Long-Term Outcomes of COVID-19 Otolaryngology Symptoms in Saudi Arabia.

OBJECTIVES: The objectives of the study are to measure the prevalence of the most common symptoms and different long-term otorhinolaryngology manifestations among COVID-19-positive patients in Saudi Arabia. METHODS: This is a cross-sectional study. Data were collected using a Google form questionnaire sent to the study sample. The data were entered and then analyzed using SPSS version 25.0 (IBM Corp, Armonk, NY). RESULTS: A total of 13,530 COVID-19-positive adult patients were enrolled in the current study. The most reported initial symptom was fever (53.3%) followed by headache (49.3%), sore throat (48.9%), nasal congestion, rhinorrhea (42.1%), and loss of smell and/or loss of taste (37.8%). Regarding the continuation of the symptoms, vertigo was mentioned by 5852 (43.3%) followed by fever (16.1%) and blocked ear sensation (15.6%). CONCLUSION: The most commonly reported initial symptom was fever followed by headache. Interestingly, vertigo is a frequent long-term complication after a COVID-19 infection. Other otology-related symptoms include hearing loss and ear blockage, while rhinology and upper airway-related symptoms were less frequent in the long term after the acute phase of the infection.

Guidelines for cochlear implantation in Saudi Arabia.

This study aim to establish unified clinical practice guidelines (CPGs) for adults and pediatric cochlear implantation (CI) for the Ministry of Health specialist hospitals in the Kingdom of Saudi Arabia. A comprehensive literature review was carried out by a task force group. Guidelines were based on evidence-based medicine including institutions and individuals' experiences. Bilateral CI is recommended for adults and pediatrics with bilateral severe/profound hearing loss. The minimum age of implantation for children is recommended at 9 months. This study provides a safe framework for the multidisciplinary team to select appropriate CI candidates. It is important to establish a comprehensive multidisciplinary team covering different aspects of health care providers.

Correlation of quality of life with speech and hearing performance after pediatric cochlear implantation.

OBJECTIVES: This study aimed to determine the correlation of the quality of life (QOL) with the Categories of Auditory Performance (CAP) and the Speech Intelligibility Rating (SIR) scales in children after cochlear implantation. METHODS: This cross-sectional study was conducted from November 2018 to February 2020 at the otolaryngology department at a tertiary referral center. Patients aged ≤16 years who had received cochlear implants (CIs) at our center were consecutively included in this study. Parents were asked to complete the Glasgow Children's Benefit Inventory questionnaire, and auditory and speech assessments were performed by the speech therapists at our center. The correlations of Glasgow Children's Benefit Inventory results with the objective data from the CAP and SIR assessment tools were analyzed. RESULTS: Seventy patients were included in this study. The mean age at implantation was 3 years and 9 months. The mean Glasgow Children's Benefit Inventory score was 52.23 (standard deviation = 23.99), indicating a positive benefit in QOL. There was a statistically significant correlation of the QOL questionnaire score with the CAP score (r = 0.40, p = 0.008), but no correlation was found between the QOL questionnaire score and the SIR score. CONCLUSION: We recommend that cochlear implant patients should undergo an evaluation that incorporates auditory, language, and QOL assessment tools to gain a more comprehensive understanding of their progress.

Reliability of the Arabic Glasgow children's benefit inventory.

OBJECTIVES: To translate the Glasgow Children's Benefit Inventory (GCBI) questionnaire into Arabic language and assess its validity and reliability in scoring the benefit of patients after cochlear implantation in children. METHODS: A cross-sectional study for a group of consecutive pediatric patients who underwent cochlear implantation between November 2018 and February 2020. The GCBI original questionnaire was translated into Arabic language and translated back to English by 2 different experts. The patients/parents were asked to complete the questionnaire given to them. RESULTS: Seventy children were included in the study. The age at implantation ranged from 7 months to 13 years with a mean of 3.4 years (SD=2.3 years). The mean GCBI score was 52.2 (SD=24.0) ranging from -6.25 to 100.00.The internal consistency of the questionnaire was high (Cronbach's α=0.9). The 4-factor dimensions explained 55.1% of the variance. CONCLUSION: The GCBI questionnaire (Arabic version) is reliable tool to evaluate retrospectively the quality of life after an intervention in pediatric age for Arabic speaking population.

Rare otologic presentation of cat eye syndrome.

We encountered an extremely rare case where a patient with cat eye syndrome (CES) who presented with symptoms of posterior semicircular canal dehiscence (PSCD). CES is a rare genetic disorder, resulting from duplication of chromosome 22. Patients may present with variable phenotypes, including characteristic of coloboma, heart defect, periauricular skin pit/tag, microtia, anal atresia and mildly retarded mental development in some cases. PSCD is also a disease of the inner ear, where patients present with third window signs and symptoms due to lack of bony coverage. PSCD is usually associated with a high riding jugular bulb and fibrous dysplasia. In this study, we report a new otologic finding in CES patient as an association of PSCD and high jugular pulp. We describe the work up and its findings and the management of this patient. SIMILAR CASES PUBLISHED:: None.

Morbidity Rate of the Retrosigmoid versus Translabyrinthine Approach for Vestibular Schwannoma Resection.

BACKGROUND AND OBJECTIVES: Controversy related to the choice of surgical approach for vestibular schwannoma (VS) resection remains. Whether the retrosigmoid (RS) or translabyrinthine (TL) approach should be performed is a matter of debate. In the context of a lack of clear evidence favoring one approach, we conducted a retrospective study to compare the morbidity rate of both surgical approaches. Subjects and. METHODS: 168 patients underwent surgical treatment (2007-2013) for VS at our tertiary care center. There were no exclusion criteria. Patients were separated into two groups according to the surgical approach: TL group and RS group. Signs and symptoms including ataxia, headache, tinnitus, vertigo and cranial nerve injuries were recorded pre- and postoperatively. Surgical complications were analyzed. Perioperative facial nerve function was measured according to House-Brackmann grading system. RESULTS: Tumor resection was similar in both groups. Facial paresis was significantly greater in RS group patients preoperatively, in the immediate postoperative period and at one year follow-up (p<0.05). A constant difference was found between both groups at all three periods (p=0.016). The evolution of proportion was not found to be different between both groups (p=0.942), revealing a similar rate of surgically related facial paresis. Higher rate of ataxic gait (p=0.019), tinnitus (p=0.039) and cranial nerve injuries (p=0.016) was found in RS group patients. The incidence of headache, vertigo, vascular complications, cerebrospinal fluid leak and meningitis was similar in both groups. No reported mortality in this series. CONCLUSIONS: Both approaches seem similar in terms of resection efficacy. However, according to our analysis, the TL approach is less morbid. Thus, for VS in which hearing preservation is not considered, TL approach is preferable.

Eosinophilic otitis media diagnosis using flow cytometric immunophenotyping.

OBJECTIVES: (1) To assess the ability of flow cytometric immunophenotyping to detect and quantitate eosinophils in patients with eosinophilic otitis media (EOM). (2) to evaluate the association of EOM to bronchial asthma. METHODS: Twenty-one patients with chronic otorrhea or middle ear effusion (MEE) were included in this prospective cohort study. Group I composed of 10 patients (14 ears) and associated to bronchial asthma. Group II included 11 patients (11 ears) without bronchial asthma. Samples of MEE were sent for flow cytometric analysis at initial presentation. Patients with positive eosinophils on flow cytometric immunophenotyping were analyzed after one-month course of dexamethasone eardrops. RESULTS: EOM was diagnosed in all patients of group I and in three patients of group II. The mean eosinophils percentage was 43.5% and 14.2% for group I and group II, respectively (p = .006). Those patients showed a significant response to dexamethasone eardrops, both on clinical examination and on flow cytometric analysis with a decrease in eosinophil levels post-treatment. However, this improvement was temporary and symptoms recurred after treatment cessation. Bronchial asthma was not associated to all patients with EOM. CONCLUSION: Diagnosis of EOM remained mostly clinical; flow cytometry immunophenotyping of MEE may be helpful as an additional tool in diagnosis and monitoring the response to treatment, particularly in non-asthmatic patients.

Study of Methylene Blue Ototoxicity in the Guinea Pig.

BACKGROUND: Methylene blue is widely used in the medical field, especially as a blue dye for staining. It is also used as a photosensitizing agent in antimicrobial photodynamic therapy, which once photoactivated is effective for the eradication of several multi-resistant bacteria. The objective of this study was to investigate the ototoxic potential of methylene blue and precise its use in otology. METHODS: It was a prospective animal study performed on guinea pigs in our tertiary medical center. We divided the animals into two groups: an experimental group and a control group, who underwent a series of three intratympanic (IT) injections. In the control group (n = 10), they received injections of gentamicin in one ear (positive control) and normal saline in the contralateral ear (negative control). The experimental group (n = 10) received injections of methylene blue in one ear, compared to injections of normal saline in the contralateral ear. We conducted auditory-evoked brainstem response (ABR) before and 1 week after the injection series. Once this is completed, the cochlea was dissected and caspase-3 was analyzed by immunohistochemistry. RESULTS: The mean difference of hearing loss in the methylene blue group compared to normal saline was 1.50 dB, and it was not shown to be statistically significant (P = 0.688). For the positive control group, which received IT injections of gentamicin, the mean threshold of hearing loss difference for all the frequencies combined was 66.25 dB (P < 0.001). Furthermore, uptake of caspase-3 by immunohistochemistry (apoptotic marker) was negative in our group, which received injections of methylene blue. CONCLUSION: In light of our results, IT injections of methylene blue did not demonstrate an ototoxic potential. We recommend further studies to precise its use in the otologic field.

Reliability of the Arabic Glasgow benefit inventory after otolaryngology interventions.

We aim to translate the Glasgow benefit inventory (GBI) questionnaire into Arabic language and assess its reliability in scoring the benefit of patients after otolaryngology interventions. This is a pilot study of an ongoing prospective cohort study. The original GBI questionnaire was translated into Arabic language and back-translated into English by two different experts. The questionnaire was given to patients who were asked to fill it themselves. A group of consecutive adult patients were included in the study. Fifty-one patients were included. Reliability using Cronbach's α was higher than 0.70 for total score and the three subscales. Five loading factors explained 72.9% of the variance reached. The mean benefit of the GBI total score was 30.0 ± 36.37. Subscales scores were as follows: 35.21 ± 25.98 for the general health, 25.81 ± 45.98 for the physical benefit and 29.08 ± 34.45 for the social support. The Arabic GBI questionnaire is reliable to evaluate the quality of life after otolaryngology interventions for Arabic speaking population.

Postoperative diffusion weighted MRI and preoperative CT scan fusion for residual cholesteatoma localization.

OBJECTIVE: To evaluate the ability of preoperative mastoid high resolution Computerized tomography (CT Scan) fusion with the postoperative diffusion weighted magnetic resonance imaging (Non-EPI DWI) to accurately localize the residual cholesteatoma thus sparing an unnecessary postoperative CT scan radiation. PATIENTS AND METHODS: this is a prospective study performed in our tertiary care center. We followed up prospectively a consecutive group of patients presenting with middle ear cholesteatoma using preoperative mastoid CT scans, postoperative mastoid CT scan and mastoid diffusion weighted MRI (DWI) between 2012 and 2013. Postoperative DWI were fused to both: the preoperative and postoperative mastoid CT scans. Fused images were evaluated for their ability to detect accurately the location of residual cholesteatoma if any. Results were correlated to the surgical findings. RESULTS: Twenty-eight patients were included in this study. Ten patients showed middle ear opacity on the postoperative CT scans; the remaining negatively patients were excluded. DWI detected residual cholesteatoma in 3 out of the ten patients. Both CT scans; the pre and postoperative were able to precisely localize the residual cholesteatoma when fused to the postoperative DWI. Intra-operatively, three patients had a residual cholesteatoma that corresponded to the fused radiological images while a fourth patient presenting low signal intensity on the Non-EPI DWI had no cholesteatoma. CONCLUSION: Diffusion weighted MRI/CT scan fusion combines the advantages of residual cholesteatoma detection and precise localization. Preoperative CT scans performed before the first surgery can be used for the fusion with the Non-EPI DWI in order to spare the patient an unnecessary another CT scan and thus decreasing radiation exposure.

Temporal bone metastasis as a sign of relapsing chronic lymphocytic leukemia.

Otologic manifestations in chronic lymphocytic leukemia (CLL) are common presentations. However, temporal bone metastasis is rarely described as a sign of relapsing CLL. A 65-year-old male diabetic patient known to have CLL on remission presented to the outpatient otolaryngology clinic with a one month history of progressive bilateral otalgia and right otorrhea, despite multiple courses of antibiotics. He was admitted with suspicion of malignant otitis externa. Left ear showed large hemorrhagic bullae on the posterior segment of tympanic membrane. Left sided facial paralysis developed on the third day of admission. Full recovery of facial paralysis is achieved by 10 days course of corticotherapy. Histological examination of middle ear tissue biopsy showed infiltration by monotonous small lymphoid cells, showing round nuclei, condensed chromatin suggestive of CLL. Although rare, unusual otologic manifestations should raise the suspicion of a temporal bone metastasis as a sign of relapsing CLL.

Common features in patients with superior canal dehiscence declining surgical treatment.

BACKGROUND: Superior canal dehiscence (SCD) is a benign condition in which a surgical treatment may be considered depending on the patients' tolerance of their symptoms. In this study, we aim to identify driving factors behind the patients' choice of a surgical management over watchful waiting. METHODS: Sixty-two patients with cochlear and/or vestibular symptoms and a temporal bone high-resolution CT (HRCT) scan showing SCD were included in the study. All patients have been offered either surgical management or watchful waiting. RESULTS: Of these, 28 elected surgery and 34 declined it. The operated group showed more cochlear (6.6 vs. 2.4) symptoms than the non-operated group (P < 0.001) except for hypoacousis, but no significant difference (P = 0.059) was found for the number of vestibular symptoms between both groups (3.4 vs. 1.1). Footstep and eating hyperacousis were both present in 57.1% of operated vs. 3% of non-operated patients (P < 0.001). Oscillopsia with effort and with walking was found in 50% and 35.7% of operated patients, respectively, but none in the non-operated group (P < 0.001). Hearing tuning fork at malleolus and Valsalva and pneumatic speculum induced vertigo showed a statistically significant difference between the two groups (P = 0.003, P < 0.001, P = 0.010 respectively). Cervical vestibular-evoked myogenic potential (cVEMP) thresholds, air and bone conduction thresholds, and mean air-bone gap (ABG) were similar in the two populations (P > 0.05). The average dehiscence size was 4.7 mm (2.0 - 8.0 mm) and 3.8 mm (1.3 - 7.7 mm) in the operated and non-operated patients, respectively (P = 0.421). CONCLUSIONS: The natures of cochleovestibular signs and symptoms were shown to be key factors in patients' choice of a surgical management whereas paraclinical tests seem to be less significant in the patients' decision for a surgical treatment.

Endolymphatic duct blockage: a randomized controlled trial of a novel surgical technique for Ménière's disease treatment.

OBJECTIVES: To compare the effectiveness of the endolymphatic duct blockage (EDB) and the endolymphatic sac decompression (ESD) to control Ménière's disease symptoms and to evaluate their effect on hearing level. STUDY DESIGN: Prospective nonblinded randomized study. SETTING: Tertiary medical center. SUBJECTS AND METHODS: Fifty-seven patients affected by a refractory Ménière's disease were included out of which 22 underwent an ESD and 35 underwent an EDB. Five periods of follow-up were considered: 0 to 1 week, 1 week to 6 months, 6 to 12 months, 12 to 18 months, and 18 to 24 months. Mean outcome measurements consisted of vertigo control, tinnitus, aural fullness, instability, and hearing level. Hearing level was evaluated using pure-tone average (PTA) and speech discrimination score (SDS). RESULTS: There was no significant difference between the 2 groups in the number of vertigo spells per months preoperatively (P = .153). Twenty-four months postoperatively, 96.5% of the EDB group had achieved a complete control of vertigo spells against 37.5% of the ESD group with a statistically significant difference (P = .002). There was a better control of tinnitus and aural fullness with EDB (P = .021 and P = .014, respectively). There was no statistically significant difference in hearing level preoperatively (P = .976) and 24 months postoperatively (P = .287) between the 2 groups. Hearing level was preserved in each group with no significant difference between the preoperative and the postoperative levels (P > .05). CONCLUSION: EDB is more effective than the traditional ESD in controlling the symptoms of Ménière's disease. It is a novel surgical technique with promising results for a complete treatment of Ménière's disease. There are no significant complications or adverse effect.

Perilymphatic fistulas: can we predict the diagnosis?

This study intends to identify factors that could better predict the diagnosis of perilymphatic fistula (PLF) since exploration surgery is currently the only confirmatory method. This retrospective chart review in a tertiary care center is based on all 71 available patient files operated for a suspicion of PLF between 1983 and 2012. History of predisposing factors, clinical findings and investigations were documented pre- and postoperatively. Patients were divided according to intraoperative findings into two groups: group I (fistula negative) and group II (fistula positive). In addition, group II was divided into two subgroups: patients with or without a history of stapedectomy. Both groups were demographically similar. With the exception of history of previous partial stapedectomy (p = 0.04), no statistical difference could be identified in predisposing factors and in clinical findings between the two groups. The evolution of symptoms showed an overall improvement of vestibular symptoms (91 %) and cochlear symptoms (53 %) postoperatively. Audiograms showed a significant improvement postoperatively in the pure tone audiometry and bone conduction threshold of group II while the air-bone gap and speech discrimination score did not improve. Group I did not show any significant improvement postoperatively in any audiogram parameter. This study failed to identify factors that could better predict the diagnosis of PLF. However, it shows that middle ear exploration with oval and round window obliteration is effective in PLF especially to decrease vestibular symptoms even when fistula is unidentified intraoperatively.

Hyaluronic acid fat graft myringoplasty vs fat patch fat graft myringoplasty.

We aim to compare the hyaluronic acid to fat graft myringoplasty (HAFGM) technique to a recently described modified-FGM (M-FGM) in the repair of tympanic membrane perforation (TMP). We also aim to evaluate the hearing level improvement postoperatively. We conducted a prospective study in an adult tertiary care center between 2012 and 2013. Adult patients presenting with simple TMP were operated on randomly using either HAFGM or M-FGM under local anesthesia in outpatients' settings. Success was considered when complete closure is achieved. Audiometric parameters were evaluated pre and postoperatively. Twenty-four patients were included in the study (HAFGM: 10 patients and M-FGM: 14 patients). Complete closure was achieved in 80 % in HAFGM vs 42.8 % in the M-FGM (p = 0.03). The study was abandoned due to the low success rate in first 14 patients of the M-FGM group. The pure tone audiometry was improved postoperatively in the HAFGM only. The study was aborted because of the unsatisfactory obtained results using the MFGM. It also shows the beneficial effect of hyaluronic acid application to FGM for a successful TMP repair.

Hearing loss in the shaken baby syndrome.

OBJECTIVES: To evaluate hearing in children diagnosed with shaken baby syndrome. METHODS: A retrospective study conducted in a pediatric tertiary care center between 2006 and 2012. Children diagnosed with shaken baby syndrome were included for hearing evaluation by conventional audiometry, distortion product otoacoustic emissions and auditory brainstem responses. RESULTS: Twenty-eight children were included (22 boys and 6 girls). The mean age of children at presentation was 8 months (range 1-26 months) and the mean delay before audiometric evaluation was 30 months (range 1-87 months). One child was diagnosed as having a moderate sensorineural hearing loss. The tympanic membrane mobility was normal (type A) for both ears in 22 children, one child had a reduced tympanic mobility in one ear, two children had a negative pressure, one child had a functional trans-tympanic tube and test was not performed in 2 patients. CONCLUSION: This is the first study reporting hearing loss as a possible result of shaken baby syndrome. However, further studies with larger number of children would be preferable. We recommend hearing evaluation for these children to rule out hearing loss.

Superior canal dehiscence: can we predict the diagnosis?

OBJECTIVE: Identify independent clinical and audiometric factors to predict a positive high-resolution computed tomography (HRCT) scan for superior canal dehiscence (SCD). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: Patients presenting SCD. INTERVENTION(S): Audiogram, VEMP, temporal bone HRCT, and SCD symptoms and signs chart. MAIN OUTCOME MEASURE(S): ABG, VEMP threshold, and symptoms and signs. RESULTS: Approximately 106 patients with SCD symptoms were included: 62 had a positive and 44 had a negative CT scan. The positive scan group showed a higher average of cochlear symptoms than the negative CT scan group (4.3 versus 2.6) (p < 0.001), but no statistical difference for vestibular symptoms (2.2 versus 1.8) was identified. CVEMP thresholds of the positive and negative CT scan groups were of 66 and 81 dB, respectively (p < 0.001). The positive CT scan group showed higher ABGs at 250 Hz (24 versus 14 dB) and 500 Hz (17 versus 8 dB) (p = 0.008 and p = 0.008, resectively). No statistical significance was found when comparing both groups for air and bone conduction thresholds. Approximately 23% of the positive CT scan group showed a Valsalva-induced vertigo against 2.3% of the negative scan group (p = 0.003); 27% of the positive CT scan group showed speculum-induced vertigo but none of the negative scan patients (p < 0.001). Using logistic regression, we found that each 10-dB unit increase in the 250 Hz ABG is associated to an increase odd of having SCD of 51% (OR, 1.51; 95% CI, 1.10-2.08). CONCLUSION: Nature and number of cochlear symptoms, Valsalva and pneumatic speculum-induced vertigo, VEMP thresholds, and ABGs seem to correlate with a positive HRCT. The ABG at 250 Hz is the most accurate predictor of SCD.

Growth factors expression in hyaluronic acid fat graft myringoplasty.

OBJECTIVES/HYPOTHESIS: To investigate the effect of hyaluronic acid (HA) associated to fat graft on growth factors expression during the healing process of tympanic membrane (TM) perforations in guinea pigs using the hyaluronic acid fat graft myringoplasty (HAFGM) technique. STUDY DESIGN: Prospective randomized animal study. METHODS: Thirty guinea pigs were divided equally into three groups: group I (control group), group II (fat graft myringoplasty technique), and group III (HAFGM technique). TMs were perforated on day 1 and then sampled on days 0, 3, 8, and 21 and tested for the expression of: epidermal growth factor (EGF), insulin-like growth factor (IGF), tumor necrosis factor α (TNF α), vascular endothelial growth factor (VEGF), and keratinocyte growth factor (KGF). Five perforated TMs were taken at day 0 from group I to serve as a reference level. RESULTS: Group III showed an increased expression of all tested growth factors, except for KGF. EGF was highest in the early healing process; then IGF peaked at day 8 with statistically significant increase compared to groups I and II. TNF α in group III was significantly higher than group I throughout the study, with a peak level at day 21. VEGF was significantly higher in group III compared to group I at days 3 and 21. Neovascularization and scarless TM closure was obtained in group III, while spontaneous closure was associated with thin-layered and scarred TM in group I. CONCLUSIONS: HA association to fat graft in perforated TM increases the expression of the endogenous growth factors, suggesting that such an association is advantageous for healing. LEVEL OF EVIDENCE: N/A.

Tympanic membrane retraction pocket staging: is it worthwhile?

Our objectives were to review all reported staging systems of tympanic membrane (TM) retraction pockets (RP) and to report their reliability and utility to our daily clinical practice in terms of follow-up and decision making in the management of RP. We aim to propose a new management algorithm of TMRPs. We conducted a thorough research on Ovid Medline, Pubmed and Cochrane databases for English and French languages studies published between 1963 and 2012 on the retraction pocket. Studies were excluded if it were a short comments, photo clinical cases, experimental studies or round table articles. Cholesteatoma was not included in keywords, since it is considered as an advanced pathological entity with different staging and management approaches. We included 60 of 756 articles that met our inclusion criteria. Sadé and Berco proposed the first staging system of RP in 1976, while the last one was described by Borgstein et al. in 2007. From 1976 to 2007, 12 different staging systems have been described for tympanic membrane retractions. There are three broad categories of TMRPs: localized retractions of the pars tensa, generalized retractions of the pars tensa (atelectasis) and retraction of the pars flaccida. Most of the described staging systems are useful for following up the evolution of retractions over time. However, no consensus was found concerning the decision making in its management. In conclusion, proper management of TMRPs requires a reproducible, easily applicable staging system with low inter- and intra-observer variability. We propose a management algorithm that considers the functional handicap of the patient rather than the topographic description of the TM.