Does surgery affect the neurodevelopmental outcome of moderate laryngomalacia?

BACKGROUND: Moderate laryngomalacia lies in the grey zone where the parents and treating team might hesitate to decide the treatment plan for the child. Neurodevelopmental assessment of the child was neither assessed nor incorporated in surgical decision-making in the past. OBJECTIVES: To evaluate the neurodevelopmental outcome of moderate laryngomalacia treatment strategies (surgery versus conservative). METHODS: We conducted an observational multicentric cohort study. We compared two groups of patients according to their moderate laryngomalacia treatment strategy: surgical treatment and no treatment. The neurodevelopmental outcome was assessed by Griffiths-III developmental scales. RESULTS: A total of 150 children were diagnosed with moderate laryngomalacia of which 56 were successfully treated with surgery and 94 improved without intervention. The median Griffiths-III developmental quotients (DQs) of subscales A, B, C, E, and general development were significantly higher in the surgically treated group compared to conservatively treated ones. CONCLUSION: Untreated moderate laryngomalacia cases have worse neurodevelopmental outcomes than surgically treated cases.

Endoscopic-Assisted Cochlear Implantation in Far Advanced Otosclerosis.

OBJECTIVES: To evaluate the effectiveness of cochlear implantation (CI) in case of far advanced otosclerosis and to evaluate the value of using intraoperative otoendoscopy to facilitate the identification of the round window membrane and the scala tympani without the need to remove the posterior canal wall or to perform a subtotal petrosectomy. STUDY DESIGN: Retrospective case-series study. SETTING: Tertiary academic CI center. PATIENTS AND METHODS: This study was conducted on patients with far advanced otosclerosis who underwent endoscopic-assisted CI between January 2010 and June 2020 at the same CI center. The minimum follow-up period was 2 years after surgery. RESULTS: Fourteen patients were included in the study. Ten patients had undergone a previous stapedotomy. Electrode insertion in the scala tympani was successfully accomplished in all cases included in the study. There was a statistically significant improvement in pure-tone average and speech discrimination scores in all cases of the study group (p < 0.0001). There were no statistically significant differences in postoperative pure-tone average or speech discrimination scores between cases with and without cochlear ossification or between cases with and without a previous stapedotomy (p > 0.05). CONCLUSION: Endoscopic-assisted CI is an effective option for hearing restoration in patients with far advanced otosclerosis. Otoendoscopy can facilitate visualization and access to the scala tympani without the need to remove the posterior canal wall or to perform a subtotal petrosectomy.

Endoscopic transcanal coblation excision of glomus tympanicum: a novel technique.

OBJECTIVE: To evaluate the feasibility of coblation in excision of glomus tympanicum tumors. PATIENTS AND METHODS: A retrospective study carried out over 28 patients with types I and II glomus tympanicum tumors according to GLASSCOCK-JACKSON classification. Preoperative radiological and endocrinal evaluation were performed. All patients underwent endoscopic transcanal excision of their glomus tympanicum tumors using coblation. RESULTS: None of the patients developed recurrence during the 1-year follow up period proved radiologically. None of the patients developed facial palsy postoperatively. Differences between preoperative and postoperative dizziness and taste disturbance were statistically non-significant. Tinnitus disappeared completely in 22 patients postoperatively. A statistically significant reduction in Tinnitus Handicap Inventory (THI) after surgery was found. Statistically significant reductions in postoperative air conduction (AC) threshold and air bone gap (ABG) were recorded while bone conduction (BC) threshold showed statistically non-significant change. CONCLUSION: Coblation is an effective and safe tool in excision of glomus tympanicum tumors. Further studies comparing coblation with laser and piezosurgery are strongly recommended.

Endoscopic ossiculoplasty in traumatic conductive hearing loss with intact tympanic membrane: a five-year experience.

BACKGROUND: Exploratory tympanotomy in cases of traumatic ossicular disruption with intact tympanic membrane is crucial for both diagnostic and therapeutic purposes. Performing this procedure using the endoscope is gaining popularity. Hence, this study aimed to demonstrate varieties of ossicular pathology and their management in our institution. METHODS: A retrospective evaluation was conducted of 136 ears in patients with traumatic ossicular disruption with an intact tympanic membrane, who underwent endoscopic exploratory tympanotomy. A proposed algorithm was followed, to incorporate different traumatic ossicular possibilities. Assessment of hearing outcomes and surgical complications was performed six months post-operatively. RESULTS: Incudostapedial dislocation was the most commonly encountered type of traumatic ossicular disruption (35.3 per cent). Air conduction threshold improved significantly following endoscopic ossiculoplasty, from 50.9 ± 6.35 dB pre-operatively to 22.35 ± 3.27 dB post-operatively, with successful air-bone gap closure. CONCLUSION: Endoscopic ear surgery is effective in the diagnosis and management of challenging cases of post-traumatic ossicular disruption with an intact tympanic membrane.

Assessment of the ability of the radiological incudo-stapedial angle to predict the stapedotomy technique type: a prospective case-series study.

PURPOSE: This study aimed to propose a radiological classification of the incudo-stapedial angle by preoperative high-resolution computed tomography (HRCT) images and to highlight its importance for predicting the use of reversal-steps stapedotomy (RSS) rather than the traditional non-reversal technique. METHODS: We included 83 candidates for stapedotomy operation. Two physicians measured the radiological incudo-stapedial joint angle in the preoperative HRCT. According to this measurement, the radiological incudo-stapedial joint was classified into three types: obtuse, right, and acute. In addition, this radiological classification was correlated with the intraoperative use of the stapedotomy technique, either reversal or non-reversal. RESULTS: The RSS technique was used in forty-two (97.7%) cases with an obtuse angle and twenty-six (89.7%) with a right angle. At the same time, the traditional non-reversal technique was used in all patients with an acute angle. The three groups differed significantly regarding the method used for stapedotomy (P value < 0.001). Moreover, Spearman's correlation coefficient revealed a significant correlation between the used technique and the radiological type of the incudo-stapedial angle (P value < 0.001). CONCLUSIONS: This prospective study proposed a preoperative radiological classification of the incudo-stapedial angle. This classification was significantly correlated with the type of stapedotomy technique. The RSS technique was feasible in most cases with an obtuse and right radiological incudo-stapedial angle. In contrast, the non-reversal method was used in all patients with an acute radiological incudo-stapedial angle. This radiological classification could predict the choice for the stapedotomy technique with an accuracy of 95.18%, a sensitivity of 73.33%, and a specificity of 100%.

Clinical and Imaging Evaluation of COVID-19-Related Olfactory Dysfunction.

BACKGROUND: Olfactory dysfunction has been reported in 47.85% of COVID patients. It can be broadly categorized into conductive or sensorineural olfactory loss. Conductive loss occurs due to impaired nasal air flow, while sensorineural loss implies dysfunction of the olfactory epithelium or central olfactory pathways. OBJECTIVES: The aim of this study was to analyze the clinical and imaging findings in patients with COVID-related olfactory dysfunction. Additionally, the study aimed to investigate the possible mechanisms of COVID-related olfactory dysfunction. METHODS: The study included 110 patients with post-COVID-19 olfactory dysfunction, and a control group of 50 COVID-negative subjects with normal olfactory function. Endoscopic nasal examination was performed for all participants with special focus on the olfactory cleft. Smell testing was performed for all participants by using a smell diskettes test. Olfactory pathway magnetic resonance imaging (MRI) was done to assess the condition of the olfactory cleft and the dimensions and volume of the olfactory bulb. RESULTS: Olfactory dysfunction was not associated with nasal symptoms in 51.8% of patients. MRI showed significantly increased olfactory bulb dimensions and volume competed to controls. Additionally, it revealed olfactory cleft edema in 57.3% of patients. On the other hand, radiological evidence of sinusitis was detected in only 15.5% of patients. CONCLUSION: The average olfactory bulb volumes were significantly higher in the patients' group compared to the control group, indicating significant edema and swelling in the olfactory bulb in patients with COVID-related olfactory dysfunction. Furthermore, in most patients, no sinonasal symptoms such as nasal congestion or rhinorrhea were reported, and similarly, no radiological evidence of sinusitis was detected. Consequently, the most probable mechanism of COVID-related olfactory dysfunction is sensorineural loss through virus spread and damage to the olfactory epithelium and pathways.

Endoscopic transcanal management of incus long process defects: rebridging with bone cement versus incus interposition.

OBJECTIVES: to compare hearing outcomes between endoscopic transcanal rebridging with bone cement and endoscopic transcanal incus interposition in patients with incus long process defects secondary to chronic suppurative otitis media (inactive mucosal type). METHODS: This retrospective study was performed on 83 ears of 83 consecutive patients with incus long process defects secondary to chronic suppurative otitis media (inactive mucosal type). According to the extent of incus long process erosion and subsequent ossiculoplasty technique, patients were divided into 2 groups. Patients in group 1 had erosion involving up to two thirds of the length of the incus long process and underwent endoscopic transcanal rebridging with bone cement. Patients in group 2 had erosion involving more than two thirds of the length of the incus long process and underwent endoscopic transcanal incus interposition. RESULTS: Hearing gain (mean ± standard deviation) was 21.39 ± 2.15 dB in group 1 and 19.71 ± 6.12 dB in group 2. A significantly greater hearing gain was achieved in bone cement group than in incus interposition group (P value < 0.001). Successful hearing outcome (post-operative air bone gap closure within 20 dB) was achieved in 81.6% and 71.1% of patients of group 1 and group 2 respectively. CONCLUSION: Endoscopic transcanal rebridging with bone cement offers greater hearing gain than endoscopic transcanal incus interposition. The two techniques remain reliable and cost-effective techniques in management of patients with incus long process defects. The main limitation of this study was the short follow-up period. Further studies with relatively long-term follow-up are strongly recommended.

A refashioned foley catheter: novel cost-effective available stent in pediatric laryngotracheal reconstruction.

PURPOSE: Pediatric laryngotracheal reconstruction (LTR) for laryngotracheal stenosis (LTS) mandates stenting in certain situations. This study presents a novel commercially available and cost-effective stent, a refashioned foley catheter. METHODS: This prospective clinical study was performed on pediatric cases with LTS up to 8 years. The study was performed in a tertiary referral center. The selection of the proper foley catheter size for age was explained. The atraumatic insertion maneuver of the stent was also shown in detail in different situations of LTS. The endoscopic removal of the stent was also described. The mean follow-up was 6.45 ± 1.3 months. RESULTS: The study included 31 cases using the refashioned foley catheter stents. The study included 17 males and 14 females with a mean age of 3.45 ± 1.09. Subglottic stenosis was the most common cause of LTR in the study (74.2%) cases. The mean duration of stenting was 40.5 ± 3.7 days. Decannulation was achieved in 96.8% of cases. No stent complications were encountered like stent migration, excess granulation tissue, intractable aspiration, or pressure necrosis. CONCLUSION: The refashioned foley catheter is a novel, available, and inexpensive stent that can be utilized for LTR cases for pediatric LTS. The newly described stent is soft, pliable with atraumatic insertion and easy endoscopic removal with minimal complications.

Traumatic facial nerve paralysis dilemma. Decision making and the novel role of endoscope.

Objective: The management of traumatic facial nerve paralysis (FNP) has remained a controversial issue with conflicting findings arguing between surgical decompression and conservative management. However, recent advances in endoscopic surgery may consolidate the management plan for this condition. Methods: This prospective clinical study included patients with posttraumatic FNP at a tertiary referral center. Patients were categorized in two main groups: surgical and conservative. Indications for surgery included patients with immediate and complete FNP, no improvement in facial function on medical treatment, with electroneurography showing >90% degeneration or electromyography showing fibrillation potential. Patients who did not satisfy this criterion received the conservative approach. The transcanal endoscopic approach (TEA) or endoscopic assisted transmastoid approach was performed for facial nerve decompression in the surgical group. Outcome: The main outcome was facial function improvement, assessed using the House Brackmann grading scale (HBGS) 6 months after surgery, and hearing state assessed using the air bone gap (ABG). Results: The study included 38 patients, of whom 15 underwent had surgical decompression and 23 underwent conservative therapy. A significant improvement in facial nerve function from a mean of 4.66 ± 0.97 to 1.71 ± 0.69 (P = 0.001) and ABG from a median of 30 (10-40) to 20 (10-25) (P = 0.002) was observed. Conclusion: Decision-making in cases of traumatic FNP is critical. The geniculate ganglion and tympanic segment were the most commonly affected areas in FNP cases. The TEA represents the most direct and least invasive approach for this area.

Nutritional predictors of pharyngocutaneous fistula after total laryngectomy: A multivariate analytic study in a single institution.

OBJECTIVE: The objective of this study was to evaluate, through multivariate analysis, the configuration of nutritional predictors that impact the development pharyngocutaneous fistula (PCF) after total laryngectomy. METHODS: A retrospective cohort study carried out on 203 consecutive patients with laryngeal squamous cell carcinoma who underwent total laryngectomy with neck dissection between June 2015 and June 2020. Patients with risk factors for PCF formation, other than malnutrition, were excluded to eliminate the potential impact of that risk factors on PCF formation and to make the study group homogenous. Five parameters were evaluated including preoperative serum prealbumin, albumin and transferrin levels, Body Mass Index (BMI) and Malnutrition Screening Tool (MST). RESULTS: Univariate analysis revealed that preoperative prealbumin, albumin and transferrin levels significantly correlated with PCF development. Multivariate logistic regression analysis revealed that preoperative prealbumin level was the best independent nutritional predictor of PCF (P value <0.001, odd ratio 11.951 [95% CI 3.686-38.749]) followed by preoperative albumin (P value 0.006, odd ratio 3.985 [95% CI 1.485- 10.694]). CONCLUSION: Preoperative prealbumin level is considered the best independent nutritional predictor of PCF. It should be used to evaluate the nutritional status of patients undergoing total laryngectomy and hence their need for nutritional support.

Combined preoperative HRCT parameters for prediction of round window visibility in pediatric cochlear implant patient.

OBJECTIVE: To evaluate the add value of combined analysis of high resolution computed tomography (HRCT) temporal bone parameters in accurate prediction of round window (RW) visibility through posterior tympanotomy. PATIENTS AND METHODS: a retrospective observational study was held in a tertiary center, conducted on 45 cochlear implant pediatric candidates between January 2017 and September 2019. Candidates were referred for CT temporal bone. They were classified into fully visible RW cases and partially or non-visible RW cases. Radiological measurements were compared between the two groups for prediction of RW visibility separate and in combination. RESULTS: 45 patients were included in the study (26 males (57.8%) and 19 females (42.2%)). Their median age was 4 years (2-12 years). There were 38 (84.4%) fully visible and 7 (15.6%) partially or non-visible RW cases. Kashio posterior line (n:32/3), fascial recess width (FRW) (mean: 4.9 (3.5-7.5)/4.2 (4-4.7) mm) and round window location (RWL) (3 (1-4)/2.8 (1-3)mm) measurements significantly differentiated between the two groups; (P value 0.034, 0.012 & 0.025 respectively). Posterior kashio line and cut off values of ≥4.75 mm of FRW & 2.95 mm of RWL were showed sensitivity 84.2%, 63.2% & 65.8%, and accuracy 80%, 68.9% &68.9% in prediction of RW visibility respectively. Combination of Kashio prediction line with cut off value ≥ 7.45 mm (sum of FRW & RWL) showed P value 0.003 with further improve in the sensitivity and overall accuracy in prediction of RW visibility from 84.2% to 80% up to 91.4% and 88.6% respectively. CONCLUSION: combined parameters using Kashio line with FRW and RWL increases sensitivity and overall accuracy in prediction of RW visibility rather than single parameter.

Endoscopic single versus double flap tympanoplasty: a randomized clinical trial.

OBJECTIVE: This study aims to compare the results of endoscopic over-underlay tympanoplasty, single flap technique, with endoscopic over-underlay tympanoplasty combined with an anterior tab, double flap technique, in repair of the challenging total and subtotal tympanic membrane perforations with inadequate anterior remnant. This is to determine whether highly adequate visualization at the anterior meatal angle area offered by endoscopy can eliminate the need for anterior tab reinforcement. SUBJECTS AND METHODS: A prospective randomized single-blinded study involving 104 patients with total or subtotal tympanic membrane perforations was conducted. Patients were randomized into two groups: 52 with endoscopic single flap tympanoplasty, first group, and 52 with endoscopic double flap tympanoplasty, second group, between August 2017 and February 2019. The main outcome is graft take rate. Secondary outcomes include hearing results, pain score assessment, operative time and postoperative complications. RESULTS: Graft take rates were 94% and 98% for the first and second groups, respectively (P value = 0.307). Significant improvement was achieved in total air-bone gap from 21.45 ± 5.37 and 23.1 ± 4.47 preoperatively to 6.4 ± 5.46 and 6.15 ± 3.57 postoperatively for the first and second groups, respectively. Pain scores were not significantly different between the two groups. Mean operative time was significantly longer in the second group (P value = 0.010). There was no reported lateralization or anterior blunting in both groups. CONCLUSION: In repair of total and subtotal tympanic membrane perforations with inadequate anterior remnant, endoscopic enrollment provides excellent visualization and good manipulation at the anterior meatal angle area with favorable results, eliminating the need for adding an anterior tab and alleviating the burden of longer operative time. CLINICAL TRIAL REGISTRY: ClinicalTrials.gov (NCT03922295) "retrospectively registered" at 18/4/2019.