 15 children with healthy nasopharynx. RNAs were extracted from effusion and tissue samples, and semiquantitative RT-PCR was performed for MUC5AC and MUC5B to investigate their expression. RESULTS: In the middle ear effusions, MUC5B mRNA expression was detected in 48 (96%), whereas MUC5AC mRNA was detected in 8 (16%). On semiquantitative analysis, MUC5AC/glyceraldehyde 3-phosphate dehydrogenase (GAPDH) and MUC5B/GAPDH mRNA ratios in the study group were significantly increased compared with those in both control groups (P < .05). CONCLUSIONS: The results suggest that the middle ear has a unique mucin gene expression pattern when compared with that of the nasopharynx. Up-regulation of MUC5B in the ear may play an important role in the pathogenesis of middle ear effusions.

Physiologic reestablishment of ossicular continuity during excision of retraction pockets: use of hydroxyapatite bone cement for rebridging the incus.

OBJECTIVE: To analyze the results obtained from hydroxyapatite bone cement repair of ossicular discontinuity between the incus and stapes during surgery of retraction pockets. DESIGN: Clinical study of a case series. SETTING: Otolaryngology Department, Tanta University Hospitals, Tanta, Egypt. PATIENTS: A total of 62 previously untreated patients (82 ears) with retraction pockets. INTERVENTIONS: Hydroxyapatite bone cement was used to repair defects at the incudostapedial connection in 82 ears with retraction pockets. The ears were divided into 2 groups: group 1 included 48 ears with a small defect in the long process of the incus; group 2 included 34 ears with a large defect in the long process of the incus. In addition, 20 control patients underwent surgery using plastipore partial ossicular replacement prostheses. Hearing results were reported in 4 frequencies (0.5, 1, 2, and 3 kHz). Analysis of the results was performed using the paired t test with significance level at .05. MAIN OUTCOME MEASURES: Anatomic and audiologic results. RESULTS: Significant postoperative improvement of pure-tone air conduction threshold averages and air-bone gap averages were reported in the 3 studied groups. The postoperative air-bone gap averages showed significantly better outcome in groups 1 and 2 compared with controls (P<.001), while there was no statistically significant difference between groups 1 and 2 (P>.05). CONCLUSIONS: Bone cement ossiculoplasty offers cost-effective and significant improvement in conductive hearing loss. It provides an excellent alternative to ossiculoplasty with preformed prostheses. We believe the indications for bone cement were validated by these results.

Molecular assessment of neck dissections supports preserving level IIB lymph nodes in selective neck dissection for laryngeal squamous cell carcinoma with a clinically negative neck.

OBJECTIVES: It was the aim of this study to determine whether level IIB lymph nodes can be saved in elective neck dissection as a treatment for patients with squamous cell carcinoma (SCC) of the larynx. We present a prospective analysis of a case series. METHODS: Thirty-one patients with SCC of the larynx and without palpable lymph nodes at the neck who underwent an elective neck dissection were prospectively studied. The incidence of micrometastasis to level IIB lymph nodes after performing elective neck dissection was evaluated by nested reverse transcription polymerase chain reaction for cytokeratin (CK)19 and CK20 as well as by pathological examination. RESULTS: Nested reverse transcription polymerase chain reaction for CK19 and CK20 mRNA presented similar results but differed from the pathological examination. Of the 31 patients, 6 (19%) by pathological analysis and 9 (29%) by molecular analysis had lymph nodes positive for metastatic SCC. By molecular analysis, only 1 of the 31 patients had involvement of level IIB lymph nodes. CONCLUSIONS: This region may be preserved in elective neck dissection in patients with SCC of the larynx, so that accessory nerve dysfunction can be minimized and operative time can be saved.

Prevalence of Helicobacter pylori DNA in recurrent aphthous ulcerations in mucosa-associated lymphoid tissues of the pharynx.

OBJECTIVE: To determine the presence of Helicobacter pylori and, if detected, its potential prevalence in causing recurrent aphthous ulcers confined to mucosa-associated lymphoid tissues of the pharynx. DESIGN: Prospective, controlled clinical trial. SETTING: Otolaryngology Department of Tanta University Hospitals, Tanta, Egypt. PATIENTS: A total of 146 patients with recurrent multiple aphthous ulcers of the oral cavity and pharynx and 20 normal control subjects. INTERVENTIONS: Patients were assigned to group 1 (n = 58), in which the ulcers were strictly limited to the lymphoid tissues, or group 2 (n = 88), in which the ulcers were randomly distributed in the oral cavity and pharynx. Helicobacter pylori DNA was extracted from 3-mm-diameter tissue samples, and polymerase chain reaction amplifications were performed for the 16S ribosomal RNA gene. MAIN OUTCOME MEASURE: Positivity for H pylori. RESULTS: In group 1, 39 patients (67%) were positive for H pylori DNA, while in group 2, 9 patients (10%) were positive (chi(2) test, P<.001). It was not detected in any of the 20 control samples. CONCLUSION: Our results support a possible causative role for H pylori in recurrent aphthous ulcerations with a characteristic distribution and affinity to mucosa-associated lymphoid tissues of the pharynx.

Level IIb lymph nodes metastasis in elective supraomohyoid neck dissection for oral cavity squamous cell carcinoma: a molecular-based study.

OBJECTIVES: To identify the incidence of level IIb lymph nodes metastasis in elective supraomohyoid neck dissection (SOHND) as a treatment for patients with squamous cell carcinoma (SCC) of the oral cavity. STUDY DESIGN: Prospective analysis of a case series. METHODS: Forty-eight patients with SCC of the oral cavity and with no palpable lymph nodes at the neck who underwent an elective SOHND were prospectively studied. The incidence of micrometastasis to level IIb lymph nodes after performing elective SOHND was evaluated by pathologic examination and molecular analysis. RESULTS: Of the 48 patients, 15 (31%) by pathologic analysis and 22 (46%) by molecular analysis had lymph nodes positive for metastatic SCC. By molecular analysis, 5 (10%) of the 48 patients had involvement of level IIb lymph nodes. All patients with metastasis to level IIb lymph nodes have their primary lesions in the tongue and constituted 22% of patients with tongue lesions. There was no instance of isolated metastasis to level IIb lymph nodes without involvement of other nodes in the SOHND specimens. CONCLUSIONS: In this study, level IIb lymph node metastasis was only found in association with tongue carcinoma. Although this region may be preserved in elective SOHND in patients with SCC of the oral cavity, it should be included whenever the tongue is the primary site.

Endoscopic radiosurgical posterior transverse cordotomy for bilateral median vocal fold immobility.

The objectives in treatment of bilateral vocal fold immobility (BVFI) are to achieve adequate airway, preservation of voice quality and laryngeal competence. The present prospective study was designed to evaluate precisely the efficiency and long-term clinical outcome in a series of 13 patients with irreversible BVFI, consecutively managed with endoscopic radiosurgical posterior transverse cordotomy (ERPTC). The operation was performed endoscopically using an Ellman Radiosurgical Instrument and a specially designed electrode. Pre- and post-operative inspiratory function measurements and acoustical vocal analysis were conducted on the patients and were tested for potential statistical relation to successful rehabilitation of the airway. One-step, successful restoration of the airway was achieved in all patients. The post-operative improvement of spirometric values was statistically significant (p < 0.0001), and during the follow-up period of (six to 30) months, airway stability was demonstrated in all patients. In terms of acoustic analysis a non-significant difference was found between pre- and post-operative vocal functions (p > 0.05). This management approach offers an alternative to laser procedures, it provides a 'one-stage' solution for permanent bilateral vocal fold immobility, and avoids terminal loss of voice quality. The authors' data confirm the safety, ease of performance, and efficiency of ERPTC in patients with bilateral immobile vocal folds.