Endoscopic Versus Microscopic Stapedotomy: A Randomized Clinical Trial.

OBJECTIVE: To determine the outcomes and complications of endoscopic versus microscopic stapes surgery in patients with otosclerosis. STUDY DESIGN: Randomized, single-blinded clinical trial. METHODS: Patients with otosclerosis who underwent either trans-canal microscopic or endoscopic stapedotomy at a tertiary care hospital were compared. Thirty-two patients were randomly divided into two groups using blocked randomization. Group A consisted of 16 patients who underwent trans-canal microscopic stapedotomy, and group B consisted of 16 patients who underwent trans-canal endoscopic stapedotomy. Postoperative vertigo, ear pain, and complications such as tympanic membrane perforation or chorda tympani nerve injury were evaluated. Three months postoperatively, patients were assessed for dysgeusia and hearing improvement. RESULTS: The mean pre-operative air-bone gap (ABG) in the microscopic and endoscopic groups was 32.81 ± 6.82 and 30.00 ± 7.96, respectively. The mean improvement in the ABG was 25.45 ± 11.21 dB in the microscopic group and 23.21 ± 10.68 dB in the endoscopic group. Although both techniques showed improvement in auditory outcomes (p-value <0.001), there were no statistical differences between the endoscopic and microscopic groups in the pre-operative, post-operative, and mean improvement of ABG (p-value >0.05). There were no significant differences between the two methods in chorda tympanic nerve injury, vertigo scores, and the mean operating time (p-value >0.05), but the mean pain score was higher in the microscopic group (2.56 ± 1.55 in the microscopic group versus 1.31 ± 0.70 in the endoscopic group) (p-value = 0.003). CONCLUSIONS: Endoscopic stapes surgery can be a preferable alternative to conventional microscopic stapedotomy, as it yields similar hearing outcomes and lower pain scores. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:2395-2400, 2024.

Intratympanic Triamcinolone or Dexamethasone in Sudden Sensory Neural Hearing Loss: A Randomized Clinical Trial.

Sudden sensorineural hearing loss (SSNHL) is a condition in which a person experiences a rapid loss of hearing, often in one ear. The cause of SSNHL is not always clear, but it is thought to be related to issues with the inner ear, auditory nerve, or other parts of the hearing pathway. Intratympanic injection is a treatment method for SSNHL in which a medication (corticosteroids) is injected directly into the middle ear space through the tympanic membrane. This randomized clinical trial was conducted in two hospitals in Tehran, Iran. Patients with SSNHL were randomized (using the 4-block method) and included in this study. 0.5 cc of dexamethasone or triamcinolone was injected via a 25-gauge spinal needle into the cone of light of tympanic membrane. This procedure was repeated six times. In the present study, the rate of response to treatment was compared in the two groups of triamcinolone and dexamethasone, which showed that in the group where intratympanic injection of dexamethasone was performed, 70.9% of patients responded to treatment (48.4% had a complete response and 22.5% had a partial response), and in the group receiving intratympanic triamcinolone, 72.5% responded to the treatment and improved, 50% showed a complete response and 22.5% showed a partial response, and no significant difference was found in the statistical analysis of the two groups. Also, the comparison of audiometric parameters (SDS and SRT) did not show any significant difference before and after the treatment based on the treatment group, and the treatment response was found in the same group. No significant differences were noted in terms of outcome. Intratympanic dexamethasone injection was associated with a 70.9% response and triamcinolone injection with a 72.5% response.

Polysomnographic Findings Versus Degree of Obstruction During Drug-Induced Sleep Endoscopy and Muller's Maneuver.

PURPOSE: To investigate associations between polysomnographic findings and the severity of upper airway obstructions during Muller's Maneuver (MM) and Drug-Induced Sleep Endoscopy (DISE) in patients with obstructive sleep apnea syndrome (OSAS). METHODS: This was a prospective cohort study. Adult patients newly diagnosed with OSAS in a tertiary sleep center were included consecutively and evaluated by polysomnography and MM. They then underwent DISE in an operating room. The associations between polysomnographic findings and the severity of upper airway obstructions during MM and DISE were assessed. Also, the degree and pattern of obstructions were compared using a modified VOTE questionnaire. RESULTS: 145 patients (mean age 41.5 ± 10.1 years) were enrolled. There were no associations between Respiratory Disturbance Index (RDI), mean and lowest O2 saturation, and body mass index on the one hand, and obstruction degree in MM and DISE (p > 0.05). However, a significant positive correlation was observed between RDI and total VOTE scores in DISE and MM (r = 0.179, p = 0.031 and r = 0.221, p = 0.008 respectively). There were no differences between MM and DISE in diagnosing the degree of obstruction in the velum area (p = 0.687) and the epiglottis (p = 0.50). However, a significant difference was observed between the two techniques in the oropharynx lateral wall (p < 0.001) and tongue base (p = 0.017). CONCLUSION: Although there was no association between polysomnographic findings and the severity of obstruction in MM and DISE for the separate levels of the upper airway, obstruction severity may be assessed more accurately by total VOTE score, which is representative of RDI severity.

Jugular foramen versus hypoglossal canal in axial CT scan.

Background: Differentiating jugular foramen from hypoglossal canal in computed tomography (CT) scan is vital for correct diagnosis of posterior fossa pathologies; however, it has been shown that the ability for differentiating these skull base elements is limited. The purpose of this study was to produce a simple algorithm for differentiating the jugular foramen from the hypoglossal canal in axial CT scan on two levels (top level where bony carotid canal is evident and lower level where bony carotid canal is not evident). Methods: Data derived from axial CT scan of 250 patients (500 sides) were used for producing algorithm. At top level petro-occipital fissure utilized for recognizing occipital condyle in which hypoglossal canal is located; and, at lower level the distance between the posterior border of the anatomic element (jugular foramen or hypoglossal canal) and the tangent to the anterior bony part is used for producing algorithm. Results: The mean age of patients was 38.1 ± 19 years. The petro-occipital fissure can be used in all patients for differentiating hypoglossal canal. At lower level the distance between the anterior tangent and the posterior border of the element was significantly lower for hypoglossal canal (P value < 0.001). The distance more than 3.5 mm with sensitivity 83.8% and specificity 97.1% differentiate jugular foramen from hypoglossal canal. Conclusion: Simple algorithms based on quantitative morphologic features of the jugular foramen and hypoglossal canal can be used with high sensitivity and specificity to distinguish these elements.

Prevalence of otic capsule dehiscence in temporal bone computed tomography scan.

PURPOSE: To investigate the radiologic prevalence of otic capsule dehiscence in temporal bone computed tomography (CT) scan. METHODS: This was a cross-sectional study. The temporal bone CT scans of the patients presenting to a tertiary center were evaluated for possible dehiscence in any part of the otic capsule; then, all of the dehiscence were confirmed by a trained academic radiologist. For each type of otic capsule dehiscence, at least three planes were used with a specific type of reconstruction. When a dehiscence was present in at least two consecutive images in all planes, it was considered as a true dehiscence. RESULTS: Six hundred patients (mean age: 40 ± 18.1 years) were enrolled. The prevalence of superior and posterior semicircular canal dehiscence was 6.0% and 2.7%, respectively. The prevalence of cochlear-facial dehiscence, cochlear-internal auditory canal dehiscence, and cochlear-carotid dehiscence was 6.3%, 0.7%, and 0.7%, respectively. The prevalence of vestibular aqueduct-jugular bulb dehiscence was 6.3% and the prevalence of posterior semicircular canal-jugular bulb dehiscence was 0.2%. CONCLUSIONS: Considering different types of otic capsule dehiscence described, care should be taken in patients with vestibular and auditory signs and symptoms to diagnose these dehiscences.

Comparison of acidifying agents and clotrimazole for treatment of otomycosis: a comprehensive one-way mini-review.

Background and Purpose: This review aimed to compare the efficacy of acidifying agents and clotrimazole in the treatment of patients with otomycosis. Materials and Methods: The databases, including Research Gate, Google Scholar, ScienceDirect, Embase, Medline, Scopus, Cochrane, and library databases of clinical trials were searched in this study. The keywords were "Fungal Ear Infection" and "Otitis External" for otomycosis, "Clotrimazole", Lotrimin", "Mycelex", "Desenex", and "Clotrimaderm Mycoderm" for clotrimazole, and "Boric Acid Alcohol", "Alcohol-vinegar solution", Burow solution (Domeboro), "Isopropyl Alcohol", "VoSol" and "Acetic Acid" for acidifying agents. Regarding search strategy, a total of 53 studies were collected, 11 of which were maintained for assessment. Almost all studies were published after 1990. These articles discussed the role of clotrimazole and acidifying compounds in the treatment of otomycosis. Moreover, the route of administration, dosage, and side effects of these medications were highlighted. Results: Eight studies had similar results and claimed that clotrimazole has the best or most significant effect on the treatment of otomycosis for patients suffering from pain, itching, swelling, and hearing loss. Conclusion: Although all medications appear effective, there is a paucity of evidence to fully support the decision to choose between clotrimazole or acidifying agents for the treatment of otomycosis in terms of both efficacy and safety. However, in the biomedical field, the re-emerging investigation attention is due to the statements of a number of mechanisms defending the use of acidifying agents to treat mycosis (of antifungal-resistant species).

Sleep Medicine Evaluation in the Annual Patient Management Problem (PMP) Exam for Otolaryngology Residents.

The sleep medicine has not been previously included in the patient management problem (PMP) exam for otolaryngology residents at Tehran University of Medical Sciences. The aim of this study, is to evaluate the results of this first implementation. This was a cross-sectional study. The examinees included all 62 residents from the 1st to 4th years of the Tehran University of Medical Sciences otolaryngology department. The resident scores obtained in this exam were evaluated and compared by residency year. The overall participant score was low for this part of the PMP. There was no score difference between years 1 and 3, but there was a significant positive change in year 4 (p = 0.007). This score pattern was not evident in other parts of the exam. Otolaryngology residents have insufficient knowledge toward the sleep medicine. The reasons for such scoring patterns may be due to the structure of sleep medicine training within the department which may lead to undesirable consequences.

Is Cartilage Thickness Important in Cartilage Tympanoplasty? A Systematic Review and Meta-analysis.

Cartilage is used as a grafting material for tympanoplasty. The rigidity of the cartilage is the main concern. There are debates regarding slicing the cartilage when it is used as a graft. Therefore, this systematic review and meta-analysis aimed to compare the hearing results of full vs. partial-thickness cartilages in patients undergoing cartilage tympanoplasty. We systematically searched google scholar, PubMed, Cochrane, Ovid, Scopus, and gray literature including the references of the selected studies, and conference abstracts which were published up to 6 May 2020. The search syntax for identifying studies was: ((Cartilage) AND (tympanoplasty) AND (thickness)). The literature search found 1047 articles. After eliminating duplicates, 908 studies remained; from these, we excluded observational studies, reviews, case reports, and non-randomized trials, and 12 studies remained. Finally, only 5 articles were included for analysis. The pooled standardized mean difference (SMD) for the post-operative gap was -0.87 95% CI: (-1.66, -0.08) (I2 = 87.1%, p < 0.001). The pooled SMD of the reduction in gap in the full-thickness group was 2.84, 95% CI (1.39-4.3), I2 = 93.2%, p < 0.001). The pooled SMD of the reduction in gap in the partial-thickness group was 4.02, 95% CI (1.97-6.02), I2 = 95.3%, p < 0.001). The pooled results of this systematic review showed that partial-thickness cartilage graft has better hearing outcomes than full-thickness in patients undergoing cartilage tympanoplasty.

Subglottic mucormycosis in a COVID-19 patient: a rare case report.

Mucormycosis is an opportunistic fungal infection caused by fungi of Mucorale order. Uncontrolled diabetes mellitus and other immunosuppressive conditions such as neutropenia and corticosteroid therapy are known risk factors. A new risk factor for this infection is COVID-19 which facilitates mucormycosis by different mechanisms. The rhino-orbito-cerebral involvement is the most common form. Involvement of other anatomical regions may occur in rare situations. As we presented here, a 51-year-old woman presented with respiratory distress and subglottic lesion during COVID-19 (Delta variant) treatment which was diagnosed by histopathological examination as a subglottic mucormycosis postoperatively. The patient underwent tracheostomy and debridement of the necrotic tissues followed by antifungal treatment. New manifestations of COVID-19 are appearing over time. The association between coronavirus and mucormycosis of the laryngeal and airway region must be given serious consideration. Current guidelines recommend a combined medical and surgical approach for achieving the best outcome.

New Modification of Smell Identification Test for the Detection of Malingerers: A Pilot Experimental Study.

Background: A major problem with the University of Pennsylvania Smell Identification Test (UPSIT) is its poor sensitivity for malingering detection in a group of people familiar with the test mechanism. This study aimed to evaluate the modification of UPSIT to detect anosmia malingering. Methods: This was a pilot experimental study conducted in 2019 in Tehran. The participants were 60 healthy subjects classified into two groups of 30 people. The first group was requested to deliberately feign a negative result on the Iranian version of UPSIT, Iran Smell Identification Test (ISIT) (malingering group). The second group consisted of participants, who did not scratch the odorant part of ISIT during the tests (anosmia group). ISIT was modified in two steps. At each step, one incorrect option was deleted from the available choices. The number of each group's answers, altered away from the correct choice, was then calculated and compared. Results: The coached malingering group participants were able to feign anosmia in the original ISIT exam. In the modified ISIT, the number of answers changed from correct to wrong during the second stage (from three available choices to two choices) was significantly higher in the anosmia group (P<0.001). In the ROC analysis, the area under the curve was 0.92 (P<0.001). The cut-off of 4.5 for this test showed 93% sensitivity, 82% specificity, and 90% PPV and NPV. Conclusion: The ISIT is not capable of detecting malingering in the coached participants, yet by deleting the choices step-by-step, the sensitivity and specificity of the test increased.

Safety and feasibility of simultaneous left and right heart catheterization via single-arm arterial and venous access.

BACKGROUND: Catheterization via the radial artery has become the method of choice for evaluation of the coronary arteries; however in patients requiring simultaneous coronary and right heart catheterization upper extremity access is not commonly used. AIMS: In the present study we aimed to assess whether simultaneous left and right heart catheterization via the radial artery and antecubital vein might increase the vascular access site complications. METHODS: In this prospective cohort study, 49 patients with congenital and valvular heart disease requiring both left and right heart catheterization were enrolled, and rates of vascular access complications, including radial artery obstruction (RAO), were compared to 49 subjects in the control group who underwent catheterization only via radial artery access. RESULTS: No major vascular complications occurred in the study population. Post-procedural radial artery obstruction was detected in 14 patients (28.5%) in the venous-radial artery group and 7 (14.2%) in the control group (P = 0.09). Age, sex, body mass index, wrist circumference, hemoglobin concentrations, and history of smoking, diabetes mellitus, hypertension, and anticoagulant use did not affect the rate of radial pulse perseverance. However, shorter times of radial compression device removal were significantly related to lower rates of radial artery obstruction in both groups. CONCLUSION: Right and left heart catheterization via an upper-extremity route in patients with congenital and valvular heart disease is safe and practical with greater patient comfort and no serious vascular complications. A longer duration of radial compression is an important predictor of RAO, regardless of using additional upper-extremity venous access.

Fixed vs Measured Length of Stapes Prosthesis in Stapes Surgery.

Aims The aim of this study is to assess the relationship between the prosthesis length and the outcome of the primary stapes surgery in patients with otosclerosis. Material and Methods This was a retrospective cohort study. We reviewed medical records of 218 patients between January 2015 and August 2020 in two different referral centers. It was conducted in two hospitals by two different well experienced otologic surgeons that one of them believes in fixed length (4.75 mm) of stapes prosthesis (group A) and, the other one believes in measuring the distance between the footplate and incus long process to choose the proper length of prosthesis (group B). The surgery success rates and complications between these two groups were compared 3 months postoperatively. Results Mean age, preoperative bone conduction (BC) audiometric threshold and air-bone gap, postoperative BC and air-bone gap were similar in both groups (All p > 0.05). Vertigo frequency was not significantly different between the two groups (p = 0.303). There were no significant differences regarding the number of favorable postoperative outcomes between group A and B (70 (97.2%) vs. 142(97.3%) respectively) (p = 0.632). Conclusion This study found no significant difference regarding the hearing outcomes between fixed length vs measured length of stapes prosthesis.

Effect of Paracetamol versus Ibuprofen in Adenotonsillectomy.

INTRODUCTION: The present study aimed to compare the effects of paracetamol and ibuprofen on pain, bleeding, nausea, and vomiting following adenotonsillectomy in children. MATERIALS AND METHODS: This was a prospective, double-blinded, randomized clinical trial. Block randomization was used to assign 50 patients to two groups of paracetamol and ibuprofen. In the paracetamol group, subjects received 15 mg/kg oral paracetamol 30 minutes before the induction of anesthesia, followed by the same dosage every 6 hours postoperatively. Meanwhile, the ibuprofen-treated group took 10 mg/kg oral ibuprofen 30 minutes before and every 6 hours after the operation. The subjects in both groups received the medication for three postoperative days. The postoperative pain score was assessed 6 hours after the surgery and during the second and the third postoperative days. Nausea and vomiting episodes were recorded in the first postoperative day and first postoperative week. RESULTS: Based on the results, intraoperative and postoperative bleeding in both groups was not significantly different. The mean score of pain in the first postoperative day (6 hours after the surgery) and the second and the third postoperative days did not show any statistical difference. The ibuprofen group experienced fewer vomiting episodes, compared to the paracetamol group during the first postoperative day (P=0.011). Vomiting episodes in the first postoperative week did not illustrate any significant difference. CONCLUSION: As evidenced by the results of the current study, Ibuprofen had the same effect on the alleviation of postoperative pain, caused fewer vomiting episodes, and did not cause excessive bleeding as an NSAID. Therefore, oral administration of ibuprofen is suggested for pain relief and management of other complications following adenotonsillectomy in children.

A Comparison of Uvulopalatopharyngoplasty and Modified Radiofrequency Tissue Ablation in Mild to Moderate Obstructive Sleep Apnea: A Randomized Clinical Trial.

STUDY OBJECTIVES: To compare the efficacy of modified radiofrequency tissue ablation (MRFTA) with uvulopalatopharyngoplasty (UPPP) based on both subjective and objective outcome measures in patients with mild to moderate obstructive sleep apnea (OSA). METHODS: Forty patients with mild to moderate OSA were randomly divided into UPPP and MRFTA groups. Evaluation was made based on the apneahypopnea index (AHI), Sleep Apnea Quality of Life Index (SAQLI) and Epworth Sleepiness Scale (ESS), immediately before the surgery and 6 months postoperatively. RESULTS: The postoperative AHI scores were improved significantly in both groups, although the postoperative AHI in the UPPP group was significantly lower than in the MRFTA group (P = .02). The difference between success rates for moderate OSA in UPPP and MRFTA was significant (77% versus 30%, P = .03) but there was no significant difference between success rates for mild OSA in UPPP and MRFTA groups (70% versus 50%, P = .36). Comparing postoperative ESS scores in the 2 groups showed no significant difference (P = .24). The postoperative scores in social interaction, treatment-related symptoms domain, and SAQLI total score were significantly higher in the MRFTA group. CONCLUSIONS: MRFTA as well as UPPP can greatly improve daytime sleepiness and AHI, especially in patients with mild OSA. MRFTA proved to be more effective than UPPP to enhance quality of life of patients with OSA. Further studies with longer follow-up are required to evaluate long-term safety and efficacy of these procedures. COMMENTARY: A commentary on this article appears in this issue on page 1023. CLINICAL TRIAL REGISTRATION: Trial name: Comparison of RFTA (Radio-Frequency-Tissue-Ablation) and UPPP (Uvulopalatopharyngoplasty) in patients with mild to moderate obstructive sleep apnea. URL: http://en.search.irct.ir/view/18617. Registration number: IRCT2014060910160N3.

Rate of Occult Cervical Lymph Node Involvement in Supraglottic Squamous Cell Carcinoma.

INTRODUCTION: To assess the rate of cervical lymph node involvement in patients with supraglottic squamous cell carcinoma (SCC) with no lymph node in clinical assessments and radiological studies. MATERIALS AND METHODS: Fifty-six patients who underwent elective dissection of the cervical lymph node of the second through fourth level were enrolled, and pathologic evaluation of the dissected lymph nodes was performed. Lymph node involvement and association between tumor grade, smoking and gender with lymph node involvement were assessed. RESULTS: The rate of the occult neck metastasis in this series was 37.5%. There was no statistically significant association between lymph node involvement and tumor grade, smoking, or gender. CONCLUSION: Based on the results of our study, we recommend elective bilateral neck dissection in all stages of N0 supraglottic SCC patients.

Quality of life comparison in common rhinologic surgeries.

Various questionnaires are used in patients who undergo rhinologic surgeries but a unique comprehensive questionnaire is needed to evaluate quality of life (QOL) in rhinologic surgeries. The purpose of this study was to prepare a comprehensive questionnaire and compare QOL among four common rhinologic surgeries including functional endoscopic sinus surgery, septoplasty, septorhinoplasty, and septoplasty with turbinoplasty preoperatively and 6 months postoperatively. This was a prospective interventional before-and-after study. Preoperative and 6 months postoperative evaluations were performed with a Modified Health-Related Quality of Life (HRQL) questionnaire designed to cover all needed QOL aspects and the 22-item Sino-nasal Outcome Test questionnaire to cover all needed QOL aspects. The Modified HRQL included 33 items in six subgroups (nasal symptoms, sleep problems, headache, nonnasal symptoms, and practical and emotional problems) and general feeling. From 202 patients who completed the questionnaire before the procedures, 146 (72% of all patients) who were interviewed 6 months postoperatively were included in this study. Comparing preoperative data between followed up patients and missed patients showed no statistical difference among surgeries (p = 0.90). Comparison of patient's pre- and postoperative QOL showed a significant improvement in global QOL and in all questionnaire items (p < 0.0001 in all comparisons). Comparison of QOL changes before and after surgery among different surgeries revealed no statistical difference (p = 0.282). Our data showed a significant improvement in each surgery but the amount of improvement in different surgeries was almost constant.